Great. Thank you very much. I'm delighted to be able to do this webinar this evening and I hope you'll find it as interesting as I find this subject.

So we'll get straight into it. When it comes to maggot therapy, it's certainly, I'm sure you've all been aware of these sort of, sort of dramatic sayings that been in the newspapers about the We're heralding a post-antibiotic era where common infections and minor injuries are going to kill us, because of massive antibiotic resistance. And certainly in Sweden, where I work, we are extremely restricted about the antibiotics we're allowed to use.

And that's becoming more and more prevalent. In the States, you know, they, they're a little bit behind, but certainly within Europe, we're trying to be as responsible as possible, and we need to look for other ways to deal with multi-resistant infections. So, Maggot therapy has been around for a long, long time.

If you start to look back for, some sort of, indications previously, if you can go back as far as the Bible, and, with, Job, where his body was clothed in worms and scabs and his skin is broken and festering. So that's, the earliest example I could find. Certainly, Napoleon surgeon, as you can see, reported that in the French campaign in Syria in the sort of 1800s, that, that was noted that certain species of fly only consumed dead tissue and that wounds were seen to heal faster.

But it wasn't really documented or in any article at that point. It was really during the Civil War in America that people started to notice. The beneficial effects of maggots.

And this guy, Doctor Zacharias, you can see him on the left with a big cigar, reported that during the civil war that maggots in a single day would clean a wound far better than any agents, and he was sure it saved lives. I think During the Civil War, I think the last place you actually wanted to be was in one of their army hospitals. Then there was a sure way to die.

So some patients that were left out on the field, they couldn't, they couldn't get to them with broken legs and open, communitative fractures. They were, they're the ones that got the maggots, and they were, seem to actually do a lot better than, then people that went into the hospital. Certainly a bit later on during World War One, this guy William Bauer observed that soldiers again left for days when they couldn't get to these soldiers.

They were left on the battlefield in no man's land, they couldn't get to them. Those soldiers actually seemed to survive better with their open wounds because they became maggot infested and, and were debrided. And again, the last place I actually wanted to be was in the, these war clinics.

The sort of cigar seems to be a common trait at that time. I haven't picked that up, as a, as to help me with my maggot therapy, but, that's something for the future. That something more recent that anybody that's seen the film The Revenant, with Leonardo DiCaprio on the left, and the original guy on the right is Hugh Glass.

And he, if you guys have seen the film, this is where he was attacked by a grizzly bear, who was trying to protect her cub, and he was horrible, horrible scenes in the film. But in the real story with Hugh Glass, he was left completely torn apart and had to crawl for 200 miles with a broken leg. And he allowed, according to the reports, he allowed maggots to eat all the necrotic tissue in his wounds, and then helped him to survive.

So, as I said, Maggots have been around for a hell of a long time, so why did they go out of favour? Well, it was when antibiotics first came into the scene. Then, you know, that was the way to then cure all the infections, and maggots weren't seen, won't be very popular anymore.

But with the resurgence, sorry, with the multiple antibiotic resistance, now maggots have started to see a resurgence. And in 2004, maggots were FDA approved as a medical device. And in 2006, just in the USA alone, there were 50,000 maggot treatments on the human side.

So, it's only on the human side, they used a huge amount. These are the sort of indications. I'm sorry, I'm sorry if any of you are feeling a bit queasy this evening, but these are the sort of indications on the human side and most common way they're used.

And they're these pressure ulcers, diabetic ulcers, chronic multi-resistant infections, and sort of malignant wounds. And if you can see, And these sort of Diabetic type ulcers, very common with people with chronic diabetes. And then application of maggots, you can see the small larvae in the wound here, and then the wounds actually starting to heal and they removing all this chronic infection.

And this is a poor person that's had toes amputated again following diabetes and chronically infected wounds following toe amputation. These are maggots. I'll talk to you about this in a minute.

These are maggots applied within a bag, not the way I apply them, but that's one way you do them on the human side more, and then healthy granulation tissue following maggot treatment. So this is a common use on the human side. How do they work?

Or how do we think they work? 3 main mechanisms. One is, debridement, and that's a, that's a very important mechanism is, direct debridement of necrotic tissue.

And they do that by releasing, Proteases, colagenase, or this is a trypsin-like colagenase, which dissolves fibrin and necrotic tissue. And this is critical, of course, and they On the right species, they're unable to dissolve, viable collagen. And I'll get to that in a minute.

You know, you can't use any old maggots on different species, or you could get into big trouble. But that's the first mechanism, debridement. They have an antibacterial effect.

They produce antibacterial substances. They, they haven't really been identified yet, and they directly ingest bacteria. So that's the second mechanism.

And then the 3rd mechanism is that to stimulate healing directly by increasing pH and oxygenation in the tissue by literally by burrowing through the, the infected tissue, they increase oxygenation in the tissue and stimulate granulation tissue production. Those are, it's important to remember those three mechanisms. The maggots that we use are come from the common green bottle fly, Leuccilia seracao.

And we are taking advantage of this larvae phase. And it's during this larvae phase, which is only 4 to 7 days long, when they go through their feeding phase. This is the only time these are feeding and they you have to use them during that critical period when they have this sort of feeding frenzy before they pupate.

