Medical Leech Therapy (Hirudotherapy)

Abstract

Leeches are a class of segmented invertebrates, known for their blood-feeding habits and used in phlebotomy to treat various ailments since antiquity. Hirudotherapy is the application of medicinal leeches for therapeutic use. The therapeutic use of leech therapy is an established method and dates back to ancient Egypt and the beginning of civilization. At the end of the 20th century new therapy concepts took the place of leech therapy. With microvascular surgery techniques there has been a “rebirth” in the use of medicinal leeches in recent years. Hirudo medicinalis has widest therapeutic usage among the leeches, but worldwide, many different species were tested and studied. Leech therapy involves an initial bite, which is usually a painless bite, followed by the sucking of 5 and 15 ml of blood. It’s major therapeutic benefits are not only due to blood sucked during the biting, but also from the various bioactive substances. Saliva of leech contains various bioactive compounds such as: eglins, bdellins, hirudin, hyaluronidase, calin, destabilase, apyrase, decorsin, hirustatin, tryptase inhibitors, and histamine like substances, complement inhibitors, carboxypeptidase A- inhibitors and acetylcholine. These substances are responsible for inhibiting blood coagulation, analgesic effect, dilating effect on muscles and regulation on immune system. Hirudotherapy has a broad spectrum of therapeutic application in the medical field ranging from cardiology, orthopedy, gynaecology, ophthalmology, plastic and reconstructive surgeries. This review presents an overview of leech including the history, general characteristics and mechanisms of action of leeches, and its application as medical device.

Keywords

• Medicinal leech,Hirudotherapy,Indications

Tıbbi Sülük Terapisi (Hirudoterapi)

Abstract

Sülükler halkalı omurgasızlar sınıfındadır, kan ile beslenirler ve antik dönemden beri çeşitli hastalıkları tedavi etmek için flebotomide kullanılırlar. Hirudoterapi, tedavi için tıbbi sülüklerin uygulanmasıdır. Sülük tedavisinin terapötik kullanımı köklü bir yöntemdir ve eski Mısır'a, medeniyetin başlangıcına dayanır. 20. yüzyılın sonunda yeni terapi kavramları sülük tedavisinin yerini almıştır. Mikrovasküler cerrahi tekniklerle birlikte son yıllarda tıbbi sülüklerin kullanımında bir “yeniden doğuş” olmuştur. Hirudo medicinalis, sülükler arasında en geniş terapotik kullanıma sahiptir ancak dünya çapında birçok farklı tür test edilmiş ve incelenmiştir. Sülük tedavisi genellikle ağrısız olan bir ilk ısırığı, ardından 5 ila 15 ml kan emmeyi içerir. Başlıca terapötik faydaları sadece ısırma sırasında emilen kandan değil, aynı zamanda çeşitli biyoaktif maddelerden de kaynaklanmaktadır. Sülük tükürüğü; eglin, bdellin, hirudin, hyaluronidaz, calin, destabilas, apiraz, dekorin, hirustatin, triptaz inhibitörleri ve histamin benzeri maddeler, kompleman inhibitörleri, karboksipeptidaz A-inhibitörleri ve asetilkolin gibi çeşitli biyoaktif bileşikler içerir. Bu bileşikler; koagülasyonun inhibisyonundan, analjezik etkiden, kas gevşetici etkiden ve bağışıklık sistemi üzerindeki düzenlemeden sorumludur. Hirudoterapi; kardiyoloji, ortopedi, jinekoloji, oftalmoloji, plastik ve rekonstrüktif cerrahi gibi alanlarda geniş bir terapötik uygulama yelpazesine sahiptir. Bu derleme sülükler hakkında; tarihçesi, genel özellikleri, etki mekanizmaları ve tıbbi bir cihaz olarak uygulanmasını içeren genel bir bakış sunar.

Keywords

• Tıbbi sülük,Hirudoterapi,Endikasyonlar

References

1. 1) Abdullah S, Dar ML, Rashid A, Tewari A.Hirudotherapy /Leech therapy: Applications and Indications in Surgery:ArchClinExpSurg 2012;1:172-180.
2. 2) Whitaker IS, Rao J, Izadi D, Butler PE. Historicalarticle:Hirudomedicinalis: ancientorigins of, andtrends in theuseofmedicinalleechesthroughouthistory:Br J Oral MaxillofacSurg 2004;42:133–7.
3. 3) Hildebrandt JP, Lemke S. 2011. Small bite, large impact – saliva and salivary molecules in the medical leech, Hirudo medicinalis. Naturwissenschaften. 2011; 98:995-1008.
4. 4) Bernard Aschner. Theories and Philosophies of Medicine. Institude of History of Medicine and Medical Research, New Delhi, 1973; 242-253.
5. 5) Weinfeld AB, Yuksel E, Boutros S, Gura DH, Akyu¬rek M, Friedman JD. Clinical and scientific consid¬erations in leech therapy for the management of acute venous congestion: an updated review. Ann Plast Surg 2000;45:207-212.
6. 6) Gödekmerdan A, Arusan S, Bayar B, Sağlam N. Tıbbi Sülükler ve Hirudoterapi :Turkiye Parazitol Derg 2011; 35: 234-9.
7. 7) Porshinsky BS, Saha S, Grossman MD, Beery II PR, Stawicki SP. Clinical uses of the medicinal leech: a practical review.: J Postgrad Med. 2011; 57(1):65-71.
8. 8) Wells MD, Ralp T, Manktelow RT, Boyd JE. Bowen V. The medical leech: an old treatment revisited, Microsurgery 1993; 14: 183–6.

