• 8/10/2004
  • NEW YORK
  • By Anthony J. Brown, MD
  • Reuters Health

New findings from a long-term study provide further evidence that leeches can be used to save head and neck free tissue flaps typically considered unsalvageable. In the study, the flaps were saved in all 15 patients treated with leeches. Although this therapy is associated with considerable blood loss and other problems, the chance to avoid a second reconstructive surgery is probably worth the risk, lead author Dr. Douglas B. Chepeha told Reuters Health. “The speech and swallowing results, as well as the cosmetic results of a second flap operation are never as good as the first.”In a report published in 2002, Dr. Chepeha and colleagues, from the University of Michigan in Ann Arbor, described the outcomes of eight patients who were treated with leech therapy at their institution between 1995 and 2000. The flaps were saved in all cases, although transfusion requirements were often high and ICU psychosis and prerenal azotemia were common problems. In a study update, presented Monday at the 6th International Conference on Head and Neck Cancer in Washington, DC, Dr. Chepeha described the outcomes of the original cohort as well as seven additional patients who were treated after 2000. All of the subjects had free tissue flaps that developed venous obstruction that could not be corrected with surgery or thrombolytic therapy. Patients undergoing leech therapy were admitted to the ICU where three leeches are placed every hour until inosculation occurs. During the ICU stay, antithrombotic therapy and antibiotic prophylaxis for Aeromonas hydrophila were administered. Flap care and hemodynamic measurements were performed regularly and blood transfusion given if the hemoglobin level fell below 8 g/dL. Leech therapy was successful in restoring blood flow and salvaging the free flap in all 15 patients. On average, 270 leeches were required per patient, the treatment period was 6.9 days, and the ICU stay was 9.9 days. Leeches were applied extraorally in 10 patients, intraorally in 4 patients, and in both sites in 1 patient. As in the earlier report, transfusion requirements were high — an average of 13 U of packed red blood cells per patient. In fact, in one patient, 62 U were needed. ICU psychosis and prerenal azotemia were observed in five and four patients, respectively. Dr. Chepeha believes that leech therapy should be tried in all patients with seemingly unsalvageable flaps, provided that “they have good arterial inflow, are healthy enough to sustain ongoing blood loss, have adequate tissue for inosculation to occur,” and have a tissue bed and flap that compare well in size and vascularization.