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) · Microsurgery · n=35
Study Profile
- Design
- single-center, retrospective 4-year clinical series and risk-benefit review (Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, UK)
- Sample size (n)
- 35
- Intervention
- Hirudo medicinalis leeches prescribed for venous congestion in pedicled flaps and digit/limb replantations between July 2004 and 2008 (mean age 49.3 years, range 2-98)
- Comparator
- Retrospective comparison of leech-treated cases with and without prophylactic antibiotic coverage (no parallel non-leech arm)
- Primary endpoint
- Tissue salvage rate at 30 days; secondary endpoints: infection rate (Aeromonas), transfusion requirement, antibiotic prophylaxis stratification
- Primary result
- 40% (14/35) of cases salvaged in entirety; 20% (7/35) with 80% or more salvage; 5.7% (2/35) with 50-79% salvage; 2.9% (1/35) with less than 50% salvage; 31% (11/35) total tissue loss; infection rate 20% (7/35) overall and 14.2% (5/35) with Aeromonas; transfusion required in 34% (12/35), mean 2.8 units (range 2-5)
- Follow-up duration
- 30 days post-procedure
- PMID
- 21520265
Key Findings
- Largest published UK single-center microsurgery leech case series (n=35) at the time of publication
- Infection rate 20% overall including 14.2% Aeromonas - higher than many German centers, reinforcing prophylactic-antibiotic case
- Infection rate significantly higher in patients not receiving prophylactic antibiotics (Fisher exact test p=0.0005) - direct evidence supporting routine ciprofloxacin prophylaxis
- 60% of cases achieved 80% or greater tissue salvage; 31% complete tissue loss reflects the salvage population (failed cases referred for leech therapy)
- Identified species shift to Hirudo verbana as standard supplied leech and Aeromonas veronii as primary pathogen of concern
Limitations
- Retrospective design - no randomization, no control arm
- Small absolute sample size (n=35) over 4 years
- Wide age range (2-98 years) with no stratified analysis
- Single UK center - antibiotic and surgical practices may not generalize
- Salvage population represents pre-selected failures of standard care, complicating outcome interpretation
Clinical Implications
Whitaker 2011 is a foundational UK case series that established the empirical basis for routine antibiotic prophylaxis (ciprofloxacin) in leech therapy. The Fisher exact test result (p=0.0005) for prophylaxis-vs-no-prophylaxis is one of the strongest pieces of evidence in the literature supporting current guidelines that mandate antibiotic coverage for any leech application. The case series also documented the practical clinical experience of a UK academic plastic surgery unit, with realistic infection and transfusion rates that contrast with the lower numbers reported in highly-selected German RCTs. For clinicians, Whitaker 2011 should be read alongside Merlino 2020 (Italian flap-salvage RCT) and Elyassi 2014 (US digit replantation series) as part of the international risk-benefit literature.
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 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)
Hirudotherapy for limb ischemia in the pediatric intensive care unit: a retrospective observational cohort
Resch JC, Hedstrom R, Steiner ME, Said SM, Somani A (2023)