title: Leech therapy in flap salvage: Systematic review and practical recommendations.
abstract: BACKGROUND
  Medicinal leeches have been part of the therapeutic armamenterium of plastic surgeons for more than 50 years. While their use in hand surgery is a matter of course, their use in salvage of flaps with venous congestion remains facultative depending on teams.
  
  
  METHODS
  We conducted a systematic review of leech therapy for flap salvage between 1960 and 2015, analyzing 121 articles and subsequently taking into consideration 41 studies. In parallel, we collected data from 43 patients for whom leach therapy had recently been applied in treatment of venous insufficiency in pedicled or free flaps after revision surgery had failed to improve flap vascularization, or in cases where flap revision was not appropriate. The data collected pertained to relevant indications, treatment procedure, efficacy, adjuvant therapies, side effects and complications.
  
  
  RESULTS
  For this indication, the success rate of leech therapy ranged from 65 to 85% (83.7% in our series) according to the situations encountered. Optimal frequency of application ranged from 2 to 8hours, while average overall duration ranged from 4 to 10 days. The number of leeches to be applied can be determined depending on volume of the flap. In 50% of the cases reported in the literature, the patients required transfusion. Antibiotic prophylaxis against Aeromonas is highly advisable. A ciprofloxacin and trimethoprim-sulfametoxazole combination currently appears as the most relevant prophylactic antibiotherapy.
  
  
  CONCLUSIONS
  Hirudotherapy is a reliable treatment in cases of patent venous insufficiency of pedicled or free flaps (or when revision surgery is not recommended). Even though the relevant literature is highly heterogeneous, we have attempted to put forward a specific protocol bringing together dosage, delivery route, frequency of administration and appropriate prophylactic antibiotherapy. An algorithm for treatment and management of venous congestion and a practical information sheet have been placed at the disposal of plastic surgery teams.
authors.affiliation: Service de chirurgie plastique et reconstructrice, centre des brûlés, CHRU Lapeyronie, 325, avenue du doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France; Service de chirurgie plastique et craniofaciale pédiatrique, CHRU Lapeyronie, 34295 Montpellier, France; Unité de plaies et cicatrisation, CHRU Lapeyronie, 34295 Montpellier, France. Electronic address: drchristianherlin@gmail.com.
authors.forename: C
authors.initials: C
authors.lastname: Herlin
authors.affiliation: Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Rennes, 35000 Rennes, France.
authors.forename: N
authors.initials: N
authors.lastname: Bertheuil
authors.affiliation: Service de chirurgie plastique et reconstructrice, centre des brûlés, CHRU Lapeyronie, 325, avenue du doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France; Service de chirurgie plastique et craniofaciale pédiatrique, CHRU Lapeyronie, 34295 Montpellier, France; Unité de plaies et cicatrisation, CHRU Lapeyronie, 34295 Montpellier, France.
authors.forename: F
authors.initials: F
authors.lastname: Bekara
authors.affiliation: Service de chirurgie plastique et reconstructrice, centre des brûlés, CHRU Lapeyronie, 325, avenue du doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France; Service de chirurgie plastique et craniofaciale pédiatrique, CHRU Lapeyronie, 34295 Montpellier, France; Unité de plaies et cicatrisation, CHRU Lapeyronie, 34295 Montpellier, France.
authors.forename: F
authors.initials: F
authors.lastname: Boissiere
authors.affiliation: Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Picardie, 80080 Amiens, France.
authors.forename: R
authors.initials: R
authors.lastname: Sinna
authors.affiliation: Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Rangueil, 31400 Toulouse, France.
authors.forename: B
authors.initials: B
authors.lastname: Chaput
mesh_terms: D000333:Aeromonas; D000465:Algorithms; D019072:Antibiotic Prophylaxis; D006801:Humans; D006940:Hyperemia / Q000628:therapy*; D024763:Leeching / Q000379:methods*; D016879:Salvage Therapy / Q000379:methods*; D013524:Surgical Flaps / Q000601:surgery*
keywords: Biotherapy; Biothérapie; Flaps; Lambeaux; Leeches; Review; Revue; Sangsues