American Society of Hirudotherapy

A Disaster and Salvage Revisited: Chest Wall Reconstruction (5-Rib Defect) With Gore-Tex, TRAM Flap, and Salvage With Leeches

Gatti JE (2026) · Annals of Plastic Surgery · n=1

RCT evidence detailTrial reference
GRADE Very LowInsufficient evidence
Sample size of this trial compared with other venous-congestion-flap trialsMarquard JM 20251215Bishop JL 2023843Doğan S 2024570Troeltzsch M 2016330Kucur C 2015260Wang ZD 2022210Lehnhardt M 202196Kruer RM 201459Mozafari N 201056Gatti JE 20261
This trial (highlighted) by sample size alongside other indexed venous-congestion-flap trials. Larger trials generally carry more statistical weight.

Study Profile

Design
single retrospective case report (revisited from 1993) of TRAM (transverse rectus abdominis myocutaneous) flap reconstruction of a 5-rib chest wall defect after radical resection of a recurrent desmoid tumor, salvaged by medicinal leech therapy when venous congestion developed within 18 hours postoperatively (Division of Plastic Surgery, Virtua Medical Center, Voorhees, New Jersey, USA)
Sample size (n)
1
Intervention
Application of 26 medicinal leeches over a 4-day period to a venously congested distal TRAM flap that could not be adjusted or advanced due to prior chest surgical scarring; concurrent management with persistent passive oozing and hemodilution for tissue perfusion and oxygen delivery
Comparator
Not applicable - single-patient case report with revisit/long-term outcome
Primary endpoint
Salvage of the TRAM flap, protection of underlying heart and lungs, and final cosmetic outcome with subsequent breast reconstruction
Primary result
Successful flap salvage was achieved with 26 leeches over 4 days; hemodilution-induced passive oozing facilitated blood flow and oxygen delivery; reconstruction successfully protected the heart and lungs; chest reconstruction continued in stages including a solid silicone pectoralis implant; subsequent bilateral silicone gel implant breast reconstruction produced acceptable cosmetic result; tumor has not recurred at long-term follow-up; report emphasizes the practical challenges of leech therapy in a hospital without an established protocol (leeches kept in author's home refrigerator)
Follow-up duration
long-term follow-up since 1993 case (over 30 years)
PMID
41719064

Key Findings

  • Detailed long-term follow-up (>30 years) of successful TRAM flap chest wall reconstruction salvaged by 26 leeches over 4 days
  • Historically important early US case (1993) predating the 2004 FDA K040187 clearance — illustrates ad-hoc leech-therapy practice in the pre-clearance era
  • Emphasizes the practical institutional challenges (no protocol, no nursing acceptance, leeches stored in author's home refrigerator)
  • Strong support for current institutional standardized leech-therapy protocols and pharmacy-based leech supply chains
  • Demonstrates that intensive multi-day leech therapy can salvage large myocutaneous flaps despite difficult anatomy and prior scarring

Limitations

  • Single case (n=1) - cannot establish generalizable efficacy
  • Historic case (1993) - clinical practice and institutional protocols have substantially evolved
  • Retrospective revisit may have selection-bias and recall-bias effects
  • Ad-hoc leech supply (author's home refrigerator) does not meet current K040187 vendor and biohazard chain standards
  • Limited generalizability to current standardized institutional practice

Clinical Implications

Gatti 2026 provides a historically important and detailed revisit of a 1993 US case demonstrating successful TRAM flap chest wall reconstruction salvaged by 26 leeches over 4 days. For US clinicians, the trial illustrates both the long-standing demonstrated efficacy of medicinal leech therapy in difficult flap-salvage scenarios and the substantial evolution from ad-hoc 1993 practice to current FDA K040187-cleared, pharmacy-supplied, institutional-protocol-driven leech therapy. The case supports the necessity of institutional readiness (standardized protocols, qualified vendor relationships, nursing training, biohazard chain) for contemporary K040187 microsurgical-salvage practice.

Related Trials

Medicinal leech therapy in venous congestion of microsurgical flaps: a randomized comparison with heparin pinprick scarification

Merlino G, Carbone S, Servillo G, Marletta DA (2020)

Adjunctive medicinal leech therapy for venous congestion in free flaps: a German multicenter randomized trial

Lehnhardt M, Daigeler A, Behr B, Schmidt SV, Wallner C (2021)

Medicinal leeches and the microsurgeon: a four-year study, clinical series and risk benefit review

Whitaker IS, Josty IC, Hawkins S, Azzopardi E, Naderi N, Graf J, Damaris L, Lineaweaver WC, Kon M (2011)

Medicinal leeches for surgically uncorrectable venous congestion after free flap breast reconstruction

Pannucci CJ, Nelson JA, Chung CU, Fischer JP, Kanchwala SK, Kovach SJ, Serletti JM, Wu LC (2014)

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This website provides educational information and does not constitute medical advice, diagnosis, or treatment recommendations. Medicinal leech therapy carries clinically meaningful risks and should be performed only by qualified clinicians under institutionally approved protocols. FDA 510(k) clearance for medicinal leeches is limited to specific indications; investigational and off-label discussions are labeled accordingly. For patient-specific guidance, consult a qualified healthcare provider.