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Toshinskiy S, Frees M, Hillard C. Predictors of leech therapy failure in revascularized and replanted digits. J Hand Microsurg 2024; 16:100080. [PMID: 39234374 PMCID: PMC11369714 DOI: 10.1016/j.jham.2024.100080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2024] Open
Abstract
Introduction Venous congestion is a common phenomenon following digital revascularization and replantation. Leech therapy allows for venous outflow while angiogenesis and neovascularization take place. The aim of this study is to evaluate the efficacy of leech therapy in the revascularized and replanted digits and determine risk factors for unsuccessful salvage. Materials and methods A retrospective review was performed to identify all patients with complete or incomplete digital amputations at an academic Level 1 Trauma Center who underwent digital replantation or revascularization from January 2005 to December 2020. Amputations proximal to the palmar arch as well as revascularizations that showed any degree of perfusion on preoperative assessment were excluded. Leech therapy was initiated as soon as any signs of venous congestion appeared and was titrated to clinical effect. Patient demographics, medical history, injury mechanism, extent and level, operative details, leech therapy details, number of blood transfusions, hospitalization length, as well as the digit's ultimate survival data were collected. Results Of the 159 patients who underwent 213 digital revascularizations (n = 135) and replantations (n = 78), venous congestion requiring leech therapy developed in 27 digits in the revascularization group and in 26 in the replantation group. Of the digits that were leeched, 15 failed in the revascularization group (56 % failure rate) and 17 failed in the replantation group (65 % failure rate). Avulsion mechanism of injury and presence of a circumferential laceration were significantly associated with rate of failure in the revascularization cohort (p < 0.01). Proximal level of injury was significantly associated with rate of failure in the replantation group (p < 0.01). Conclusion Leech therapy has limited efficacy in avulsed or more proximally injured digits. These data can aid in determining the prognosis of a digit with venous congestion after revascularization and replantation.
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Affiliation(s)
- Sergey Toshinskiy
- University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Michelle Frees
- University of Minnesota School of Medicine, Minneapolis, MN, United States
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Song M, Zhang C, Yang S, Lu J, Sun T, Li H, Tang L, Dai K, Liu C, Meng H, Wang J. Animal healer for refractory diseases: Myth or reality? Heliyon 2024; 10:e33056. [PMID: 39027544 PMCID: PMC11255451 DOI: 10.1016/j.heliyon.2024.e33056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 07/20/2024] Open
Abstract
A vast amount of knowledge has been acquired through human activities such as farming, hunting, and fishing. Throughout history, humans have utilized living creatures for disease treatment, relying on the natural world's healing powers. The special "healers" may be able to treat patients via the power of nature. However, there was no systematic introduction or summary of these treatments. Therefore, we conducted a literature review based on PubMed, Google Scholar, Web of Science, Scopus, CNKI and WanFang DATA. Here, we defined this unique method as "animal healer" and six common kinds of animal healers were reviewed. These are fish therapy, pet therapy, worm therapy, leech therapy, maggot therapy, and bee therapy. According to the different characteristics of healers, treatment methods mainly included bite, parasitism, contact and communication. With the advantages of green and effectiveness, animal healers have great therapy potential against a variety of refractory diseases. The main purpose of this review is to draw people's attention to animal healer, promote it to become a possible clinical treatment strategy, and make further exploration in species cultivation, mechanism research, animal welfare, standard setting, safety evaluation and other aspects. In the future, animal healers will play an increasingly important role in medicine and hopefully solve more medical problems and dilemmas.