9. 9) Galen ‘On the natural faculties’ translated by A.J. Brock, The Loeb Classical Library. Harvard University Pres, Cambridge. Massachusetts and William Heinemann, London, 1952.
10. 10) Papavramidou N, Christopoulou-Aletra H. Medicinal use of leeches in the texts of ancient Greek, Roman and early Byzantine writers. Intern Med J 2009; 39 (9): 624-7.
11. 11) Ibn-i Sina, El-Kanun Fi’t-Tıbb, Vol. 1, Translated by Esin Kahya. Atatürk Language and Culture Center, Ankara, 2009: 413-4.
12. 12) Rolleston JD. Francois-Joseph-Victor Broussais 1772 to 1832: his life and doctrines. Proc R Soc Med 1959; 22: 405.
13. 13) Adams SL. The medicinal leech. A page from Annelids of internal medicine. Ann Int Med 1988; (109):399-405.
14. 14) Erdemir AD. Folklorik Tıpda Sülük Kullanımı ve Evrensel Gelişimi. İstanbul Üniversitesi Tıp Fakültesi Mecmuası 1979; (42):523-29.
15. 15) Haycraft JB. On the action of secretion obtained from the medicinal leech on coagulation of blood. Proc R Soc London 1884; 36: 478.
16. 16) Okka B. Hirudotherapy from Past to Present. Eur J Basic Med Sci 2013;3(3): 61-65.
17. 17) Whitaker IS, Izadi D, Oliver DW, Monteath G, But¬ler PE. Hirudo Medicinalis and the plastic surgeon. Br J Plast Surg 2004;57:348-353.
18. 18) Mory RN, Mindell D, Bloom DA. The leech and the physician: Biology, etymology, and medical practice with Hirudinea medicinalis. World J Surg 2000;24:878-83.
19. 19) Singh PA. Medicinal leech therapy (Hirudotherapy): a brief overview, Complementary Therapies in Clinical Practice 2010; 16 (4): 213-215.
20. 20) Dwivedi AP. Case study of leech applicationin diabetic foot ulcer. IJRAP. 2012;3(5):748-51.
21. 21) Fort CW. Leech Therapy: Current Uses for an Old Treatment. Delaware Nurses Association (DNA) Reporter 2001; 26:16-17.
22. 22) Kozur H. Fossile Hirudinea aus demOberjura von Bayern. Lethaia 1970; 3: 225–232.
23. 23) Kutschera U, Roth M. Cocoon deposition and cluster formation in populations of the leech Hirudo verbana (Hirudinae: Hirudinidae).Lauterbornia 2006; 56: 5-8.
24. 24) Sivachandran P. et al An overview of leech and its therapeutic applications.Journal of Coastal Life Medicine 2015; 3(5): 405-413.
25. 25) Sağlam N. Tatlı Su ve Deniz Sulukleri Tanı Anahtarı, Elazığ: FıratUniversitesi Basım Evi; 2004.
26. 26) Todorov M, Grozeva S, Hubenov Z, Kenderov L, Trichkova T. Taxonomic status and distribution of medicinal leeches of the genus Hirudo L. (Hirudinea) in Bulgaria Acta zool. bulg., 2016; 68(2): 171-182.
27. 27) Kutschera U, Elliott JM. The European medicinal leech Hirudo medicinalis L.: Morphology and occurrence of an endangered species. Zoosyst. Evol. 2014; 91(2): 271–280.
28. 28) Sağlam, N. Tıbbi Sülük Hirudo medicinalis 'in (L., 1758, Hirudinidae) İncelenmesi, . Sümder Su Ürünleri Mühendisleri Derneği Dergisi, 1998; (1): 28-30.
29. 29) Sağlam N. Bazı Tıbbi Sülük Türlerinin (Hirudo medicinalis L., 1758 ve Hirudo verbana Carena, 1820) ihracatı, Korunması ve Sürdürülebilirliği. Jfscom, 2011; 5(1): 1-15 .
30. 30) Lone AH, Ahmad T, Anwar M, Habib S, Sofi G, Imam H. Leech Therapy-A Holistic approach of treatment in Unani (Greeko-Arab) Medicine. Ancient Science of Life. 2011; 31(1):31-35.
31. 31) Alam SS, Ahmad W, Yunus SS. Irsal-e-Alaq (Leech Therapy/ Hirudo therapy) in Surgical Diseases: A review. IJMR; 2016 (4):23-27.
32. 32) Sig AK, Guney M, Guclu AU, Ozmen E. Medicinal leech therapy—an overall perspective. Integr Med Res,2017; 337–343.
