Hirudo medicinalis-Anwendungen in der plastischen und rekonstruktiven Mikrochirurgie - eine Literaturübersicht

 

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Zusammenfassung

Die medizinische Anwendung von Blutegeln hat in den letzten Jahren eine Renaissance insbesondere im Bereich der rekonstruktiven Mikrochirurgie erlangt. Die venöse Stase kann durch die Anwendung von Blutegeln signifikant reduziert werden, was insbesondere beispielsweise nach Replantation von Langfingern günstige Effekte auf die Überlebenswahrscheinlichkeit von Langfingerreplantaten hat. Blutegel führen zu einer temporären Abnahme der venösen Kongestion, bis die körpereigene venöse Drainage wiederhergestellt ist. Sie leben in Symbiose mit Aeromonas hydrophila, die erst das Verdauen der Blutmahlzeit, die bis zum sechsfachen des Blutegelgewichts entsprechen kann, ermöglicht. Eine Vielzahl von antikoagulatorischen Enzymen tragen die Blutegel im Speichel wie den Thrombininhibitor Hirudin, Apyrase, Kollagenase, Hyaluronidase, Faktor-Xa-Inhibitor und Fibrinase I und II. Die Laser-Doppler-Flussmessung konnte einen signifikanten Anstieg der oberflächlichen Hautperfusion in einem Radius von 16 mm um die Bissstelle herum nachweisen. Nach der initialen Blutmahlzeit mit durchschnittlich 2,5 ml führen die antikoagulatorischen Effekte der Blutegelenzyme in den folgenden 5 - 6 Stunden zu einer weiteren Verbesserung der venösen Abflusssituation.

Infektionen während einer Blutegelanwendung sind bekannt mit Inzidenzen zwischen 2,4 % und 20 %, wobei gegenwärtig die Chinolon-Antibiotikatherapie favorisiert wird, um vor allem der Aeromonas hydrophila-Infektion zu begegnen. Anämie ist eine weitere Komplikation der Blutegeltherapie, sodass während der Anwendung Blutbildkontrollen stattfinden sollten. Neben den Fallberichten und Fallstudien zum erfolgreichen Einsatz des Hirudo medicinalis sind gemäß den evidenz-basierten Kriterien randomisiert-kontrollierte Studien nötig, um den wahren Nutzen der Blutegelanwendung in der plastischen und rekonstruktiven Mikrochirurgie zu bestimmen.

Abstract

Medical leech therapy has enjoyed a renaissance in the world of reconstructive microsurgery during recent years. Especially venous congestion is decreased using hirudo medicinalis application such as following replantation of amputated fingers or congested flaps. They provide a temporary relief to venous engorgement whilst venous drainage is re-established. Living in symbiosis with Aeromonas hydrophila, who can digest the sixfold blood meal related to their body weight, and a broad number of anticoagulant agents such as the thrombin inhibitor hirudin, apyrase as well as collagenase, hyaluronidase, Factor Xa inhibitor and fibrinase I and II, leeches decrease venous congestion. Laser Doppler flowmetry could demonstrate a significant increase in superficial skin perfusion following leech application 16 mm around the biting zone. Following the initial blood meal accounting for about 2.5 ml, the anticoagulant effect of the various leeches enzymes follows within the next 5 - 6 hours, which both account for the beneficial effects.

Infection associated with leech therapy is a documented complication of leech application, with reported incidences ranging from 2.4 to 20 % and a chinolone antibiotic is currently recommended to face the potential Aeromonas hydrophila infection. Anemia is a second adverse effect during medicinal leech application which has to be taken account with repetitive blood samples. Besides the successful applications of leeches in various applications in plastic and reconstructive microsurgery, randomized-controlled trials are pending to elucidate the value of hirudo medicinalis according to evidence-based criteria above from case series and case studies.

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Priv.-Doz. Dr. med. Karsten Knobloch

Plastische, Hand- und Wiederherstellungschirurgie
Medizinische Hochschule Hannover

Carl-Neuberg-Straße 1

30625 Hannover

Email: kknobi@yahoo.com