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Affiliation(s)
- Mingzhi Song
- Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Changru Zhang
- Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Translational Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Simengge Yang
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jialin Lu
- College of Humanities and Social Sciences, Dalian Medical University, Dalian, China
| | - Tianze Sun
- Department of Orthopaedics, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Heyue Li
- Department of Obstetrics and Gynecology, Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Liang Tang
- Department of Orthopedic Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kerong Dai
- Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Southwest Jiaotong University College of Medicine, Chengdu, China
| | - Chaozong Liu
- Institute of Orthopaedic & Musculoskeletal Science, University College London, Royal National Orthopaedic Hospital, London, United Kingdom
| | - He Meng
- School of Agriculture and Biology, Shanghai Jiao Tong University, Shanghai, China
| | - Jinwu Wang
- Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Southwest Jiaotong University College of Medicine, Chengdu, China
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Larson EL, Lieb MW, Pysick HE, Mehdi M, Hoben GM. Postoperative Interventions in Pediatric Digital Replantation: A Tertiary Referral Center Case Review. J Hand Surg Am 2024; 49:276.e1-276.e9. [PMID: 35985864 DOI: 10.1016/j.jhsa.2022.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 04/22/2022] [Accepted: 06/13/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE Although a few case series have been published describing the excellent outcomes of replantation and revascularization operations in children, there has been limited study of the hospital course that these patients experience and the number of potentially harmful interventions and treatments that occur. The purpose of this study was to detail the results of various postoperative interventions, including anticoagulation, transfusion, leeching, sedation, and additional anesthetic exposures. METHODS Twenty-nine patients aged less than 18 years had 34 digital revascularizations or replantations performed between January 2000 and May 2020. The details of each patient's presentation, surgery, and postoperative care were analyzed. RESULTS Nine of 29 children underwent repeat anesthetics, including 6 revision amputations. No demographic, surgical, or postoperative variables consistently preceded revision amputation or additional anesthetic procedures. Only 5 patients had >1 hemoglobin (Hb) measurement. Two patients received blood transfusions; the average drop in Hb was 3.5 g/dL from before surgery to the lowest after surgery. Four patients underwent leech therapy. Only patients receiving leech therapy required postoperative transfusions. Anticoagulation regimens were prescribed on the basis of demographic and surgical factors, although no medication or regimen seemed to affect outcomes. CONCLUSIONS Although the experience of digital replantation is essentially the same in pediatric patients as adults, there may be different ramifications for children. Specifically, postoperative management of pediatric digital replantation or revascularization can involve multiple interventions that carry their risks. Parents should be counseled about the risks of anticoagulants, transfusions, and repeat anesthetics, and clinicians should monitor Hb closely when using leech therapy. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Ellen L Larson
- Department of Plastic Surgery, Medical College of Wisconsin, Wauwatosa, WI
| | | | | | - Maahum Mehdi
- Department of Plastic Surgery, Medical College of Wisconsin, Wauwatosa, WI
| | - Gwendolyn M Hoben
- Department of Plastic Surgery, Medical College of Wisconsin, Wauwatosa, WI.
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Yu JL, Cordero DM, Miller EA. Principles of microvascular surgery in the upper extremity. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03749-x. [PMID: 37875649 DOI: 10.1007/s00590-023-03749-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 09/25/2023] [Indexed: 10/26/2023]
Abstract
Upper extremity replantation and microsurgery can be challenging even for the experienced hand and upper extremity surgeon and requires thoughtful consideration and evaluation. This review aims to discuss the general considerations in upper extremity replantation management from the preoperative through the postoperative period.
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Affiliation(s)
- Jenny L Yu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington, 325 9th Ave. Mailstop 359796, Seattle, WA, 98104, USA
| | - Daniella M Cordero
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington, 325 9th Ave. Mailstop 359796, Seattle, WA, 98104, USA
| | - Erin A Miller
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington, 325 9th Ave. Mailstop 359796, Seattle, WA, 98104, USA.
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Bregman D, Nicholson L. Indications for replantation and factors that predict success. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03671-2. [PMID: 37596464 DOI: 10.1007/s00590-023-03671-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 08/02/2023] [Indexed: 08/20/2023]
Abstract
Since the advent of replantation techniques, there has been uneven progress in terms of success-even considering whether success is defined as continued perfusion of the digit or long term functional outcomes. Early enthusiasm and success have not been maintained despite increasing familiarity with microsurgical techniques and greater understanding of how to optimize outcomes for the individual components of replantation such as tendon repair, nerve repair, and osteosynthesis. Practitioners participating in the care of patients undergoing replantation should be familiar with the history and current understanding of both the indications and contraindications for the procedure, post-operative rehabilitation, and factors contributing to functional outcomes. A review of the literature from the first publications on the topic demonstrates evolution in practice and understanding of which patients should be indicated for replantation. Indications can be considered in three broad categories: injury factors, patient factors, and care context factors. These factors intersect with one another and can inform the surgeon pre-operatively regarding the most likely outcome for a given patient. This insight is critical to discuss pre-operatively with the patient in order to make a shared decision about how to manage their injury.
