Artificial leech technique

Negative Pressure Wound Therapy as an Artificial Leech to Save a Congestive Flap: Case Report

Historically, patients with lower limb defects have represented a challenge for plastic surgeons because of their higher rate of complications. One of the main complications is venous congestion. Recently, various studies have suggested the use of negative pressure wound therapy as a salvage flap therapy, showing promising results. In this case report, we will outline the case of an elderly patient with different comorbidities in whom we used negative pressure wound therapy (as an artificial leech) to reverse venous congestion in the flap, with a satisfactory clinical outcome and without any more surgical procedures.

Management of venous flap insufficiency: the role of low molecular weight heparin in salvage

Flap loss resulting from venous insufficiency is a difficult issue, both with pedicled or free flaps. We examined the efficiency of low molecular weight heparin administration in various forms and dressing methods in venous insufficiency. Forty-five Sprague Dawley rats were included and inferior epigastric artery perforated island flaps were obtained from the abdominal skin of the animals. Nine animals were randomly allocated to each of five experimental groups: sham-control (Group 1), venous occlusion only (Group 2), occlusion with systemic enoxaparin (Group 3), occlusion with systemic enoxaparin + local enoxaparin infusion to the punctiform incisions (Group 4), and occlusion with systemic enoxaparin + local enoxaparin infusion to the punctiform incisions and enoxaparin-impregnated sponge dressing (Group 5). Group 5 had higher flap survival rates than the other groups. Groups 3 and 4 had numerically better vitality than the control group, but the difference was not significant. Low molecular weight heparin administration, with or without punctiform incisions, is not efficient in rescuing flaps with venous insufficiency. Specialised dressing methods are necessary to maintain bleeding.

Flap Venous Congestion and Salvage Techniques: A Systematic Literature Review

Venous congestion is a frequent problem in flap surgery. Other than surgical revision, there are a multitude of procedures in the literature to tackle this problem, but their effectiveness is not clear. Through a systematic review, we aimed to identify and evaluate the different interventions available for managing flap venous congestion.

Methods

The MEDLINE, PubMed central, Embase, and Cochrane databases were searched. The study selection process was adapted from the PRISMA statement. All English and French original articles describing or comparing a method for managing flap venous congestion were included. For each article, a level of evidence was assigned, as defined by the Oxford Centre for Evidence-based Medicine. Lastly, we specifically analyzed the effectiveness of postoperative non-surgical methods. No formal analysis was performed.

Results

Through literature searches carried out in various databases, we identified 224 articles. Finally, 72 articles were included. The majority of these studies had a low-level evidence. A total of 17 different methods (7 pre- and intraoperative, and 10 postoperative) were found. Concerning non-surgical methods, the most represented were leeches, local subcutaneous injection of heparin with scarification, venocutaneous catheterization, negative pressure therapy, and hyperbaric oxygen therapy.

Conclusions

Risks of venous congestion of flaps must always be present in a surgeon's mind, at every stage of flap surgery. Apart from studies on the use of leeches, which have a significant follow-up and large enough patient numbers to support their efficacy, the low-level evidence associated with studies of other methods of venous congestion management does not allow us to draw a scientifically valid conclusion about their effectiveness.

Use of the medicinal leech for salvage of venous congested microvascular free flaps of the head and neck

OBJECTIVE

The objective of the study was to determine the utility of leech therapy in venous congested microvascular free flaps in which venous outflow could not be established or surgical revision was unsuccessful.

METHODS

We conducted a retrospective review of all patients at a tertiary referral center from January 2002 to December 2008 who received leech therapy for a venous congested microvascular free flap in which venous outflow could not be established primarily or failed surgical revision.

RESULTS

Six patients were identified. Leech therapy was required for a median of 9 days (4-14 days). The median lowest hemoglobin level per patient was 8.0 g/dL (5.4-9.3 g/dL). All patients (6/6, 100%) required blood transfusions during therapy. The median number of units of packed red blood cells transfused per patient was 13.5 U (4-29 U). All flaps (6/6, 100%) were successfully salvaged with leech therapy. There was one minor complication, observed as 2 episodes of syncope in the same patient, related to anemia. There were no cases of infection transmitted as a result of leech therapy.

CONCLUSIONS

Leech therapy can be used to successfully salvage venous congested microvascular free flaps in the absence of primary venous outflow. Leech therapy can be used safely and with little morbidity compared with other reports.

Management of flaps with compromised venous outflow in head and neck microsurgical reconstruction

Microvascular tissue transfer has become an indispensable procedure for head and neck reconstruction. Although remarkable progress has been made technically, anastomosed vessel occlusion is still a serious complication. Even with technically skilled microsurgeons, anastomosed vessel occlusion occurs because the technique is not the sole prophylaxis against thrombosis in microsurgery. Therefore, to minimize the possibility of an unfavorable result in microsurgery, microsurgeons must be familiar with management options for a vascular compromised flap. Most investigators have agreed that venous obstruction occurs more often than arterial obstruction. Here, we reviewed the published literature on the salvage of venous compromised flaps from the viewpoints of surgical correction, including reanastomosis and catheter thrombectomy, and nonsurgical procedures, such as a medicinal leech, hyperbaric oxygen, and thrombolytic therapy.