When modern medicine fails, it is often useful to draw ideas from ancient treatments. The therapeutic use of fly larvae to debride necrotic tissue, also known as larval therapy, maggot debridement therapy or biosurgery, dates back to the beginnings of civilisation. Despite repeatedly falling out of favour largely because of patient intolerance to the treatment, the practice of larval therapy is increasing around the world because of its efficacy, safety and simplicity. Clinical indications for larval treatment are varied, but, in particular, are wounds infected with multidrug-resistant bacteria and the presence of significant co-morbidities precluding surgical intervention. The flies most often used in larval therapy are the facultative calliphorids, with the greenbottle blowfly (Lucilia sericata) being the most widely used species. This review summarises the fascinating and turbulent history of larval therapy from its origin to the present day, including mechanisms of action and evidence for its clinical applications. It also explores future research directions.

Using a Clark oxygen electrode and a 133Xe clearance technique, tissue oxygen tension (T02) and blood flow have been determined in the small and large bowel of a rabbit experimental model. The predictive value of perianastomotic T02 in colonic anastomoses was determined, healing being assessed by leakage rate, tensile strength and hydroxyproline content. The effect of suture technique on colonic perianastomotic T02 has also been studied. Colonic and small intestinal T02 correlated with blood flow (r = 0.93). Basal colonic blood flow and oxygen tension were significantly lower than in the small intestine (P less than 0.01). Interrupted and continuous suture techniques decreased colonic perianastomotic T02, although mean T02 in the continuous group was significantly lower than in the interrupted group (P less than 0.01). The leakage rate was 10 per cent (1/10) for anastomoses constructed with a perianastomotic T02 above 55 mmHg compared with 100 per cent (10/10) if less than 25 mmHg (P less than 0.001). Perianastomotic T02 correlated with breaking energy (P less than 0.001), breaking strength (P less than 0.01) and hydroxyproline content (P less than 0.05).

The groin is the commonest site for graft infections in vascular surgery. This is a potentially catastrophic situation as limb loss or even death occurs in a large percentage of cases. Standard teaching for treatment of infected vascular grafts is removal and extra anatomical bypass grafting whilst commencing appropriate antibiotics. This review article suggests careful scrutiny of the wound, debridement and coverage of the graft with a vascularised muscular flap is appropriate in certain situations.

The ACR score of three or more has a sensitivity of 93.5% and specificity of 91.2% for the diagnosis of GCA. Using these criteria, 68% of patients had sufficient clinical features when referred to make a confident diagnosis of GCA. Temporal artery biopsy was therefore unnecessary in this group. In the remaining group (ACR score < or =2) there was one positive biopsy. The biopsy only changed the diagnosis in this one case-less than 3% of the uncertain cases and less than 1% of the total cases. Using the ACR criteria and restricting biopsy to those cases in which it might change the diagnosis will reduce the number of biopsies by two thirds without jeopardising diagnostic accuracy.