So that's worth bearing in mind. You need to, I'm sorry for this picture, but it's, it's just to explain that you need to use the right type of larvae, and you need the right type of host, because everybody has heard of fly strike in sheep, and that's also with Lucilia Serraatta. So, In horses and in people, the, the maggots are not able to break down healthy collagen.

But that's not the situation in sheep. Their collagen is a different type of protein, and you say, if you apply maggots to sheep, they will eat through the healthy tissue. So that's, that's really important.

How, what are the possible indications in horses, and how have they been used in horses? Certainly, the most common use that I've used, I've used them for, and we'll show you some examples now will be complex hoof disorders, chronic hoof infections that haven't resolved through more traditional methods. I've also used maggots in fistula Withers cases and sup supraspinous bursitis or polyval cases.

They're incredibly hard to resolve. If any of you had those cases, they're very difficult to control those infections, and some maggots can be useful there. And any, any chronically resistant infection.

If you have a an infection where you're growing a multi-resistant bacteria, and you've debrided it and it's not resolving, and I'll show you the a couple of cases like that, maggots play an extremely important role. I think one of the sort of take-home messages I'd like to get across this evening is, generally, maggots are seen as a last resort after everything else has been used, but I think we need to get to, we need to get to the situation where we actually put maggots in earlier and earlier. And we'll get far more successful cases that way.

So, where do we get them from? They're actually one of the most common source in, in, within Europe is a company called Bermond, which is based in Wales, and they have a subsidiary in Germany, but I order them from Wales, and they're extremely nice people, and you can, if you can call them before 2 o'clock, I can call from Sweden, I can call them before 2 o'clock one day. I get them delivered before 12 o'clock the next day.

They come by FedEx. And they, they're considering how much money is often spent on these wounds with dressings and bandages, it's not extremely expensive. It costs about 150 pounds for a treatment and that includes the delivery.

So, It sound might sound expensive, but it, these are very resistant cases, extremely difficult to manage. And if you can actually fix these horses, then it's a, and it's a, it's actually a cheap treatment. So I've mentioned before, there are, there are two ways to apply the maggots.

They're either applied, what is it, in a bag, and this is a bag of maggots, yeah. Or they replied as free larvae. And these are how, this is how they come as free larvae.

And if you, if you look very carefully at this image on the right, you can see these little tiny larvae are moving around. And when they arrive, this is how they arrive, they're only about 2 or 3 millimetres long. That's before they start feeding.

And I'll show you those images in a minute. But this is, and in horses, the main reason for using them in a bag on the human side is, is a is to, because people can't cope with this idea of free range larvae walking around their wounds. That it's more acceptable to keep them in the sort of tea bag, but you only get the benefit of the coogenases, really, and you don't get the benefit of them migrating through the wound and increasing oxygenation, and you don't get the benefit.

Of the, directly consuming bacteria. So for horses, I would recommend the free-range larvae and those, those are the type that I've used. There is a, there's actually only one really good publication on the horse side.

This was from Olivia Lepage. Now, and also getting quite old now, from 2012, where he looked at the use of maggots in 41 horses, and I think there's at least one donkey there as well. So it was Equis.

A combination of third world countries and, and in France as well. And he had 41 cases, you see, 9 ft cases, 15, limb wounds, 5 cases of fistulas withers, 5, varied abscesses, and 3 cases of wound breakdown following abdominal surgery, colic surgery. 5 of those 41 cases needed a second treatment, so pretty successful just with one treatment and resolution on infection in 38 of the 41 cases within a week.

So I think it's, it's very effective, and I've had very similar responses. The, the picture you can see on the right is a fold that had a fractured cannon bone. And, the plate became infected.

In the lower picture, you can actually see the plate slightly. And this is a chronically infected plate. And as you all know, until you remove that plate, you can, it's very hard to resolve the infection, but you can't remove it, or you'll destabilise your fracture.

So he applied maggots to this chronically infected case, and that was able to control the infection. He was able to leave the plate in long enough. Until the fracture was stabilised.

This is, I'd just like to present now a few of my cases, just to give you an idea of the sort of indications I've used them for. This is a, we have a lot of trotting horses in Sweden, standardbreds. This is a 3 year old trotting horse with a a non-healing.

Non-healing necrotic lateral sulcus. And this looks pretty horrible and in fact the horse was very lame. It smelt disgusting.

And I think it's, it's important just to look at this date of the 22nd of September. So keep that in mind. This was a few years ago, one of my first cases.

22nd of September. It had been debrided. Maggots, you cannot use maggots as your only treatment.

You need debridement. Debridement is so important, and I use the versagette, if any of you are aware of this hydrosurgery system, we use it on every single wound, and I use it in the feet as well. So I used the versaget, which brides the wound first, and that was my first way to treat this.

And it looked fantastic after debriding it, and two days later, it was disgusting again and smelt again. The problem with these foot cases is the infections are so deep that the briding the surface looks fine for a couple of days, and then the infection just gets out of control again. But I tried with debridement, and it didn't work.

So I ordered the maggots there. This is how they arrive in their little box with a little tube with the maggots in there. It's important.

They send them out the following day. You have 2 days to use them after they arrive. And they need to be, they can be kept at room temperature during those 2 days, but you need to get them into the wound within 2 days, because you only have a total of about 4 days.

So, ideally, you put them in the same day they arrive. And here you can see me, you mix them up with a little bit of saline. These will drown, so you, they can't be left in the saline, but you need to just get them out of the tube.

