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) · Microsurgery · n=23
Study Profile
- Design
- single-center, retrospective cohort study using a prospectively maintained institutional database (University of Pennsylvania, Division of Plastic Surgery)
- Sample size (n)
- 23
- Intervention
- Medicinal leech therapy for surgically uncorrectable venous congestion after free flap breast reconstruction (n=4 surgically uncorrectable cases)
- Comparator
- Surgically correctable venous congestion managed by operative revision without leech therapy (n=19)
- Primary endpoint
- Flap salvage rate, total flap loss rate, transfusion requirement, and length of hospital stay
- Primary result
- Among 4 leech-treated patients: 1 flap partially salvaged, 3 flaps completely lost (75% total loss vs 42.1% in non-leeched comparator group, p=0.32 non-significant); leech patients had lower hemoglobin nadirs and received more blood transfusions; length of stay 8.0 ± 3.6 days (leech) vs 6.5 ± 2.1 days (non-leech), p=0.43
- Follow-up duration
- post-operative inpatient stay through discharge
- PMID
- 24848693
Key Findings
- Cautionary US data: in surgically uncorrectable venous congestion after free-flap breast reconstruction, 75% of leech-treated flaps were completely lost
- Leech-treated patients had significantly lower hemoglobin nadirs and higher transfusion requirements than non-leech comparator group
- Authors concluded that when venous congestion cannot be surgically corrected, total flap removal may be a better option than attempted leech salvage
- Differences in salvage and length-of-stay were not statistically significant (p=0.32 and p=0.43) due to very small sample (n=4 leech group)
- Important counterweight to optimistic single-center German and Italian leech-salvage data in the broader breast-reconstruction literature
Limitations
- Very small leech-treated subgroup (n=4) - severely underpowered for statistical comparison
- Retrospective design with confounding by indication (only surgically uncorrectable cases received leeches)
- Single US center, single anatomical site (breast) - findings may not generalize to other free-flap locations
- No assessor blinding; salvage outcome relied on clinical judgment of attending surgeon
- No long-term follow-up on aesthetic outcome or revisional surgery requirements
Clinical Implications
Pannucci 2014 provides important cautionary data that should be presented alongside the more optimistic flap-salvage literature (Merlino 2020, Elyassi 2014). In free-flap breast reconstruction with surgically uncorrectable venous congestion, the published US experience suggests that leech therapy may not salvage most cases and that early decision-making to abandon the flap may be preferable to prolonged unsuccessful salvage attempts. For US clinicians considering leech therapy in this setting, Pannucci 2014 supports honest informed consent that includes the realistic probability of total flap loss despite leech application, particularly in surgically uncorrectable cases.
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)
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)