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Affiliation(s)
- Dana Bregman
- Department of Orthopedics, University of Southern California, Los Angeles, California, USA.
| | - Luke Nicholson
- Department of Orthopedics, University of Southern California, Los Angeles, California, USA
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6
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Zhang Z, Credico P, Bristol S, Macadam S. Determinants of Success in Single- and Multi-Digit Replant. Plast Surg (Oakv) 2023; 31:53-60. [PMID: 36755824 PMCID: PMC9900039 DOI: 10.1177/22925503211024767] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/30/2021] [Indexed: 11/15/2022] Open
Abstract
Purpose: Understanding the variables that influence success in digital replant surgery is essential to guide clinical decision-making and to counsel patients. The purpose of this study was to determine the replant success rate and identify predictors of success at our tertiary care centre. Methods: This was a single centre, retrospective cohort study of consecutive patients who underwent digital replantation from January 2000 to September 2018. Adult patients with flexor zone I to III amputations were included. Patient demographics, comorbidities, injury pattern, operative data, and post-operative care were reviewed. The primary outcome was survival of the replanted digit at discharge. Results: A total of 146 patients met inclusion criteria. Of these, 100 had single-digit replants and 46 underwent multi-digit replants for a total of 220 digits. The success rate was 71%. Predictors of success included sharp mechanism of injury (P < .01), incomplete amputation (P < .01), amputation proximal to zone I flexor level (P = .02), post-operative acetylsalicylic acid use (P < .01), absence of leech use (P = .05), and absence of operative re-exploration (P < .01). Daytime replants had similar outcome compared to nighttime replants despite having increased ischemia time (7.9 ± 3.9 hours vs 6.8 ± 2.6 hours, P = .02). However, daytime operative time (7.8 ± 3.7 hours) was significantly shorter than nighttime replant time (9.6 ± 5.9 hours, P = .01). Conclusion: Sharp amputation, intact venous drainage, proximal amputation, and acetylsalicylic acid use were associated with replant survival and are factors to consider when managing patients for digital replantation. Leech therapy and operative re-exploration were associated with poor outcome. Nighttime replants required significantly longer operative time than daytime replants despite similar survival outcome.
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Affiliation(s)
- Zach Zhang
- Division of Plastic and Reconstructive Surgery, Department of
Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter Credico
- Faculty of Medicine, University of British Columbia, Vancouver,
British Columbia, Canada
| | - Sean Bristol
- Division of Plastic and Reconstructive Surgery, Department of
Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sheina Macadam
- Division of Plastic and Reconstructive Surgery, Department of
Surgery, University of British Columbia, Vancouver, British Columbia, Canada
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Resch JC, Hedstrom R, Steiner ME, Said SM, Somani A. Hirudotherapy for limb ischemia in the pediatric intensive care unit: A retrospective observational cohort. Front Pediatr 2022; 10:1011171. [PMID: 36683785 PMCID: PMC9849792 DOI: 10.3389/fped.2022.1011171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 12/12/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Acute limb ischemia due to microvascular malperfusion may be refractory to initial therapies. Medicinal leech therapy (hirudotherapy) has been attempted in plastic and reconstructive surgery to improve venous congestion in ischemic flaps; however, there are minimal reports related to ischemia secondary to arterial malperfusion. We evaluated a pediatric cohort from an academic intensive care unit with refractory limb ischemia in whom hirudotherapy was attempted to elucidate its use and outcomes. METHOD Institutional patient database was queried to identify pediatric patients (<18 years) who received hirudotherapy in the pediatric critical care unit and met inclusion/exclusion criteria. Patient charts were evaluated for indices including demographics, primary disease, coagulative status, vascular access, vasoactive medication dosing, bleeding, leech use, limb and mortality outcomes. Data was evaluated to identify trends or suspected impact on outcomes. RESULTS Hirudotherapy was used in 7 patients for limb ischemia, 5 with congenital heart disease, and 2 others with viremic shock. Time to leech application following recognition of ischemia averaged 3 days, with duration of use averaging 3.9 days. Five patients discontinued therapy due to bleeding. Mortality rate was 57%, all secondary to multiorgan failure. In 3 surviving patients, 4 of 5 treated limbs resulted in at minimum partial amputation. Vasoactive-inotropic score tended higher prior to leech application, suggesting a vasoconstrictive pathway for arterial malperfusion. No identifiable trends appeared associated with salvaged limb or adverse effects. Blood loss predictably increased with leech application, as did total transfusion requirement. CONCLUSION This case series establishes baseline data for use of hirudotherapy in critically ill children with acute limb ischemia caused by arterial malperfusion. Based on this retrospective cohort, we cannot recommend routine use of hirudotherapy for acute limb ischemia from arterial malperfusion in the pediatric intensive care unit. Application of leeches should be aligned with a protocol defining start and stop parameters, standardized leech utilization, and monitoring for adverse outcomes. Future study would benefit from consensus definitions of study outcomes, including perfusion recovery, tissue/limb salvage and bleeding manifestations. Additional prospective studies are needed prior to any standard or systematic recommendations for use.