33. 33) Fields WS. The History of Leeching and Hirudin. Haemostasis 1991; (1):3-10.
34. 34) Electricwala A, Sawyer RT, Jones CP, Atkinson T.Isolation of thrombin inhibitor from the leech Hirudinaria manillensis. Blood Coagul Fibrinolysis1991;2:83-89.
35. 35) Bichler J, Fritz H. Hirudin, a new therapeutic tool? Ann Hematol 1991;(63):67-76.
36. 36) Zaidi SMA, Jameel SS, Zaman F, Jilani S, Sultana A, Khan SA. A Systematic Overview of the Medicinal Importance of Sanguivorous Leeches. Alternative Medicine Review 2011; (16):59-65.
37. 37) Johnson PH. Hirudin: clinical potential of a thrombin inhibitor. Annu Rev Med 1994;45:165-177.
38. 38) Hovingh P, Linker A. Hyaluronidase activity in leeches (Hirudinea). Comp Biochem Physiol B Biochem Mol Biol1999;124:319-326.
39. 39) Harsfalvi J, Stassen JM, Hoylaerts MF, et al. Calin from Hirudo medicinalis, an inhibitor of von Willebrand factor binding to collagen under static and flow conditions. Blood 1995;85:705-711.
40. 40) Nikonov GI, Titova EA. Destabilase complexes – natural liposome produced by medicinal leeches Hirudo medicinalis. Fundam Clin Pharmacol 1999;13:102-106.
41. 41) Abdisa T. Therapeutic importance of leech and impact of leech in domestic animals. MOJ Drug Des Develop Ther. 2018; 2(6):235‒242.
42. 42) Siebeck M, Hoffmann H, Weipert J, Fritz H. Effect of the elastase inhibitor eglin c in porcine endotoxin shock. Circ Shock 1992;36:174-179.
43. 43) Seemuller U, Dodt J, Fink E, Fritz H. Proteinase inhibitors of the leech Hirudo medicinalis (hirudins, bdellins, eglins). In: Barettand AJ, Salvesen G, eds. Proteinase Inhibitors. New York, NY: Elsevier Science Ltd; 1986:337-359.
44. 44) Seymour JL, Henzel WJ, Nevins B, et al. Decorsin. A potent glycoprotein IIb-IIIa antagonist and platelet aggregation inhibitor from the leech Macrobdella decora. J Biol Chem 1990;265:10143-10147.
45. 45) Hauptmann J, Kaiser B. Anticoagulant and antithrombotic action of the factor Xa inhibitor antistasin (ATS). Thromb Res 1993;71:169-174.
46. 46) Jung HI, Kim SI, Ha KS, et al. Isolation and characterization of Guamerin, a new human leucocyte elastase inhibitor from Hirudo nipponia. J Biol Chem 1995;270:13879-13884.
47. 47) Kim DR, Kang KW. Amino acid sequence of piguamerin, an antistasin-type protease inhibitor from the blood sucking leech Hirudo nipponia. Eur J Biochem 1998;254:692-697.
48. 48) Grumbine NA, Nicholas A. Feature: reviving an ancient therapy to manage chronic pain. Podiatry Today 2003;16:46-53.
49. 49) Tanyuksel M, Mumcuoğlu KY. Multidisipliner yaklaşımlı Biyolojik Temelli Doğal Tedaviler- Biyoterapi. Meta Basım İzmir 2017; 283-309 .
50. 50) Michalsen A, Roth M, Dobos G. Medicinal Leech Therapy. Thieme, New York. 2007;58-60.
51. 51) Rahul S, Swarnasmita P, Janhavi D, Bhuvan J, Shobhit P. Hirudotherapy – A Holistic Natural Healer: A Review IJOCR 2014; (2): 60-70.
52. 52) Mumcuoglu KY. Recommendations for the use of leeches in reconstructive plastic surgery. Evid Based Complement Alternat Med. 2014:205-29.
53. 53) Das BK. An Owerview on Hirudotherapy/Leech Therapy. İndian Research Journal of Pharmacy and Science 2013;1(1): 33-45.
54. 54) Isaac M. Leech Therapy: an introduction to a natural healing alternative. Bread Line Publishing, 2011.
55. 55) Yantis MA, O’Toole NK, Ring P. Leech Therapy, Hirudo medicinalis has made a comeback. AJN. 2009 ;(109):36-42.
