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Stanford Report, October 13, 1999

Stanford surgical helpers are out for blood

BY MITCH LESLIE

Thirty years of skin cancer operations had gradually whittled away William Rambo's nose, so he was delighted when surgeon Richard Goode, MD, promised to make him a new one.

But the retired Stanford professor of electrical engineering owes his new look to more than Goode's skill at molding a replacement nose from a swatch of Rambo's scalp. Because even before the anesthetic had worn off, stagnant blood began to swamp the relocated tissue, coloring it a sickly blue. To relieve the blood buildup and salvage the transplant, Goode was obliged to call for a rarely used but powerful therapy. He prescribed a course of hungry leeches.

That's right, leeches. After a century of exile, these slippery parasites have crept back to medical respectability, thanks to their unmatched ability to drain excess blood from injured tissue. In prestigious hospitals across the country, leeches are biting into patients who have undergone facial reconstruction, finger or ear reattachment, and even breast reduction. Leech therapy has even passed the test of scientific scrutiny.

Stanford pharmacy ordered 600 of the bloodsuckers last year, most of which were applied to patients at Stanford or loaned out to local hospitals.

If you're surprised, maybe even a little queasy, at the resurrection of this antique treatment, you've got company. Even the doctors who've counted on leeches for years say the astonishment hasn't worn off. "Here we are in 1999, and we're still using leeches," Goode said.

A professor of surgery with 30 years of experience in facial reconstruction, Goode began leeching just over a decade ago. He was initiated into the leech club by William Lineaweaver, MD, former associate professor of functional restoration at Stanford, who in turn had gotten the word from colleagues at Davies Medical Center in San Francisco. Lineaweaver, who now specializes in reconstructive hand surgery at the University of Mississippi, had converted reluctantly. "I was appalled when people started using leeches again. I thought, 'This is terrible; this is an icky gimmick,' " he said.

Zeal for leeches grew out of the ancient belief that an excess of blood caused disease. Many doctors preferred leeches as a painless and controllable alternative to simply slicing open a vessel.

Once doctors wised up to the true causes of disease and recognized that blood loss was not salutary and invigorating, leeches lost their license to practice. Except for sporadic use by a few diehards, leeches were banished to the gruesome relics display of medical museums.

Modern surgeons returned to leeching in desperation, after conventional therapies failed to dissipate the blood congestion that bedevils reconstructive surgery. Known as venous insufficiency, this complication destroys many a surgeon's handiwork. Venous insufficiency is a plumbing problem in which blood pools in damaged tissue because the veins that normally provide drainage have been severed. Unless the buildup is cleared quickly, the sluggish blood will begin to coagulate, spawning clots that can plug the arteries nourishing the tissue. If this happens, the tissue will starve and die.

When Goode and Lineaweaver see flesh turning puffy and blue, the external signs of sluggish circulation, they know it's time to summon a leech. "You can think of the leech as a substitute vein," Lineaweaver said. By drinking off the excess blood, leeches prevent clotting until new veins can sprout and restore normal circulation.

Leeches arrive for work on the wards in a small plastic container. Dark olive to black topside, with a mustard-colored belly, they are about one to two inches long. The job of applying leeches often falls to nurses, who handle the animals with tongs.

The benefits of the treatment continue long after the leech has drunk its fill and dropped off. To keep its liquid dinner flowing, a feeding leech drools into the wound a mix of chemicals that prevent clotting and dilate blood vessels. These substances ensure that blood keeps trickling from the wound for hours.

A single leech, which can swallow only about a tablespoonful of blood during its half-hour to two-hour meal, usually can't do the job by itself. Repeated sessions over several days or weeks -- involving a dozen or more leeches in total --are usually necessary.

Careful studies on animal and human subjects confirm that leeching outperforms drugs and further surgery. It nearly doubles the chances that a transplanted flap of tissue --like Rambo's nose --will survive. For a reattached finger in which the veins could not be rejoined, the improvement is even more impressive -- from a slim 15 percent to a robust 65 percent.

Leeches offer economic benefits, too. They are cheap --$4.75 to $6.50 apiece --and can survive for months with nothing more than simple quarters and a slightly saline solution to soak in.

Doctors like leeches. Hospitals like leeches. Health plans like leeches. But what about patients? After all, they are the ones who have to sit still while a slimy, ravenous parasite carves open their flesh and sups their blood.

With more than 20 years of leeching between them, Lineaweaver and Goode have never had a patient reject the treatment out of squeamishness.

Are patients merely gritting their teeth and enduring an unpleasant but necessary therapy? Quite the opposite. Many patients are surprisingly sanguine about the prospect of being parasitized --and some even feel affection for the leeches, said Lineaweaver.

Patients might yelp if they felt pain. But leeches bite painlessly, and their feeding causes no discomfort. Rambo confirms that while he could feel the leeches squirming on his nose and scalp, he wasn't aware of any other sensations.

After pulling off such a comeback, will leeches take on more medical roles, perhaps returning to their prominence in the mid 1800s? A mechanical leech under development could cut short the leech resurgence. Essentially an automated suction cup, the mechanical leech would drain blood without the risk of infection -- and it wouldn't frighten anyone. Goode said he would use an ersatz leech, but Lineaweaver doubted it could be as effective and cheap as the real thing. SR