Leeches and maggots: Doctors’ old-fashioned little helpers

From today’s Cleveland Plain Dealer

Featuring our colleagues Prof. AJM Boulton and Eliot Mostow.
pam-mitchell.jpgView full sizePam Mitchell says she wouldn’t be alive today if maggots hadn’t saved her feet from amputation 10 years ago. She’s had Type I diabetes since she was a child and suffered from deep ulcers on her feet as a result.

Most people’s visceral response to leeches and maggots is revulsion. That can change quickly when this old-fashioned medicine saves your finger, your foot or, possibly, your life.

Maggots saved Pam Mitchell’s feet and, she’s certain, her life 10 years ago. As the Springfield Township woman explains, “Yes, maggot therapy is kind of gross, but what would you do to save your feet from amputation?” Mitchell, who has suffered from diabetes since she was a child, has become an advocate for maggot therapy and gives talks around the country.

Doctors and surgeons at the Cleveland Clinic, University Hospitals and MetroHealth medical centers don’t commonly talk about it, but the hospitals do employ leeches and, to a lesser degree, maggots, when medically necessary. They are part of a specialty known as biotherapy.

The U.S. Food and Drug Administration gave official approval for the administration of both creatures in 2004 — making something old in medical treatment new again.

The FDA considers leeches and maggots “medical devices,” so they require a doctor’s prescription. To be used medically, they must be “germ-free” maggots and leeches, not the kind you’d scare up yourself in a pond or by the side of a road.

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  • How leeches are used to address the body’s ills has evolved over time
  • Leeches are particularly useful in two kinds of surgery — reattaching fingers, and attaching flaps of skin in reconstructive surgery — as the leeches help re-establish blood flow. Maggots can be useful in treating dying, or necrotic, flesh. The latter can happen as a side effect of diabetes, as in Mitchell’s case, or because of trauma to a limb, or even a staph infection.

    Dr. David Stepnick, a facial plastic surgeon at University Hospitals, often performs reconstructive surgery on the head and neck, which might involve attaching a flap of tissue, often from the forearm, in the reconstruction of a portion of the face or neck. Ideally, the blood flows immediately as it should, from the head and neck to the newly added tissue and back again.

    “If the vein becomes kinked or a clot develops in the vein, the flap turns blue because blood comes into the flap but cannot get out,” explains Stepnick. “The leech is used to temporarily restore blood flow through the tissues, thereby keeping the tissue alive until we’re able to get the patient back to the operating room.

    “A few times a year, I’d say, we use leeches to restore blood flow to an area after initial surgery,” he says.

    ‘–Leeches also work another way: A chemical in their saliva, called hirudin, is a blood thinner.

    When the leech bites, Stepnick explains, the hirudin is released. “Then even when the leech comes off, the bite continues to bleed, which is good.'”

    Dr. Harry Hoyen, a hand surgeon at MetroHealth, is also director of the Regional Center for Medical Leeches, housed at the hospital. That’s logical, because in hand surgery — say, the reattachment of a finger — it is sometimes difficult to establish blood flow.

    Hoyen explains that the leech center buys leeches from a leech farm (there are several in the United States) and maintains the leeches in the appropriate environment for them to thrive, so they are ready when needed in the operating room. Since MetroHealth is the area’s Level I adult trauma center, it is where patients who lose a digit or limb are likely to be sent for surgery.

    “If you replant a finger, you have to re-establish the veins,” Hoyen says. “It’s like the water supply that comes into your house, and the veins are like the drains. . . .–

    “You try to repair the veins in the replants, and sometimes it works, and sometimes not, because the veins are so thin.”

    So, he might attach a couple of leeches, “A leech –acts as a medical pump.”

    Hoyen estimates that he uses leeches in 10 percent of his finger-replantation surgeries, for between 48 to 72 hours. When a leech is engorged, it stops sucking and is replaced. Up to a dozen might be used in one case.

    Even in the operating room with medical professionals, Hoyen says, “There might be an ‘eww’ when we bring the leeches out. . . . ”–we’re used to sophisticated computerized devices. But it’s a serious adjunct to our procedures.”

