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
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.
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