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Leech therapy for complicated varicose veins

Indian Journal of Medical Research, Jun 1998 by Bapat, R D, Acharya, B S, Juvekar, S, Dahanukar, S A

R.D. Bapat, B.S. Acharya, S. Juvekar* & S.A. Dahanukar*

Accepted May 25, 1998

Several methods of limb bandaging have been described to reduce the oedema and enhance ulcer healing in complicated varicose veins, with varying success rates. Leech therapy has never before been tried for the same. We evaluated the effectiveness of medicinal leech therapy in producing venous decongestion, reversal of oedema, hyperpigmentation and healing of varicose ulcer(s). Whether the leech selectively sucks venous blood was also investigated. Hirudo medicinalis (medicinal leech) was applied to the area surrounding the varicose ulcer(s) in 20 patients with varicose veins with complications and the patients monitored for ulcer healing, and decrease in hyperpigmentation, oedema and limb girth. The partial pressure of OZ (PO2) of 7 patients' arterial and venous blood was compared to that sucked by the leech. After leech therapy all the ulcers showed healing, while 95 per cent of patients showed a decrease in oedema and limb girth. Seventy five per cent patients demonstrated a decrease in hyperpigmentation. The mean pOl of blood sucked by the leech was 40.05+7.24 mmHg, which was similar to the mean pO2 of the patients' venous blood (34.33+8.4 mmHg). Thus it appears from this study that the medicinal leech sucks venous blood and aids ulcer healing, and can probably therefore be used as an effective adjunct in the management of complicated varicose veins. This however requires further evaluation by controlled trials.

Key words Adjuvant therapy - complicated varicose veins - medicinal leech - venous decongestion

Varicose veins is a common disorder resulting in significant treatment costs and loss of man-hours, particularly when complicated. The exact cause for the skin eczema and ulceration that occurs with prolonged venous insufficiency is still under debate. Several theories have been put forward to explain the same, such as local tissue anoxia due to perivascular fibrin cuffing', white cell margination and trapping with release of free radicals and interleukin-12, etc. The basic defect seems to be low tissue capillary perfusion and anoxia, with tissue oedema being the most widely accepted cause for impaired capillary perfusion3.

All conservative therapy thus aims at reducing the venous oedema and improving oxygenation of the local tissues. This involves various methods of limb bandaging along with limb elevation. Some of the problems associated with limb bandaging are the long term costs; loss of elasticity; difficulty of self-- application; and allergic reactions.

Bloodletting [Raktamokshan] by application of medicinal leech [Jalaukacharan] as described in ayurveda by Sushruta4 is a novel approach, which may be complimentary to elastic stockings in controlling venous hypertension and oedema in patients with longstanding varicose veins with complications.

The reported beneficial effect of leech therapy in reducing oedema by bloodletting prompted us to conduct this study. Our aim was to evaluate the effectiveness of venous decongestion resulting in reversal of oedema, pigmentation and ulceration, and to investigate whether the leech selectively sucks venous blood.

Material & Methods

A prospective nonrandomized open study was carried out over a period of 24 months in the Ayurveda ward of the King Edward-VII Memorial Hospital, Mumbai with the approval of the hospital ethics committee. Male patients between the ages of 12-65 yr, with venous oedema, hyperpigmentation, and ulcers were potential study candidates. These consecutive patients were seen in our hospital by a single consultant. None of the patients refused to participate in the study. Patients with anaemia, diabetes mellitus, peripheral arterial disease, coagulopathy, any systemic illness, HIV, or HBsAg were excluded. At the time of admission, a profile of haemogram, biochemical investigations and serological tests for HIV and HBsAg was obtained. In all patients, a lower limb Doppler study was done.

Hirudo medicinalis, obtained from an ayurvedic pharmacist in Mumbai was used. The leeches were stored in a jar of water between uses. The coelomic cavity of the leech was ensured to be empty by the following: (i) Finger pressure emesis before and immediately after each application; (ii) five days of fasting of the leech prior to each application; and (iii) turmeric application to the mouth of the leech to induce further emesis4.

The leech(es) were applied to the area surrounding the ulcer(s). The number of leeches applied per patient depended upon the size of the leech, area of the affected part, and number of affected sites. The leech(es) were applied once in every three days. Once sated, the leech(es) fell off, the duration of application ranging from 5- 30 min. Each leech sucked about 20- 30 ml of blood, with a further mild ooze occurring for 1 -2 h after the leech fell off.

The limb was assessed weekly for change in oedema and hyperpigmentation, and scored on a subjective visual scale ranging from zero, representing normal, to 3 +, representing severe oedema and pigmentation. The results were analyzed using the Wilcoxan sign rank test. Limb girth measurements at the calf, ankle and foot were obtained weekly. The ulcer(s) were assessed once a week for healing, using parameters such as largest diameter, area, and appearance of healing margin, granulation tissue and epithelisation.

Blood was obtained from the coelomic cavity of the leech within 5 min of its attachment and analyzed for pO2 using the IL 1312 analyzer (Instrumentation Laboratory; Milan, Italy). The patients' arterial and venous blood samples were also obtained for comparative analysis of the pO^sub 2^ at the same time. This aspect of the study was carried out in the last 7 patients of the trial. The results were analyzed using the unpaired t-test.