So you mix them up with a little bit of saline, and they, here they are on the swab. And then you need to be quite inventive about putting them into a foot. You need to sort of, seal off the rest of the foot.

You need to stop them from escaping. And this is the, the foot now pre preparing the foot for the maggots. And now I've placed, this is the, the, the swab, the gauze swab with the maggots, face down into the wound.

And then I'm sort of putting some plaster of Paris. I was a bit nervous about using plaster Paris the very first time because I was worried I was gonna, they wouldn't be able to breathe because they need oxygen, but it wasn't a problem at all, and I'm not concerned about that now. And then I used the sort of protective heel, rubber heel to just stop the horse from squashing the maggots.

So you need to think about these things. You leave them in for about 3 days. They, the company recommends 3 to 4 days.

I, I generally need them in 3 days to feed. And then after 3 days, you get them out. And we just then covered it in silver tape to protect the foot a little bit more.

And this is what they look like now when you take them out after 3 days, you can see the dramatic increase in size. They're like more than 2 centimetres long now, and When you open up the wound, these, they go, you need, you can't be too squeamish. They go crazy.

They crawling out of the tissue, they're crawling everywhere. But you just flush them out as soon as you open up the wound, they, they tend to come out. You flush them out of the wound, and then you just lightly debride the wound again, which is what we're doing in the image on the right.

And then dress it in a normal way. I treat hooves like body wounds. I dress them with the same sort of dressings that we use, foam dressings, in this case.

Then cleaning the, the wound now, as you can see, the, the frog is starting to look very healthy and starting to get healthy, firm horn growing. And this is on the, I sort of wanted you to bear in mind the date, but I'll remind you, the first, when we applied the maggots, it was the 22nd of September, and this is now the 6th of October. So this is just over two weeks.

We now have healthy horn, and then on the right picture, we've just filled that in with some artificial plastic horn. So a really successful case and the horse never looked back. Another case, just to give you a different sort of scenario, this was a 10 year old Swedish warm-blood horse.

Chronic infection following foot penetration. So it had a foot penetration and a necrotic, part of the pedal bone. And we, I removed that at surgery, I removed a little, a small sequester from the pedal bone and debrided it, but it was, it remained infected.

And I debrided it multiple times, and it just, again, the infection just keeps coming back again and again. And now that I've used maggots more and more, I start to, Put them in earlier and earlier because you can't, you can't It costs so much money to keep going back again, you doing the same thing again and again. You need to recognise, when things are not working.

And my old professor used to say, you know, if something's not working, try some, try to do something else. Don't just keep doing the same thing again and again. So, I, I start to use maggots earlier and earlier.

But this is, again, this, we put a shoe on this, egg eggbell shoe, and then I'm using, this is farrier potty, just to try and create like a dam to seal this off from the rest of the foot to keep them in place. As I said, you need to be quite inventive. And then I'm just filling up the soul with this, it's another, it's called EquiPack, which is another Ferrier compound.

It forms like a gel. And I'm just using the. This farrier potty to seal it off, to allow me to create this equi pack.

And now I've created a nice area to put the maggots in. I'm just using the, the versajet again, and I apologise for the, how loud this is, but this is just using the versajet to debride it. And then, And then again, this is the, this gauze that they provide, which allows the maggots to breathe and I've just inverted the gauze and putting the maggots straight in.

And then I'm sealing it off. They provide you with this, this, this dressing which is very sticky and just allows you to sort of like seal in the gauze. And that that dressing is really useful.

It's called duoderm, and they give you that with a kit. And then we put a hospital plate on this one. And that, that works extremely well.

If you can put a shoe on, then you can put a hospital plate on. The first case, it wasn't possible to put a shoe on because it involved the, the heel bone. But that worked very well.

And this is the, these are the maggots again, at the time of, plate removal after 3 days. These are the maggots come. There was a, a little video of that, but it doesn't seem to play now.

But those are the maggots. And then again, the brid it, I've debrided with the versagegette. The maggots are, are eating all of this necrotic tissue, and they're producing all these collageinases, but they don't, they don't, not, you know, that necrotic tissue doesn't just disappear.

A lot of it is still there, but it just requires a, a light debridement then. When you remove the maggots. So there's the maggots removed and then this is within 10 days.

I've now got, Healthy horn covering the bone, and this horse went back to work within 4 weeks of the surgery. So You can, it can be extremely effective. Just to show you that I don't only use them on foot cases, although it is the most common indication.

This was quite a dramatic case I had about two years ago. This was a 17 year old Icelandic horse. We have a, a lot of Icelandic horses in Sweden.

I don't know how popular they are in the UK, but they're, they're very, very popular in Sweden. So this is a Icelandic horse, which unfortunately, suffered this quite dramatic, bilateral mandibular fracture, and you can see it's severely, displaced. Completely unstable.

And to repair that sort of fracture, you can You can use a plate, two plates, or my method of treatment in this case was to, initially, I repaired it with a, an aluminium U bar and then intraloural sol wire. So this is my repair. You can see that this is, you can just about see radiographically, the aluminium bar here and then solge wire holding it together, and it seemed like it was good.

But Not everything was going well, unfortunately. So, the horse came back after a few weeks, horribly infected. Unstable And I had to, I had to remove the, the U bar.