56. 56) Duruhan S, Biçer B, Tuncay MS, Uyar M, Güzel S. Travma ve Plastik Cerrahi Operasyonları Sonrası Sülük Uygulamaları. Integr Tıp Derg 2014;2(2):32‐7.
57. 57) U.S. Food and Drug Administration Dept of Health and Human Services. http://www.fda.gov/fdac/features/2004/504_leech.html
58. 58) Geleneksel ve Tamamlayıcı Tıp Uygulamaları Yönetmeliği. Türkiye Cumhuriyeti Başbakanlık Resmi Gazete. 2014; 29158.http://www.resmigazete.gov.tr/eskiler/2014/10/20141027‐3.htm
59. 59) Gileva OS. Modern hirudotherapy: Experimental background and clinical efficacy. 8th International Conference on Biotherapy, Abstract no:22, November 11-14, 2010, Los Angeles, CA.
60. 60) Pooja K, Pareek RK, Vikas S. Clinical Assessment of Jalaukavcharan in Management of Varicose Veins IAMJ. 2014 (2); 199-204.
61. 61) Yakışan Maden RŞ (2015). Varis Tedavisinde Rutin Tedaviler ile Tıbbi Sülük Tedavisinin Karşılaştırılması (Uzmanlık Tezi, Atatürk Üniversitesi) Erişim Adresi: https://tez.yok.gov.tr/UlusalTezMerkezi/TezGoster?key=sY7m19PfcL6F1NUw-cr80KfCKaCYybIC8B7in6edEPCFq9esgnQO4ARd--pT4Kmp
62. 62) Lauche R, Cramer H, Langhorst J, et al. A systematic review and meta-analysis of medical leech therapy for osteoarthritis of the knee. Clin J Pain. 2014;30(1):63–72.
63. 63) Rai PK, Singh AK, Singh OP, Dwiwedi AK. Efficacy of leech therapy in the management of osteoarthritis (Sandhivata). Ayu 2011 Apr-Jun; 32(2): 213–217.
64. 64) Shiffa M, et al. Comparative clinical evaluation of leech therapy in the treatment of knee osteoarthritis European Journal of Integrative Medicine 2013(5); 261–269.
65. 65) Abdualkader AM, Ghawi AM, Alaama M, Awang M, Merzouk A. Leech Therapeutic Applications Indian J Pharm Sci. 2013; 75(2): 127–137.
66. 66) Knobloch K. Leeches in microsurgery – An evidence-based approach. In: Kini RM, Clemetson KJ, Markland FS, McLane MA, Morita T, editors. Toxins and Hemostasis. Netherlands: Springer Science; 2011. pp. 735–45.
67. 67) Shanker KMP, Rao SD, Umar SN, Gopalkrishnaiah V. A clinical trial for evaluation of leech application in the management of Vicarcikā (Eczema); Anc Sci Life. 2014; 33(4):236-241.
68. 68) Jahangir U, Akram M, Urooj S. Leech therapy in Dermatology. Journal of Pharmacognosy and Phytochemistry 2016; 5(3): 214-216.
69. 69) Mohammed AA, MohammadGA, Mohamed A, Mohamed A, AhmedM. In vivo anti-hyperglycemic activity of saliva extract from the tropical leech Hirudinaria manillensis. Chinese Journal ofNatural Medicines. 2013;11(5): 488-93.
70. 70) Dwivedi AP. Case study of leech applicationin diabetic foot ulcer. IJRAP. 2012;3(5):748-51.
71. 71) Gönen İ, Özşahin M, Turan H, Uslu M, et al. Acinetobacter Infection Developed After Leech Therapy In a Patient with Gonarthrosis: A Case Report. Turkish Journal of Geriatrics, 2013; 16 (2): 237-240.
72. 72) Pietrzak A, Kanitakis J, Tomasiewicz K, Wawrzycki B, Kozłowska-Łój J, Dybiec E, Chodorowska G. Cutaneous complications of improper leech application, Ann Agric Environ Med. 2012;19(4):790-2.
73. 73) Houschyar KS, Momeni A, Maan ZN, Pyles MN, Jew OS, Strathe M, Michalsen A. Medical leech therapy in plastic reconstructive surgery. Wiener Medizinische Wochenschrift 2014;164(5‐6):95‐102.
74. 74) Schnabl et al. Acute postoperative infection with Aeromonas hydrophila after using medical leeches for treatment of venous congestion. Arch Orthop Trauma Surg, 2010; (130):1323–1328.