TREATMENT

In general leeches should be applied on the darker spots of the reattached body parts or flaps. In the case of replanted fingers, leeches should be placed on the dorsal part of the finger as the skin is thinner. They could be also placed on the region of the removed nail. Leeches normally start feeding immediately, although in some cases the skin has to be punctured with a sterile needle so that oozing blood will stimulate the leeches to feed. Pricking the site to be treated could also demonstrate whether there is sufficient blood-flow in the area. When the leech refuses to feed in a given place, the syringe is moved to the neighboring area, until an appropriate place is found as close as possible to the congested area. Depending on the intensity of blood-flow in the area, feeding can last for 30–90 min. During feeding drops of clear liquid can be seen oozing from the leech; this is the superfluous water in blood, which the leeches remove to concentrate the red blood cells in their digestive tract.

During hirudotherapy the patient should be under permanent surveillance by a healthcare provider; leeches may seek other places to suck blood or after feeding may drop into the surrounding area. Attention should be paid to leeches, which attach but do not change in size and have no visible gut peristalsis within 30 min after their attachment. It could be assumed that they are only attached but not feeding and should be replaced with other leeches or they should be transferred to other parts of the treated area. The use of active (swimming) and larger leeches could be of help.

Depending on the severity and the size of the congestion, 1– 10 leeches are used for each treatment, although some authors recommend higher numbers of leeches. The degree of venous congestion is estimated from the percentage of violaceous color of flap skin pedicle, testing capillary refill, and color of the blood oozing from the bite site or after having been pierced with a needle. At the beginning of the treatment, the patient might need two or more treatments per day [35]. Chepeha et al. [40] used a protocol according to which leech placement was continuous (3 leeches per hour) and tapered slowly according to clinical assessment of inosculation. In the Iowa Head and Neck Protocol [41], leeches are applied every 2 hours. The number of treatments per day depends also on the bleeding of previous bite sites. In cases where the bleeding stops shortly after the leeches detach, or when leeches do not become fully engorged, a more aggressive treatment should be followed by using a larger number of leeches and more treatments per day.

Leech therapy is continued until venous capillary return is established across the wound border by angiogenesis. Usually the treatment with leeches lasts for 2–6 days. In fact, the decision regarding the duration of the leech treatment is empiric, based on subjective appreciation of the color of the skin, capillary refill, and the color of bleeding after pinprick [28,40-43]. Flap monitoring consists of listening to the Doppler signal and examining the flap every 1-2 hrs until the flap is stabilized and thereafter every 2–4 hrs [40]. Antithrombotic therapy could be administered with aspirin, heparin sodium, and/or dextran 40 in parallel with hirudotherapy, although it should be noted that the leech saliva also demonstrates antithrombotic activity (see Leech Saliva).

Successful salvage of such tissues with leeching has been reported in 70–90 % of cases [3,18,34,44-47].

Leech therapy should be considered as an integral part of the armamentarium used in reconstructive surgery. It improves greatly the success rate of the surgery in cases of post-operative venous congestion and hematomas, allowing blood drainage until angiogenesis is established.

A. HISTORY
E. BIOLOGY
I. APPLICATION TO THE SKIN
M. CASE REPORTS
Q. MAINTENANCE IN THE CLINIC
V. EXTERNAL LINKS
B. LEECHES
F. THE SALIVA
J. THE BITE AND BITE REACTIONS
N. SIDE EFFECT
R. LEGAL CONSIDERATIONS
W. REFERENCES
C. MEDICINAL LEECHES
G. USE OF LEECHES IN MEDICINE
K. PROPHYLAXIS
O. CONTRAINDICATIONS
T. TRAINING COURSES
D. MORPHOLOGY
H. LEECHES IN PLASTIC SURGERY
L. TREATMENT
P. REMOVAL OF THE LEECHES
U. VETERINARY MEDICINE