I put, I had to then replace that with the plate and screws instead because it was unstable. I cleaned it all up, put the plate and screws in, but Inevitably, it remained infected and unfortunately, grew multi-resistant bacteria, not MRSA but a multi-resistant Staphylococcus still. I couldn't, a little bit like that case of Olivia Lepage, I couldn't remove the plate.

If I remove the plate, the fracture is unstable, and I would need to put the horse to sleep. So what I needed to do was come up with some way of controlling the infection long enough for me to, for the fracture to stabilise. And in the head, it's such a good blood supply there, they will stabilise if they're not, if the infection is under control.

So we Decided to, you can see that you can see the plate exposed here and the screws, you know, it's, it's scary, really. And then we put maggots in this. And again, you have to be a little bit inventive, trying to keep them in place.

This is this duoderm dressing, which is very sticky and helps you to place this barrier. And we put the maggots in, they were in for 4 days. The infection was controlled and allowed me to keep that plate in for another 6 weeks, and I had a stable fracture and complete wound healing, and extremely happy.

Very very happy owner and extremely happy horse. This is what Icelandics look like. They've got cool haircuts.

So, a, a really nice case where we managed to save the horse, despite multi-resistant infection. Just another example I'd like to mention is very difficult to manage, . Supraspinous, bursitis cases, it used to be called polyval.

These are chronically infected bursa, and they're, they're extremely difficult to manage because This is a fistula. I think I've got a A he a hemostatin place just to show you that this is a chronic fistula inside this, bursa, chronically infested infected bursa. And you can imagine.

The bursa sits, sits under the supraspinous ligament. It's incredibly hard to get drainage. For a burst, you know, to control this infection, you need to drain it.

If you want to drain this, you're gonna have to Cut a, you know, make an incision straight through the muscle to get down to it, and then you're gonna have infected fluid draining through the muscle. It's, it's, they're really difficult. I tried lavaging it multiple times.

I did this arthroscopically because there was a report on that, and I put in XNL ceftihore in there. And it, it, I got a response from it, and I was quite hopeful for about 2 months, it seemed to be doing well. And then after a couple of months, the infection just came back again, started to heal, and then it just burst out.

The owner was getting Very frustrated. She was really dedicated to this mare. She had bred the mare, it was a really good bloodline, and she just wanted to do everything to save her.

And it was, I think it was like the 2nd case I'd used maggots on. So it was a little bit of an experiment at that time. But we put the maggots in.

It's very important. If you're, I mentioned at the beginning that maggots need to, they need to breathe. And they, they will drown either in a lot of exudate or in, in the saline you put them in.

But they certainly can't, they can't cope with a lot of exoate. So What I did, what you need to do if you have these supraspinous bursa cases, this just, this just shows the maggots that I've sort of like put in about 10 mLs of saline, and then I'm using a 100 mL syringe with a conical end, so that I can inject them really into the bursa. But you can't, you can't just inject them in there and leave it swimming in the soup of exudate and saline.

You need to provide some sort of drainage. So I, I made a, an additional drainage hole, . With and put in a Penrose drain.

So there was a route for the exudate to escape. But I sealed it off enough so that the maggots weren't able to come out. But you need to provide some way for oxygen to get in and for exudate to get out.

Otherwise, they'll just, they'll drown straight away and you'll have wasted your time. But we, they're, they're, they're quite challenging to manage and to, to sort out those complications. So we debrided following the magnet therapy again.

I used the verge to debride it, and then we resolved the infection and complete healing of that fistula after two months. And the horse hasn't, this is not, it's actually, I've written 2 years here, this is actually 3 years further down the line, and the horse has never had a, a problem again. Which is again just showing injecting the maggots in, and then covering up with this duoom dressing before making a drainage, a drainage hole.

And then, and she went on to have a fall and, just horse and hound were interested in that case and last, quite dramatic. The last chance, maggots saved my much loved mayor's life. So it was a, it was a really lovely case, and the owner and I are quite close friends now and the And she's proceeded to have 2 more falls after this.

So it's, you can save some of these cases, but And supraspinous bursitis or and fistulous withers cases, they are, if any of you have managed those cases, they are extremely hard to get under control. And some maggots can play a real role here. Before I move on to my next subject, I just, yeah, I think my sort of the take home message here really is.

They play, they play an important, certainly an important role in chronic foot infections. You need to start And I, I've used them several times, but you need to start using them earlier and earlier in these cases and not use them as a last resort. It's not like the sort of, you know, everything should have steroids before they die.

Not everything should have maggots before they die. You need to get in there earlier and earlier. As soon as you see these wounds that you've, of course, you need to, they, they're not an excuse for good debridement.

You need to debride really well, but as soon as you have a case that is You've debrided, the infection is coming back. Deep rooted canker cases. I've treated really nasty canker cases.

I had a horse last year with canker in 3 out of 4 legs, and we managed to put maggots in all 3 legs, and we fixed that horse as well with one treatment. So there are a lot of indications besides the feet, but you need to get in there earlier and earlier. Great.

I'll just take a quick drink of water and then I'll move on to the next subject. I can probably just slow down a little bit because we're doing quite well for time. Next, the next thing I want to talk about when it comes to, still, if you look up biosurgical.

Therapy on the internet, they only talk about maggots, but By surgical therapy is the use of a living organism to aid wound management. And the next subject I want to discuss. Certainly not used very much on the horse side at all, but used quite routinely on the human side, is the use of, medicinal leeches.

