Leech Therapy in Nearly Total Amputation of Fingers Without Vascular Repair
November 4, 2015
Management of finger amputation, due its difficulties, is a dilemma and in many cases microvascular replantation is not possible, especially in those with crash injury. Since the purpose of replantation is obtaining a near normal function (motion, sensation, and handgrip), amputation of the injured finger seems to be the best treatment. Nowadays, microsurgical techniques have improved and more and more finger replantations are performed. However, replantation would be possible if there is the plausibility of microsurgery (patient’s condition, hospital facilities). Venous congestion, even for a short period, could cause thrombosis at the digital arteriole anastomosis, and may result in replantation loss.
Leech therapy has a long history in different branches of medicine. The use of leech in finger replantation after microvascular surgery has been reported to decrease venous congestion. In this report, we presented a case in which microvascular surgery was not performed (due to crush injury) and after a simple repair, leeches therapy was performed. The idea behind this technique is to suck blood into small remaining vessels from the volar part of the finger (the only attached skin).A 25-year-old man was admitted to the emergency ward of Shahid-Kamyab Hospital, Mashhad, Iran, with traumatic-near-amputation condition of the third, fourth and fifth fingers of the left hand in January 2011. Trauma occurred during an occupational accident where the carpenter’s saw injured his fingers in the proximal phalanx. The patient had no previous history of disease or surgery. He was immediately transferred to the operation theatre. The lateral neurovascular bundle of the third finger was intact. Nevertheless, the third finger was completely ischemic and with no capillary filling. In fourth and fifth fingers, neurovascular components were crushed and only a small volar skin flap existed. According to the situation of hospital, having no access to microvascular surgery equipment, and vascular surgeon consultation, microvascular replantation was not applicable. After a meticulous debridement, bone was fixed using a K-wire.Soft tissue was sutured without vascular surgery. The cutaneous nerves of the fingers were not repaired. After reaching a good alignment, capillary filling of the third finger was not returned. It may be due to severe intimal lesion and thrombosis. The third finger could be assumed near amputated.
Appropriate prophylactic antibiotic and low molecular weight heparin commenced (40 mg, SC, BID). Leech therapy commenced 12 hours after the operation. The leeches applied were obtained from breeders, since they were not available in the center. Leeches were applied until they were satiated (mean 20 minutes) on a daily basis. In the beginning days, a small incision was applied to cause a minimal amount of bleeding to encourage leeches to bite the ischemic fingers. The leeches were handled by pancit. After each leech therapy, blood oozing continued for one hour, which it amount was less in early days, increasing day by day. In general, 15 leeches were used for this patient. On the first postoperative day, his fingers were assessed for color, capillary refill and blood oozing every two hours. Where necessary, leeches were applied to decrease venous congestion.