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Affiliation(s)
- Joseph C Resch
- Department of Pediatric Critical Care, University of Minnesota, M Health Fairview Masonic Children's Hospital, Minneapolis, MN, United States
| | - Rachel Hedstrom
- Department of Pediatric Critical Care, University of Minnesota, M Health Fairview Masonic Children's Hospital, Minneapolis, MN, United States
| | - Marie E Steiner
- Department of Pediatric Critical Care, University of Minnesota, M Health Fairview Masonic Children's Hospital, Minneapolis, MN, United States
| | - Sameh M Said
- Department of Pediatric Cardiac Surgery, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, United States
| | - Arif Somani
- Department of Pediatric Critical Care, University of Minnesota, M Health Fairview Masonic Children's Hospital, Minneapolis, MN, United States
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8
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Elmaraghi S, Israel JS, Gander B. Systematic Review of Replant Salvage and Cost Utility Analysis of Inpatient Monitoring After Digit Replantation. J Hand Surg Am 2022; 47:32-42.e1. [PMID: 34548183 DOI: 10.1016/j.jhsa.2021.07.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 05/30/2021] [Accepted: 07/28/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Digit replantation is a high-stakes procedure that has been shown to be cost-effective, especially for multiple-digit replantation. However, it is associated with prolonged lengths of stay (LOS) for monitoring and attempts at salvage. The cost-effectiveness of prolonged inpatient stays presumes that this is necessary and inherent to the replantation. We hypothesized that prolonged monitoring of replanted digits, in the hope of possible salvage after primary failure, is cost-ineffective due to the low rates of vascular compromise and salvage after replantation. METHODS Using previously published data comparing quality adjusted life years lost after traumatic digit amputation versus digit replantation, we devised a cost utility model to evaluate the incremental cost-effectiveness ratio of inpatient monitoring. To determine rates of vascular compromise and salvage after digit replantation, we performed a systematic review of the literature through MEDLINE and SCOPUS database searches to identify relevant articles on digital replantation since 1990. Cost-effectiveness was stratified based on the number of digits replanted. RESULTS Fewer than 9% of replanted digits both experience vascular compromise and are successfully salvaged. Adjusting for this, inpatient monitoring for single-digit and thumb replantation becomes cost-ineffective after 1 day of admission and monitoring for multiple-digit replantation becomes cost-ineffective after 2 days of admission. CONCLUSIONS In the United States, prolonged admissions for inpatient monitoring quickly become cost-ineffective, especially with relatively low rates of salvage. Surgeons should avoid extended hospitalizations for replant monitoring and should pursue enhanced recovery protocols for replantation, especially considering burgeoning health care costs in the United States. TYPE OF STUDY/LEVEL OF EVIDENCE Economic/Decision Analysis III.