You might, not use, I say, not as many indications and something more, I suppose, more, useful within a hospital-based clinic, where we're seeing these sort of, terrible wounds that are referred to us, but certainly have a place, very labour intensive. It's not the sort of thing you're going to do on a daily basis, but I wanted to just show you what can be done with them. So We, I certainly see this sort of thing, several times a year.

This is a large skin flap on the forelimb of a horse, upper forum, and The problem with these sort of skin flaps, as you all know, you, we all want to close them. You don't want to leave this, you know, if you have this big flap of skin, we can't, we don't want to leave that and cut it off. We want to close it.

But when you have a distally-based flap, the chances of this flap surviving are quite poor. So complete or partial necrosis is a common complication. As you all probably know, the arteries and limbs, run from proximal to distal.

They don't run from distal to proximal. So as soon as you have a distally-based flap, and then you suture this flap back up. The blood, blood supply to that flap needs to be provided by underlying, the underlying tissue here.

So they can get a blood, the flat can get a blood supply from the underlying tissue, or it can get it from vessels that are crossing the suture line. And most of the time, When we put a lot of sutures in to close this wound, we're probably occluding the space for most of the vessels to come through. So it's, it's, it's, it's a tough call for this flap to remain viable.

The most venous congestion. Certainly on the human side and on the horse side is a common problem. So venous congestion is when the blood, venous outflow becomes obstructed, and then you have the continual arterial flow, but venous obstruction.

And because of that continual arterial flow, you get edoema, microthrombi forming, and then, further ischemia and tissue necrosis. And this, this scenario of venous congestion is one of the common reasons why, things like, and I'll show you in a minute on the human side, the transplant, transplants fail on the human side because of congestion. And so, Sort of have, I've seen these pictures so many times, but I apologise if they're a little bit gory.

But this is, this is where leeches are used on a routine basis on the human side. So, you know, a bad Friday night out in Glasgow, apologise to anyone that comes from Glasgow, but This is a young lady that's had her, I'm not sure how this has happened, but she's had her ear severed. It's, it's a little bit freaky, but she still has the little, diamond in the ear.

And when the ear was repaired, I think she, she decided to put the diamond back in again. But this is, this is a typical sort of case ear a sort of an ear severed, and that they need to be sutured back on. But you can imagine the sort of microthrombin in this ear, and Making it very difficult for, blood vessels to revascularize this.

So it's routine to Use leech therapy to decrease this venous congestion and tissue necrosis during reconstructive surgery. So they'll place the, they'll suture the, this, in this case, suture the ear back on, or in this case, digital replantation, suturing, digits back on after they've been severed, and then they'll put leeches on at the time of surgery. And that's, that's the critical.

This is why it's difficult for us as vets. And I'll, I'll, I'll get to a minute how you order these and how you use them, but it's Big hospitals will have leeches available all the time at the hospital waiting to be used. You know, for the occasional case that we get, that's, that's a little bit hard to manage.

If you're gonna, there are cases where you could wait 24, it only takes about 24 hours to get these leeches sent as well. So if you can just delay the surgery by 24 hours, you can have the leeches there for the time of surgery as well, which I've done. But it's, it's, it's a little bit more fiddly.

So, but again, main indications of the human side are facial reconstruction. Just an example is the area and digital replantation. There, that's where they will be used routinely.

On the veterinary side, there is, there is no, there is no report on, on the equine side at all, but there are a couple of case, reports of the use of leeches for oral hematoma in dogs. I've never been a small animal vet, but I know, I know these can be a problem, and then you can use leeches to try and decrease the hematoma and decrease all the edoema. In, in these oral hematoma cases.

How do leeches work? There are two main reasons, two main methods how they increase blood flow. Number one, anticoagulant activity.

This is how leeches feed. They feed by producing an anticoagulants. And these two anticoagulants are heroin, which inhibits thrombin, and kalin, which binds to collagen.

So that's, that's one of the main methods of increasing blood flow. And the second is producing histamine, which leads to vasodilation. So the two mechanisms of action.

The Where you can get these from. For some reason, I'd, I'd like to go and visit this part of South Wales because The maggots and the leeches, they're not the same company, but they, they almost next door to each other in South Wales. So I'm tempted to do a little road trip to visit the leech place and the maggot place at the same time.

But this was established a long time ago in buyer farm leeches, again supplying leeches to most of Europe, established in 1812. Can you believe it? And there again, Extremely nice people to talk to and we'll send you them very fast.

Within Europe, they have subsidiaries, and I can, I can obtain leeches within Sweden, and in most European countries, you can get them within your own country. You don't need to get them from Wales, but obviously, if you're in the UK, this is where you'll get them from. And you need to order them, .

You need to sort of estimate how many you need. And, and then they cost about around sort of 10 pounds each, but you don't need, depends on the size of your wound, you don't need so many. And again, it sounds, they sound like quite a lot, but compared to all the The amount of money that you're spending on these cases, initial surgery, all the bandage changes, it's a very small percentage.

And if you can get a successful outcome, you're saving the horse a long, long time of rehabilitation. Just the sort of protocol you need for these leeches, they need to be kept in a warm environment before application. If you're not going to apply them directly, then you can put them actually in the fridge, and that slows down their metabolism.

