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o the Editor:A 2-year-old boy, born with polysplenia syndrome, esophageal

tresia, and tracheoesophageal fistula (TEF), who had division of theEF, end cervical esophagostomy, and tube gastrostomy in infancy,nderwent substernal transposition of a segment of midcolon, theuccess of which was threatened by acute venous congestion of theransposed colon. Because none of the usual maneuvers to improveenous outflow were successful (including reoperating to examine theesocolic vessels, enlarging the substernal tunnel, and ruling out to our

atisfaction both intra- and extracolonic venous compression), theervical end of transposed colon was exteriorized to permit continuingbservation. In the immediate postoperative hours, the condition of thexteriorized colon deteriorated alarmingly, becoming a deepening pur-le—swollen and turgid to the point of rigidity. Doppler pulsations,xcellent at the close of operation, were faint to the point of inaudabil-ty. There was every reason to expect that removal of the interposedowel would be required. Taking a leaf from the widely reporteduccess of plastic surgeons in salvaging tissues, the viability of whichere threatened by acute venous congestion, “medicinal” leeches

hirudo medicinalis) available through our pharmacy, were applied, 2resh leeches at a time, to the exteriorized cervical colon sequentiallyith improvement of color and consistency apparent within minutes.ithin 48 hours, the colon had regained normal color, consistency, and

apillary refill. Esophago-colic anastomosis was performed 31⁄2 weeksater. Postoperatively, an intractable anastomotic fistula required oper-tive closure and a long period of swallowing re-education was neededefore the child became independent of gastrostomy feedings. At age 7ears, he is an active little boy who eats a normal diet and is catchingp in height and weight. Results of a recent barium swallow show rapidmptying of the interposed colon into the right-sided stomach.

Bloodletting with leeches (hirudinea) has a tradition of over 2,000ears; however, in the twentieth century, the success of modernedical practice relegated these close relatives of earthworms to the

ringes of alternative medicine. In the past 35 to 40 years, leeches have

REFEREN

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egained respect as an adjunct in reconstructive operations in whichiability of free flaps or reimplantation of traumatically amputatedtructures such as fingers, ears, or scalp, is threatened by inadequateenous drainage.1,2 Venous insufficiency of a colon interposition canesult in life-threatening necrosis and may require innovative solutionso preserve the transplanted colon.3 Medicinal leeches (hirudo medici-alis) suck as much as a half ounce of blood at a feeding; the larger theeech, the more blood it extracts.4 Moreover, the leech introduces intohe bite wound an array of anticoagulants, including the potent anti-hrombotic agent hirudin, that results in oozing of as much as andditional 50 mL of blood from the site of the leech bite for hours afterhe leech finishes its meal.2,4 By these 2 mechanisms, leeches areffective, sometimes dramatically so, in relieving acute venous stasisnd allowing time for accomodation of venous drainage to arterialnflow. Although recent experimental studies in a porcine model oferformance characteristics of medicinal leech bites by Laser Dopplermaging4 have shown that surface perfusion increases in congestedissue were localized to a relatively small area around the bite, theffect in our case and in that of others1 suggests that the actualherapeutic effect of leech-induced bleeding extends much moreidely.

Anthony Shaw, MDClifford Ko, MDDepartment of SurgeryDavid Geffen School of Medicine at UCLA

James Tomlinson, MDDepartment of SurgeryUCLA Medical CenterLos Angeles, CA

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1. Weinfeld AB, Yuksel E, Boutros S, et al: Clinical and scien-ific considerations in leech therapy for the management of acuteenous congestion: An updated review. Ann Plast Surg 45:207-212,0002. Utley DS, Koch RJ, Goode RL: The failing flap in facial and

econstructive surgery: Role of the leech. Laryngoscope 108:1129-

3. Patel HD, Chen YC, Chen HC: Salvage of right colon interposi-ion by microsurgical venous anastomosis. Ann Thorac Surg 74:921-23, 20024. Conforti ML, Connor NP, Heisey DM, et al: Evaluation of

erformance characteristics of the medicinal leech (hirudo medicinalis)or the treatment of venous congestion. Plast Reconstr Surg 109:228-

35, 2002