Results

The total study population consisted of 20 males. The mean age was 43 yr. All patients had varying degrees of oedema and hyperpigmentation, and 19 had venous ulcers. The lower limb Doppler study done to determine patency of the deep veins revealed that one patient had deep vein thrombosis with postthrombotic limb. All the others had patent deep veins. Three patients had recurrent varicosities following surgery. The disease was bilateral in one of the patients. None had anaemia, diabetes mellitus or any other illness.

The number of leeches applied during each session ranged from 1-4 and the number of applications required per patient ranged from 2 -20 times (mean 8.1), depending on the area and severity of involvement. The applications were continued until ulcer healing or significant reduction in oedema.

All the ulcers in the study showed complete epithelisation.

Nineteen (95%) patients showed a decrease in oedema of the involved limb (as per visual score) with mean basal score of 1.9+/-0.72, decreasing significantly (P

Ninety five per cent patients showed a decrease in ankle limb girth, ranging from 0 - 4.5 cm. The distribution of decrease was as follows : 0 cm: 1 patient (5%); 0.5 cm: I patient (5%); 0.5 cm : 1 patient (5%); 1 cm: 4 patients (20%); 1.5 cm : 5 patients (25%); 2 cm: 4 patients (20%); 3 cm : 2 patients (10%); 3.5 cm: 2 patients (10%); and 4.5 cm : 1 patient (5%). On applying the paired t- test to the initial and final values, the mean basal score was 28.27 +/- 2.2, decreasing significantly (P

Fifteen of 20 (75%) patients showed a decrease in hyperpigmentation, with mean basal score of 2.13 +/0.35, decreasing significantly (P

The mean pO^sub 2^ of the blood sucked by the leech (40.05+/-7.24 mmHg) was similar to the mean venous PO2 (34.33+/-8.4 mmHg), P = 0.197 (not significant).

Discussion

Varicose veins and its complications are a common recurring problem. Management schemes for venous ulcers and oedema have been evolving through the years, with the primary goal of reducing oedema and enhancing tissue perfusion and wound healing. Typically, conservative management with a regime of double elastic stockings, leg elevation at rest and calf muscle exercises requires good and prolonged patient compliance, and has its own problems.

Leech treatment was first described in Sushruta Samhita in 2000 BC in raktamokshan (blood letting) by jalaukacharan (application of leeches), for haematomas, boils, abcesses, etc.4 Such therapy was also described as early as 200 BC for mental illnesses and headaches as reported by Adams and Lassen5.

Modern medicine has seen a resurgence of the therapy for reducing oedema in reconstructive surgery* and paediatric surgery7, thus favouring greater salvage of flaps and free tissue transfers. The rationale for such use has been that greater capillary perfusion and hence better tissue healing occurs due to decreased venous congestion and oedema following blood sucking by medicinal leech8.

Leech therapy, however, has never before been tried in the conservative management of complicated varicose veins with oedema, hyperpigmentation and ulcers. In the present study, it has been used to enhance healing of venous ulcers and reduce oedema and hyperpigmentation by getting rid of venous stasis.

The potential complications6 with such therapy are (i) wound infection by the gut flora of the leech; (ii) excessive bleeding; and (iii) wandering by the leech. None of these complications were observed in our study.

Another potential limitation to this form of therapy is the non-availability or limited availability of medicinal leech. We have overcome this by inducing gentle finger pressure emesis immediately prior to and after re-application of the same leeches, turmeric application to induce emesis and 5 days of fasting of the leech; this enables re-application of the same leeches. Posterior crop incision and serotonin insertion for 20 min has also been described to enable reuse of the leech9.

We have presented the preliminary data from an ongoing study. In this study, leech therapy effectively decreased oedema and limb girth in 95 per cent patients, decreased hyperpigmentation in 75 per cent patients and resulted in ulcer healing in all the patients, probably by the sucking up of venous blood leading to venous decongestion. However, extrapolation of these results for a more general use must be made with caution until a randomized, controlled, blinded clinical trial confirms the current results; this is the next part of our study.

References

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2 Moyses C, Cederholm-Williams SA, Michel CC. Haemoconcentration and accumulation of white cells in the feet during venous stasis. Int J Microcirc Clin Exp 1987; 5 311-20.
3. Arnoldi DD, Linderholm H, Vinnerberg A. Skeletal and soft tissue changes in the lower leg in patients with intracalcanean hypertension. Acta Chir Scand 1972; 138: 25-37.
4 Sushruta. Raktavistaran. In : Atridev [translator]; Sushruta
Samhita, 5th ed. Chap 25. New Delhi : Narendra Prakash Jain. 1981, shloka 12-5.
5. Adams JF, Lassen LF. Leech therapy for venous congestion following myocutaneous pectoralis flap reconstruction. ORL Head Neck Nurs 1995; 13: 12-4.
6. 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.
7. lat`olla AK. Medicinal leeches in the postoperative care of
bladder exstrophy. J Perinatol 1995; IS : 135-8.
8. Smoot EL, Ruiz Inchaustegui JA, Roth AC. Mechanical leech therapy to relieve venous congestion. J Reconstr Microsurg 1995; ll: 51-5.
9. West BR, Nichter LS, Halpern DE. Emergent reuse leech therapy: a better method. Plast Reconstr Surg 1994; 93: 1095-8.
Departments of General Surgery & *Pharmacology, Therapeutics & Ayurveda Research Centre Seth G.S. Medical College dc KEM Hospital, Mumbai
Reprint requests: Dr S.A. Dahanukar, Professor and Head, Department of Pharmacology, Therapeutics & Ayurveda Research Centre Seth G.S. Medical College & K.E.M. Hospital, Parel, Mumbai 400012

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