But before you apply them, they need to be kept at about 37 to 40 degrees. So if you have a a warming cabinet for fluids, that's perfect temperature. And then you need to apply them to the flap, and you can encourage them to feed.

They're, you know, they're, they are starved. They're extremely hungry when they arrive. And you can encourage them to feed by just stabbing the skin with a needle to get a little bit of blood flow.

What's, I didn't realise, but they, how leeches work. But what they do is they They feed for about between 20 and 90 minutes. And when they've stopped feeding, and when they're completely engorged with blood, they, they drop off themselves.

So you, you attach them to the wound. And you let them engorge, and I'll show you the, a case of mine, and then they drop off. There is no standard protocol that I've found on the human side, but generally, what they seem to do is, place them at the time of surgery, and then once daily for several days after surgery.

That obviously becomes quite expensive and cost is not such an issue on the human side. But again, it depends on the size of the flat because They suggest 1 leech per every 3 cm squared of venous congestion. But for a normal size flap, you probably just want 5 or 6 leeches and It's, it's not a huge amount of money again, considering in when you put it in perspective.

This is a case I'd like to just show you. I've done a few cases, but this one was quite interesting. This is a, a 10 year old warm-blood gelding that had this acute wound on the dorsal aspect of the fat lock.

So this is the horse had surgery. This is the hoof wrapped up. The proximal part of the limb is here.

The horse is lying in lateral recumbency. And this is, I hope you can all see, this is the wound. And, and this little flap, and I was at this time, I was just playing around.

I wanted to try them. I mean, You know, this flap was pathetic and, and hardly had a blood supply. And, in most cases, you would just remove that.

But I wanted to When it it's a whole different lecture, but when it comes to wound healing, my philosophy is to close everything. I want to use the horse's original skin. I want to close absolutely everything and avoid secondary intention healing, which is so slow, and you get very poor quality skin anyway.

So I had this oval-shaped flap about 5 by 2 centimetres with a medial base and very poor blood supply. I thought if leeches can work here, they can work anywhere. This is, debriding the wound under anaesthesia with the versage again, get nice bleeding again.

The flap was actually surprisingly, was still warm, and I was getting some venous bleeding. So I sutured the flap. This is the flap suture back in place and applied 4 leeches to the surface.

You know, what you need to do is, you know, the leeches will start to go everywhere. You need to sort of give them a little bit of a clue of where to attach. So I've just, I used a sterile plastic cup that I've sort of gas sterilised, and then made a little hole so that the leeches have a bit of a target.

And then these, these are the leeches coming out of their little cup. It's very hard sometimes to see, to know which is the head and the tail. But generally, they come out to say hello, and this is the head here standing up on its sort of on its butt at the other end.

And so you can work because you need to know which is the head because you need to know where to place, which end to place on the wound. And you can pick these leeches up with a A sort of, a pair of forceps without any teeth, just gentle sort of forceps, you can pick them up and place them on the wound. And so here's the, here's the leeches now placed on the wound, they've started feeding.

You need to be quite patient and get, getting them to attach, and give them like a bit of guidance of where to go. But once they attached, they start, you can see them like pumping away. There's like a peristaltic pumping in them and as they suck the blood.

This is, it's a little bit, I, I like them and I like the look of them. I think they're, they're beautiful, but not not to everyone's taste. But you can see this is 4 leeches attached to the wound, and they're completely engorged with blood, and they're about to drop off.

I repeated this. But, oh yeah, sorry, this is interesting. This is This is one thought to be one of the main, this is what you want to see when you're, when the, when the leeches drop off.

You can see this sort of free bleeding now from the wound. And this bleeding can carry on for a couple of hours after leech removal because of the anticoagulants they've produced. But this is a really good sign.

So you allow this free bleeding after leech removal, and then we repeated it. We took the leeches off. They can actually You can keep the leeches in the fridge for up to 3, they take about 3 months before you can, before they can feed again.

But if you're careful with them and you clean their water, then you can use them again in about 3 months. And I kept them for funds like pets for about 3 months, but I didn't have a suitable case again. So I eventually had to kill them.

But, but you can use them again. But I, I used, Some more again with the horse standing after 48 hours. And again, using a similar little cup, we applied the leeches again to the wound after 2 days.

And then I put on a half limb cast because I needed to immobilise this wound because there was so much mobility. Yeah. I put on a half limb cast, and then this is the horse 4 weeks after the injury, and I think, I mean, I think, I think you can see that it's pretty impressive, really.

We've got hair growth already coming back. There's a little bit of area that needs to grow some hair, but fantastic, healing after, after 4 weeks, I think, and complete survival of that flap. So I think If If it can work in this case, it can work in some of these big flaps.

And I've used it in a couple of larger flaps. But as I said, the problem I have with the leeches compared to the maggots is that it's just the logistics of it. You know, the horse comes to us in the middle of the night with this big flap.

It's You need to get that. You can't leave the flap hanging. You can't sort of say, well, I'm just gonna call Wales tomorrow.

We'll get them in a couple of days and you've got this flap that you need to still deal with. I think, by that time, the flap is probably necrotic anyway, has lost its blood supply. So I think You need to be able to get them really fast, and we don't have that sort of situation they have on the human side where they're on site all the time.

But If you have the ability to maybe just tack the flap in place, you can get the leeches, they can make a dramatic difference to these difficult large distally-based flap cases and increase the survival of the flap and get complete healing. Great. That's, that's the end of the, of my talk.

