Introduction
Use of leeches to salvage a flap with
venous congestion is well known.1,2 But a methodical way and an aesthetic approach to leech application is always beneficial.
Usually leeches are applied to the flap and left alone to feed. This method has following disadvantages-
1. An active leech may migrate and get attached to the part of the extremity other than the flap. Then it becomes necessary to search and retrieve it.
2. Monitoring of leech activity may not be possible.
3. Secretions of leech may soil the dressing and increase the incidence of infection.
4. The scene of leech hanging from the flap in itself is crude and at times may be frightening to the patient, especially to children and also the relatives.
Procedure
Our technique is simple, inexpensive, aesthetic and overcomes all the disadvantages listed above.
Steps -
1. A stab would is made in the flap.
2. A 20 ml syringe without the piston is taken.
3. A fresh leech is put into the syringe using plain tissue forceps (Fig. 1).
4. Piston end of the syringe is held near the stab wound. Leech will get attached to the stab wound and start sucking blood.
5. Attachment of the leech can be verified by slightly withdrawing the syringe (Fig. 2).
6. Now the piston end of the syringe is placed around the leech over the flap. This does not allow the leech to migrate elsewhere (Fig. 3).
7. Few gauze pieces are kept around the base of the syringe.
8. The syringe is loosely immobilised using gamgee bandage (Fig. 4).
9. Leech activity is monitored through the syringe.
10. Once the leech has stopped sucking blood and fallen back into the syringe, the syringe is removed.
11. Standard care of the stored leech is essential.
Discussion
This technique has following advantages-
1. It allows controlled application, verification and removal of leeches.
2. It does not allow the leech to migrate elsewhere.
3. Progress of the leech enlargement can be easily seen through the syringe.
4. Secretions of the leech get collected in the syringe and do not contaminate the wound. Thus, this method may reduce incidence of wound infection associated with leech usage. However, this aspect needs to be studied further.
5. It is simple, inexpensive and definitely more aesthetic.
The authors would appreciate suggestions to further improve on this method.
References
1. Dabb RW, Malone JM, Leverett LC. The use of medicinal leeches in the salvage of flaps with venous congestion. Ann Plast Surg 1992; 29 :
250-6.
2. Smoot CE, Ruiz JA, Roth AC. Medicinal leech therapy to relieve venous congestion. J Reconst Microsurg 1995; 11 : 51-5.
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| Fig. 1 : 20 cc syringe with leech |
Fig. 2 : Confirming leech attachment |
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| Fig. 3 : Ensuring non migration |
Fig. 4 : Dressing in place with filled leech |
Results
Microscopic observation revealed the eggs to be grayish oval/oblong in shape with few striations. The eggs were hatched into larvae measuring about 1 mm in length (Fig. 2). The larvae were creamy to light brown in colour and motile. The larvae were collected and transferred into sterile lukewarm sand within a protected, screened cage to pupate. The larvae developed into reddish brown coloured pupa measuring approx, 1-2 cm (Fig. 3). The adult fly develops within this puparium and emerged by rupturing the skin with the ptilinum. The newly emerged adult bears little resemblance to the familiar green bottle
little resemblance to the familiar green bottle but within a short while the wings expand and the body takes on its familiar green hue.
The adult flies were fed a mixture of honey, yeast and water insid e the cage. Temperature and humidity were kept stable well within the human comfort range. Gravid females laid eggs one week after emerging. Small cubes of meat were placed in the cage for egg laying. The meat was removed and the eggs were washed off into containers.
The external surfaces of the eggs are normally very heavily contaminated with bacteria. These must be removed or killed before hatching if the emerging larvae are to remain sterile. The eggs were disinfected using 0.5% sodium hypochlorite solution. The sterilized eggs were transferred aseptically into a sterile blood agar medium and placed in an incubator at 37oC for 24 hrs. Maggots were tested for sterility by culturing for aerobic organisms in Tryptone Soya Broth and in Thioglycollate Broth for anaerobes. Sterile maggots were kept viable for 5 days under refrigeration.