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Affiliation(s)
- Shady Elmaraghi
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Jacqueline S Israel
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Brian Gander
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
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9
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Davoodi F, Taheri S, Raisi A, Rajabzadeh A, Zakian A, Hablolvarid MH, Ahmadvand H. Leech therapy (Hirudo medicinalis) attenuates testicular damages induced by testicular ischemia/reperfusion in an animal model. BMC Vet Res 2021; 17:256. [PMID: 34315461 PMCID: PMC8314469 DOI: 10.1186/s12917-021-02951-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/30/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Testicular torsion/detorsion triggers tissue ischemia/reperfusion, leading to reactive oxygen species overgeneration and apoptosis. The saliva of leeches is full of anti-inflammatory, anticoagulants, antioxidants, and antimicrobial agents. Therefore, this study aimed to assess the protective mechanism of leech therapy on testicular ischemia/reperfusion damage. METHODS 18 adult male rats were randomly divided into three groups: 1-Sham-operated group (SO). 2-Torsion/detorsion (T.D) group: two hours of testicular torsion with two hours of testicular detorsion was performed. 3-Torsion/detorsion + Leech therapy (TDL) group. Sperm parameters (motility, vitality, morphology, and concentration), oxidative stress biomarkers (MDA, CAT, GPx, and TAC), histopathological factors (Mean seminiferous tubular diameter, Germinal epithelial cell thickness, Testicular capsule thickness, Johnson's score, and Cosentino's score), and immunohistochemical markers for apoptosis detection (Bax, Bcl-2, and Caspase-3) were measured. RESULTS There was a significant difference for all sperm parameters in the T. D group compared to the sham group. Leech therapy significantly increased progressive motility and normal morphology and reduced non-progressive motility. In the TDL group, MDA concentration significantly reduced, and levels of GPx, TAC, and CAT remarkably increased. All evaluated histopathological parameters in the TDL group significantly increased compared to the T. D group except for the testicular capsule thickness. T. D notably increased the expression of Bax and Caspase-3, while the treatment group slowed the rate of apoptosis compared to the control group. Bcl-2 expression in the T. D group was significantly lower than that in the sham group. Leech therapy increased the Bcl-2 expression. CONCLUSION Leech therapy attenuates damages to testicular tissue following torsion/detorsion due to its antioxidant, anti-inflammatory, and anti-apoptotic effects. Hence, it can be considered as an effective remedy for testicular ischemia/reperfusion.
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Affiliation(s)
- Farshid Davoodi
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Lorestan University, Khorramabad, Iran
| | - Shayan Taheri
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Lorestan University, Khorramabad, Iran
| | - Abbas Raisi
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Lorestan University, Khorramabad, Iran.
| | - Asghar Rajabzadeh
- Razi Herbal Medicines Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran
- Department of Anatomical Sciences, Faculty of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Amir Zakian
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Lorestan University, Khorramabad, Iran.
| | - Mohammad Hassan Hablolvarid
- Razi Vaccine and Serum Research Institute, Agriculture Research, Education and Extension Organization (AREEO), Karaj, Iran
| | - Hassan Ahmadvand
- Razi Herbal Medicines Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran
- Medicinal Plants and Natural Products Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
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10
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Resch JC, Said SM, Steiner ME, Somani A. Hirudotherapy for neonatal limb ischemia during ECMO support: A word of caution. J Card Surg 2021; 36:2549-2557. [PMID: 33811665 DOI: 10.1111/jocs.15539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/09/2021] [Accepted: 03/13/2021] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Disordered coagulation, clot formation and distal limb ischemia are complications of extracorporeal membrane oxygenation (ECMO) with significant morbidity and mortality. Medicinal leech therapy (hirudotherapy) has been attempted in plastic and orthopedic surgeries to improve venous congestion and salvage ischemic flaps. To our knowledge this has not been reported in pediatric cardiac surgery or during ECMO support. We present a complex neonate whose ECMO course was complicated by distal limb ischemia for whom leech therapy was attempted. PATIENT AND INTERVENTION A 2-week-old 2.7 kg infant required ECMO support secondary to perioperative multiorgan system dysfunction following repair of critical coarctation and ventricular septal defect. Despite systemic anticoagulation, his clinical course was complicated by arterial thrombus, vasopressor-induced vascular spasm and bilateral distal limb ischemia. Medicinal leech therapy was tried after initially failing conventional measures. RESULT Following the third leech application, this patient developed significant hemorrhage from the web space adjacent to the left great toe. An estimated 450 ml of blood loss occurred and more than 300 ml of blood product transfusions were required. He ultimately progressed to irreversible systemic end organ dysfunction and comfort care was provided. CONCLUSION The use of medicinal leech therapy in pediatric cardiac surgery may be considered to minimize the consequences of advanced limb ischemia and venous congestion. However, this should be used with caution while patients are systemically anticoagulated during ECMO support. A directed review is presented here to assist in determining optimal application and potential course of therapy.