A little bit, a little bit early, but there's plenty of time for any questions you might have, that you might have had during the talk or you might think of some now. So I'm, I'm happy to accept any questions. Fantastic, thank you, Dylan.

Really, really, fascinating topic today and I'm sure many of you joining in have taken a lot of your useful pointers from there. We have had a number of questions coming in already. So I will start with them very shortly, but as Dylan says, we have, got about 9 or 10 minutes left.

So please do if you've got any questions or just want to share your thoughts on what has been discussed this evening, then please do pop that in and I'm happy to read that out. So let's have a look what we've got here. .

First question is from Jose. He says, can we still use maggots if the horses have been treated with ivermectin or analogue? Is there any guidance around that?

Yeah, I mean, I think that's a, that's a really good question. I think certainly, I mean, I've been, I've also been asked, you know, can you, can you use maggots if the horses are on systemic antibiotics and they, you know, there are, you have a lot of antibiotic in the wound and certainly, In that case, I would, I want the horse to be off antibiotics. I mean, anti, you know, we, in these cases, antibiotics are a waste of time anyway, and I, I don't mean to divert from your question, but it's a good point anyway.

I'm glad you made it, because you shouldn't, these horses should not be on systemic antibiotics at the time of treatment, because you don't want antibiotics, concentrated antibiotics in the wound. The horses, of course, should not be on. Any, on ivermectin or any of those sort of products prior to treatment.

But I think It's a good, it's a question that I, I would, I don't know the exact answer. You certainly, what I don't know is how long the horses need to be, how long you can have, how long the, the treatment with ivermectin can be before you can use leeches. And if it's possible, I don't know if it's possible, I can, I can maybe answer that question.

I can or I can send an email. To webinar and answer that question. I don't know if that's possible.

That's fine. So I, I, it's a really good question. I don't know, you certainly ideally don't want any sort of like ivermectin in place because that's going to affect the viability of the leeches.

But I'll, if it's OK, I'll, I'll get back to you on that. But try and not have these horses on antibiotics. There's no indication for antibiotics anyway.

No problem. So that, that, that'd be really useful if you could send us that and then we're happy, we'll distribute that through that, that to the attendees that are on tonight, so that'd be great. Thank you very much.

. Question around the actual, you know, the maggots, and I think this question was asked before then you talked about the life cycle of the maggots and before they, you know, turn into pupa etc. So presume. That the maggots are only used used only once, before then, you know, they're discarded once you've used them on that one patient, you don't use them on multiple patients because of the short, life, you know, the short time span you've got of when they're most sort of, active, would that be correct?

Yeah, I mean, I think, as I said, that what it's that, that life cycle picture is quite relevant because you, you've only got, if you, you know, they're only feeding for about 4 days in total. And you want to get them at their peak of feeding. So, as I said, the great thing about Bermand is they'll get you, they'll get you them within 24 hours.

And then you've got, you've got a sort of a two-day window to get them on the wound, but I would try and do it almost the same day. And then they feed, and then they're going, and then if you, if you don't remove them, at all, you know, they will go through the rest of their life cycle and start to want to pupate. But they, but that's why you need, you need, there are two reasons why you can't keep them on for longer than 3 days.

And I don't mean to get to sort of divert a little bit, but the Two reasons. One is, one is you don't want them, you know, that you go, you, you're using them during that peak feeding activity. And once they've gone through that, they're not actually that beneficial anymore.

And And secondly, they will start, if you leave them on for longer than 3 days, unfortunately, they will start to defecate in the wound. And they'll start to defecate in the wound after about 4 days. So you absolutely don't want to leave them in for longer than that.

But the original question is, yes, they're, unfortunately, there are, the leeches can be used multiple times, but maggots are a one-off, unfortunately, but they, they're worth every penny. Fantastic, thank you. Hillary saying, please excuse this question, she's found it absolutely fascinating.

Can you use the wound debridement system in small animals too? Obviously, you know, this is obviously the equine focus, but have you got any knowledge of it being used in small, I mean, if she, if she, if Hillary's talking about the versa, if that's what I think she's talking about, hydrosurgery system, and, and if I can give Hillary some information that I've published actually, I've published, I've published a paper on the use of the Versajet in horses. So if you look up my name, you'll find that, but, but I.

Unfort, what's amazing is the versageject was used, came from the human side. It's used routinely in burn wounds and Unfortunately, in sort of in war situations to debride people that stand on landmines and things. But, and the equine side has taken it to heart, and there are a lot of veragejets around.

For some reason, and I've tried, my wife is a small animal vet. I've tried to get her clinic to use it because the number of, I know from her, the number of cats and dogs that get dragged along the road in traffic accidents and embedded with grit and stuff. There are, it's far more applications on the small animal side, but for some reason, the small animal side hasn't taken to it, but it's, it's absolutely applicable to the small animal side.

And if you, if you want more information on the versajet at all, again, You can get in touch with me. I can, I don't know if that's possible through webinar, you can, I don't, I have no problem with webinar, supplying my email address. I can, I can give, I can give you some information on the, on the, on the versajet and how to get access to it.

Fantastic. Yeah, if anyone wants to, I was interested in getting more information, if you email into office at the webinar vet.com, and then we can share Dylan's contact details, email address with you, for that purpose.