    The use of maggots is similar in terms of efficacy, but different, of course, in that maggots consume dead tissue, not blood.

    The ick factor might be even worse, though, given the CSI lab-scene image that comes to mind, of maggots feasting on corpses.

    Doctors use maggots to go into a wound and digest dead tissue while leaving normal tissue alone. Most often, they are applied underneath an opaque bandage, so the patient doesn’t see them doing their work.

    As Cleveland Clinic staff dermatologist Dr. Edward Maytin explains, “In three or four days, they can clean out a wound.” Maytin is a research specialist in wound healing at the Clinic’s Lerner Research Institute.

    Maytin says on Civil War battlefields doctors saw what maggots could do. They noticed that some soldiers who’d been lying on battlefields with maggot-infested wounds began healing and their fevers were gone –because the maggots cleaned the wounds of necrotic flesh.

    Doctors working near World War I battlefields in Europe observed the same effect, and some began to use maggots therapeutically.

    Maytin acknowledges that the yuck factor for doctors and patients poses a hurdle, which helps explain why maggot therapy is not more widely accepted or used in hospitals.

    But, he says, in a case where antibiotics are not working, the maggots could be an adjunct for dealing with chronic wounds, such as foot or leg ulcers.

    “I’d love to see more research on it,” he says.

    In a 2007 research trial at the University of Manchester in England, maggots were used successfully to treat patients whose wounds were infected with methicillin-resistant staphylococcus aureus, or MRSA, the bacterium that is resistant to most antibiotics. Maggots cleaned up dead tissue and prevented spreading the infection.

    Professor Andrew Boulton, of that university’s School of Medicine, called maggots “the world’s smallest surgeons.”

    As in the case of leeches, it’s not just the maggots’ action of digesting the dead tissue that is effective. Scientists have isolated a key enzyme that maggots secrete, which speeds healing.

    While scientists are trying to translate the isolation of that enzyme to a wound-healing product, Maytin is one of many doctors who believes you might still need the living maggot to do the work.

    Debriding — or cutting away — necrotic tissue, whether mechanically or with maggots, is a prerequisite for wound healing. Necrotic tissue doesn’t just prevent healing, it creates a breeding ground for bacteria, which could lead to gangrene, amputation and possibly fatal sepsis.

    It was Pam Mitchell herself who persuaded her Akron doctors — orthopedic surgeon David Kay and dermatologist/wound-care specialist Eliot Mostow — to try maggot debridement. As amputation of one of her feet was imminent, Mitchell happened to talk to a friend who’d seen a special on The Learning Channel about the medical use of maggots.

    “She had two horrendous ulcers, one on each heel,” Mostow says of Mitchell. “I’d only done this once, which made me the local expert — but I still spent a half-hour telling her I didn’t think it would work because her ulcers were so huge and deep.

    “But she said, ‘What do I have to lose?’ And the maggots worked exceptionally well.”

    Says Mostow, whose office is in Akron, “In medicine, we often learn from our patients. Pam’s case was not just a story of maggots but about being flexible as a doctor.”

    maggots_miracles_and_me_cover.jpgView full size

    Since then, Mostow has used the therapy dozens more times, though he says it’s not apt for everyone or every wound. The maggots cost less than $100 per treatment, so they aren’t expensive. But, says Mostow, the treatment is best for patients “who are motivated. It can be uncomfortable, though nothing a Tylenol can’t take care of.”

    Mitchell went on to get certified by Monarch Laboratories in Irvine, Calif. — which supplies germ-free maggots — as someone who advocates for people receiving maggot therapy (a doctor has to write the patient a prescription for it first). She does that for free, considering it part of her role.

    “The maggots cleaned my wounds, helped them heal and close up,” says Mitchell, who ended up writing a book called “Maggots, Miracles and Me,” (available through Amazon.com).

    She’s certain that the therapy saved her life, because she has known a lot of diabetics who died either immediately after an amputation or within a few years.

    “I think biotherapy is one of the most underappreciated medical treatments there is,” she says.

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