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Affiliation(s)
- Joseph C Resch
- Department of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Sameh M Said
- Department of Pediatric Cardiac Surgery, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Marie E Steiner
- Department of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Arif Somani
- Department of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
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11
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How to manage leech therapy. Nursing 2020; 50:11-12. [PMID: 33105421 DOI: 10.1097/01.nurse.0000718916.16465.aa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Tang JB, Wang ZT, Chen J, Wong J. A Global View of Digital Replantation and Revascularization. Clin Plast Surg 2020; 47:437-459. [PMID: 32892794 DOI: 10.1016/j.cps.2020.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Survival rates of digital replantation vary in different regions and countries, and Asian surgeons see more challenging cases and have developed some unique methods. Replantation of multiple digits in one or both hands can follow a structure-by-structure method or a digit-by-digit method. For replanting all 10 digits, 3 or 4 teams should be organized. Flow-through flaps, often venous flaps, can be taken from the distal forearm or lower extremity to repair defects of soft tissues and arteries. A pedicled digital artery flap from the adjacent digit can also repair tissue defects and supply blood to the replanted digit.
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Affiliation(s)
- Jin Bo Tang
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China.
| | - Zeng Tao Wang
- Department of Hand and Foot Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Jing Chen
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - Jason Wong
- Department of Plastic and Reconstructive Surgery, The University of Manchester, Manchester, UK
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13
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Leech Therapy Following Digital Replantation and Revascularization. J Hand Surg Am 2020; 45:638-643. [PMID: 32493632 DOI: 10.1016/j.jhsa.2020.03.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 02/13/2020] [Accepted: 03/30/2020] [Indexed: 02/02/2023]
Abstract
Venous congestion after digital replantation or revascularization threatens digit survival in the immediate postoperative period. External bloodletting, including leech therapy, provides a central role in salvage of the congested finger. Although there have been previous studies describing the initiation of leech therapy for digits experiencing venous insufficiency, few published articles and no consensus guidelines have discussed the weaning of leeches in the postoperative period. We review the current evidence behind leech therapy and offer a treatment algorithm based on available data and existing leech weaning protocols.
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Barbato B, Salsac AV. Finger and thumb replantation: From biomechanics to practical surgical applications. HAND SURGERY & REHABILITATION 2019; 39:77-91. [PMID: 31837487 DOI: 10.1016/j.hansur.2019.10.198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 10/23/2019] [Accepted: 10/31/2019] [Indexed: 01/13/2023]
Abstract
Finger and thumb amputations, which are always dramatic injuries with major functional and psychological repercussions, remain a surgical challenge. This review on digit replantation develops the underlying biomechanical and surgical aspects as well as practical indications. The different stages from trauma to postoperative monitoring are described. We describe the steps to follow from theory to practice in order to optimize the surgical acts that must as effective possible in terms of management and decision-making efficiency. Indications recognized as standards such as thumb amputation, multi-digit amputations and distal amputations are detailed, as well as the more controversial ring finger replantations. The challenge of successful finger and thumb replantation lies in searching for the best functional and cosmetic outcome and not performing irrelevant microsurgical manipulations.
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Affiliation(s)
- B Barbato
- Urgences Main Val de Seine, Centre hospitalier privé du Montgardé, 32, rue de Montgardé, 78410 Aubergenville, France.
| | - A-V Salsac
- Laboratoire de Biomécanique et Bioingénierie (UMR 7338), CNRS-université de Technologie de Compiègne, Alliance Sorbonne université, rue du Docteur Schweitzer, CS 60319, 60203 Compiègne cedex, France.
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