Discussion
Review of literature revealed the use of ‘Blowfly’ Lucilia sericata to be the most appropriate for maggot therapy for wounds healing.5 Maggot therapy could be used to clean festering and foul-smelling wounds. Maggots not only eat the rotten flesh, they also get rid of harmful bacteria in the wound.11 Maggots of the blowfly have been used to treat patients with infections from injuries like pressure ulcers (“bed sores”), leg and foot ulcers, stab wounds, and post-surgical wounds that don’t heal properly. Maggots can also be used successfully in a wide variety of wounds.
Using maggots heals wound faster than other non-surgical methods and does not injure healthy tissue. Maggots are implanted directly onto a wound, where they eat dead flesh, clean out dead skin, and kill harmful bacteria within 2-3 days and they’re removed from the wound, and new maggots are applied, if required. The larvae are introduced into the wound with the help of fine nylon mesh hydro colloidal dressing and absorbent pads. Apart from the above material hydrolysing agents such as varidase or scherisorb gel and semi-permeable films such as tegaderm are also used in dressing, depending on the type of wound.
A review of the literature has revealed no significant risks or adverse events causally linked with the clinical use of sterile larvae of Lucilia sericata. There is also a theoretical possibility that a patient could develop an allergic reaction to the foreign protein of the larvae but such an effect has never been reported. According to the literature, the principal disadvantage of larval therapy appears to be a tickling sensation. This sensation can be eliminated by preventing the larvae are from leaving the wound and migrating onto the surrounding skin by the use of an appropriate dressing system.12
In an age of increasing antibiotic resistance maggot therapy should be considered a viable alternative when, a wound becomes severely infected, does not heal, despite appropriate antibiotics and surgical care.
Conclusion
In our present study we successfully collected and identified the specific species of ‘greenbottle fly’ Lucilia sericata used for maggot therapy. We were also able to culture sterile larvae on the blood agar media in our first phase of study. Further, we plan to take up the maggot therapy to its clinical application in our second phase of the study to treat chronic non-healing wounds.
Acknowledgement
The authors acknowledge Dr. A Sundararaj, Veterinary Surgeon, Department of Laboratory Medicine, KJ Hospital, for his valuable help during the study and also Ms. Manju Alex, Microbiologist, Department of Laboratory Medicine, KJ Hospital for her valuable assistance in this study.
References
1. Church JC. The traditional use of maggots in wound healing and the development of larval therapy (biosurgery) in modern medicine. J Altern Complement Med 1996; 2 (4) : 525-27.
2. Namias N, Varela JE, Varas RP, Quintana O, Ward CG. A case report of maggot therapy for limb salvage after fourth degree burns. J Burn Care Rehab 2000; 21 (3) : 254-57.
3. Thomas S, Jones M, Shutler S, Andrew A. All you need to know about maggots. Nursing Times 1996; 92 (46) : 63-76.
4. http://www.worldwidewounds.com/2002/august/Thornton/Larval-Therapy-Acute-Burn.html.
5. Lee DJ. Human myiasis in Australia. Med J Aust 1968; 1 : 170-72.
6. Vistnes LM, Lee R, Ksander GA. Proteolytic activity of blowfly larvae secretions in experimental burns. Surgery 1981; 90 : 825-41.
7. Ziffren SE, Heist HE, May NA, Womack SC. The secretion of collagenase by maggots and its implication. Ann Surg 1953; 138 : 932-34.
8. Prete PE. Growth effects of Phaenica sericata larval extracts on fibroblasts: mechanism for wound healing by maggot therapy. Life Sci 1997; 60 (8) : 505-10.
9. Schmidt RJ, Chuny LY, Andrews AM, Spyratou O, Turner T. Biocompatibility of wound management products. J Pharmacy Pharmacol 1993; 45 : 508-13.
10. Sherman RA, Hall MJ, Thomas S. Medicinal maggots: an ancient remedy for some contemporary afflictions. Annual Review of Entomology 2000; 45 : 55-81.
11. Sherman RS, Pechter EA. Maggot therapy: a review of the therapeutic applications of fly. Medical and Veterinary Entomology 1988; 2 :
225-30.
12. URL:http:www.smtl.co.uk/WMPRC/Maggots/maggots.html. Thomas S, Jones M, Shutler S, Jones S. Maggots in wound debridement - an Introduction. |