So thank you for that. So obviously great to know that, you know, a small animal, is applicable to. We've got Florin here calling in from Romania.

The question is, for the case with the small flap and leeches on top, if leeches are sucking blood, will my flap survive, flaps the blood supply, so theoretically it can be a risk of necrosis if we'll have less blood supply. Yeah, sorry. I mean, you just have to, no, no, it's just, I understand the point, but I understand the question completely, but I think the point is that They are, the leeches are, These, as I said, these flaps are congested and the, the, the, the veins are congested.

They have these microthrombin. So what, what the leeches are doing by producing sort of anticoagulants, they are breaking down those thrombie and encouraging free flow of blood. So you shouldn't be, there is plenty, plenty, plenty of blood supply underneath that wound and underneath the flap.

So you should have no concern about blood flowing through the flap, because all that means is that you're, you're actually increasing the blood supply. So that's not really any, that's nothing to worry about at all. If you looked at the, the flap that I shown in that example is tiny flap, and it's a miracle that, I mean, I'm still amazed that that one made it, but, As I said, if that small flap can make it, then, then I think any, any flap can be improved with leech therapy.

No problem, thank you very much. Hillary's then asked, about how long the leech is down for, but I think you touched on that. It's about 9 hours for them to gorge and unlike, oh sorry, is that wrong?

Yeah, no, not 9 hours, 20 to 90 minutes. 20 to 90 minutes, sorry. So they .

I didn't mean to interrupt, if, if there's so. What they do is, you know, you, you, you, you apply it to them. What I haven't really sort of, you know, now that we're just having a chat, I can be a bit more informed, but it takes, it, you need to be quite patient with these little things and you need to treat them a bit like your pets in a way that you, you know, you need to coax them onto the wound, and you need to, I say, it helps a lot just to get a sort of a, a 23 gauge blue needle and just prick the wound a little bit and get it to sort of sort of pinpoint bleeding so that you can focus them on that area.

And then once they attach, you get this like, it's, it's quite amazing. You get this sort of peristaltic pumping through the body. So you can see when they start feeding.

First, they attach, and then after about one minute, you get this peristalsis. Through their body, which means they're feeding. And then after about, yeah, about 2030 minutes.

They'll start to, fall off themselves, or you can just touch them and they'll fall off. So, yeah, about 20 to 90 minutes, and you don't, you don't want to pull them off too early because you don't want to leave, any part of their teeth in the wound. No problem.

And, but unlike maggots, you can, once they've sort of then you gorge themselves, they can then, you know, become, you can use them again for future use, can you, rather than maggots being single use sort of thing. Absolutely. I mean, the leeches, I think you need to, you need to like quite like them and they, and sort of see them as little pets because they, you can keep what you do is you keep them in the fridge because that slows down their metabolism and maybe not next to your yoghurt and stuff, but I think you should.

You can keep them in a little Tupperware with holes in for air. And then, and then all you need to do is just keep changing the water. And you can use just a mild saline solution, so just water with a little bit of salt, and, and you just change the water once a week.

And then after, they say, after about 2 to about 3 months, they'll then have digested that meal, and you need to change the water because they will, to not put too blunt a point, they will defecate in that water. And that's why you need to change the water that once they're, get nice and small again. Then, then you can use them again.

OK, fantastic. Yeah, that's very useful and a bit of advice on how to look after them as well. Susan has asked, so it's brilliant talk, thank you very much.

Are leeches of any value in chronic non-healing wounds? No, I mean, that, I mean, if you, if you have a chronic non-healing wound, which is, you can't put leeches onto an open, you don't put leeches onto an open wound. So a chronic non-healing wound implies that you've got a second intention healing.

So you don't have any skin over the top of the wound. And then leeches don't have an application. So, that's where you want, that's, that's where you want the maggots, because it depends on why it's not healing.

But most common reason for a chronic non-healing wound. Is that you have chronic infection. So you start by debriding it.

This, as I said, debriding is always the first thing to do. And then If that's not resolving it, that's where maggots come in. But the leeches are there for, for flaps or reconstructive surgery and let's say on the human side, for attaching bits that fall off, but we don't have that.

But I think we don't have that much. I probably has more of a sometimes a small animal application, but not so much in horses, but we get a lot of wound flaps, and that's certainly a lot of wound flaps on the small animal side as well. No problem.

That's fantastic. Well, I think that is it for the, majority of the questions. I think we've gone through the main topics there.

So, you know, as I say, if you have got any other questions, as John says, you can, Google him, to find the paper that he's written, but also, if you do have any other questions, then, you know, please do, I know Hillary's put her email address in there, but if anyone else got anything, please do email into office at the webinar vet. Dot com. And we will forward those questions on to Dylan.

All you need to do is to say, if you would be kind enough to complete the short survey when you navigate away from here, just give us some feedback, which is really good for us to be able to use and also help develop our programme going forward. Thank you to Simon for being on the other, line to be able to support it with any technical questions you've had. And obviously, you know, lastly, thank you to Dylan for giving such a fantastic, presentation this evening.

It will be available for you to watch again within the next 48 hours on our website. So if there are anything that you want to revisit, you can go back on the website in the next 24, 48 hours and it'll be there ready for you to watch. So thank you very much, Dylan.

Enjoy the rest of your evening and, we look forward to welcoming you on a webinar soon. Thanks a lot. Bye.