Infection with the human immunodeficiency virus (HIV) is a major cause of morbidity and death globally, and the number of individuals infected with this virus is increasing in many nations. Advanced HIV infection causes immunocompromise that predisposes to opportunistic infections and malignancies that characterise the acquired immunodeficiency syndrome (AIDS). Although the management of many of these AIDS-associated infections and malignancies is by medical means, surgeons play an important role the diagnosis and management of many of these conditions. Furthermore, patients with HIV infection may present with surgical disorders or traumatic injuries that are not related to HIV or AIDS. Health care workers managing patients with HIV infection and AIDS, particularly those involved in performing invasive procedures, are at risk of exposure to this virus in infected blood and body fluids. St. Vincent's hospital, Sydney, is a teaching hospital and major treatment centre for patients with HIV infection and AIDS located in the inner-eastern suburbs of Sydney. Patients with HIV infection who underwent surgical procedures at St. Vincent's hospital during the period 1990 to 1999 were retrospectively reviewed in order to describe the nature of the operative procedures required in the management of these patients. There were 636 patients with documented infection with HIV who underwent 889 surgical procedures at St. Vincent's hospital during the period 1990 to 1999. The number of procedures performed for patients with known HIV infection was increasing during this period. Patients with HIV infection accounted for 1.1% of all surgical procedures performed at this institution during this period. The proportion of total operative cases that patients with known HIV infection represented was seen to be increasing during this period. Surgical procedures were performed during only a small proportion of admissions of patients with HIV infection to St. Vincent's hospital for this period (2.4% of these admissions). The patients were predominantly males in younger age groups. Anorectal procedures for the local treatment of benign conditions were the most common procedures performed for these patients, followed by procedures for the insertion or removal of long-term vascular access devices and other minor general surgical procedures. A large proportion of procedures were performed as day surgery cases (30%). Only a small proportion of cases were for the management of traumatic conditions (3%). A large proportion of patients with HIV infection (26%) underwent more than one procedure during this period, with anorectal disorders a common cause of repeat surgical admission. The operative findings after 498 surgical procedures performed for 360 patients with documented HIV infection during the period 1995 to 1999 were retrospectively reviewed. The number of cases in which AIDS-defining conditions were encountered were recorded, and varied according to the types of procedures performed. Overall, seventy AIDS-defining conditions were found at operation during sixty-five procedures (13% of all procedures for patients with HIV infection). Non-Hodgkin's lymphoma was the most frequently encountered AIDS-defining disorder found at operation, accounting for 41% of such conditions. Kaposi's sarcoma was the next most frequently encountered condition, accounting for 20% of cases followed by cytomegalovirus infection (11%). Procedures in which AIDS-defining conditions were commonly encountered included neurosurgical procedures (20 of 36 procedures were for AIDS-defining conditions), particularly stereotactic brain biopsy. Lymph node excision biopsies had AIDS-defining pathologies seen in 18 of 26 cases, particularly non-Hodgkin's lymphoma. AIDS-defining conditions were diagnosed in only 4% of anorectal procedures, with anal squamous cell malignant lesions a far more frequently observed disorder (diagnosed in 11% of cases). The clinical details of all patients who met the clinical criteria for AIDS who underwent midline laparotomy at St. Vincent's hospital during the period 1987 to 1998 were retrospectively examined. Thirty patients with AIDS underwent thirty laparotomies during this period. AIDS-defining conditions were found at fourteen procedures (47%). Non-Hodgkin's lymphoma was found in eleven of these laparotomies, Kaposi's sarcoma in two and cytomegalovirus in one. In nine of the patients with AIDS-defining conditions, the post-operative diagnosis was different to that expected pre-operatively. Patients with AIDS-defining conditions found at laparotomy had significantly lower serum albumin concentrations and body weight compared with those with more conventional surgical diagnoses. There was no difference in CD4 T-lymphocyte counts, the number of patients with a history of AIDS-defining conditions or the duration of HIV infection between these two groups. Patients with AIDS-defining conditions diagnosed at laparotomy required significantly longer post-operative hospital stays compared to those with other causes, although there was no difference in the incidence of post-operative complications or deaths occurring in these two groups. There was a high number of patients with post-operative complications seen after laparotomy (thirty-two complications in twenty-one patients; 70% of all patients). Chest infections, systemic sepsis and wound infections were the most frequently encountered post-operative complications. Five deaths occurred within thirty days of operation (17% of patients), and were due to overwhelming systemic sepsis in four cases and from blood loss and coagulopathy in one. The number and the nature of the complications and deaths occurring in patients with AIDS undergoing laparotomy at St. Vincent's hospital is in keeping with previously published reports from other centres. The clinical details of patients with documented HIV infection who underwent biliary tract procedures at St. Vincent's hospital during the period 1989 to 1998 were retrospectively reviewed. Eighteen patients with HIV (fourteen of which met the clinical criteria for AIDS) underwent cholecystectomy; ten for cholecystitis secondary to gallstones, one for mucocoele of the gallbladder due to obstruction of the cystic duct by a gallstone and seven for acalculous cholecystitis. Biliary tract procedures accounted for 24% of all abdominal procedures during this period. Patients were mostly male and in a relatively young age range. Cytomegalovirus infection was found in five cases of acalculous cholecystitis, Cryptosporidia in five and Microsporidia in two. A significantly greater proportion of patients with acalculous cholecystitis had a history of AIDS, and these patients had lower CD4 T-lymphocyte counts, compared with those patients with cholelithiasis. There was no statistical difference in the length of hospital admission or number of complications occurring in these two groups. Patients who had cholecystectomy performed as an elective procedure (n=7) were compared with those who had this procedure performed during admission for acute cholecystitis (n=11), and had a significantly lower duration of post-operative hospital stay. There was no difference in the number of complications occurring in these two groups. Laparoscopic cholecystectomy was performed in eight patients, and was not associated with a significant difference in hospital admission duration or incidence of complications when compared with the ten patients who underwent open cholecystectomy. The medical records of all patients presenting to St. Vincent's hospital during the period 1994 to 1998 with major penetrating wounds (gunshot wounds and stab wounds to the trunk or neck) were retrospectively examined to determine the number of such patients with a documented history of infection with HIV or hepatitis C virus (HCV), or with risk factors for these infections. Of the 148 patients with major penetrating wounds who were managed at St. Vincent??s hospital during this period, 5.4% had documented infection HCV and 1.3% with HIV. Risk factors were documented in thirty-one individuals (21%), with injecting drug use the most commonly recorded (19%). Individuals infected with HIV represent a substantial workload for surgical specialists at St. Vincent's hospital. Surgical procedures were an uncommon cause of admission for patients with HIV infection, but were important in the diagnosis and management of many AIDS-associated conditions and were increasing in number. AIDS-defining conditions accounted for only a small proportion of operative interventions in patients with HIV infection. Surgical procedures required in the management of patients with HIV infection encompassed a broad range of surgical specialties and types of procedures. AIDS-associated opportunistic infections and malignancy were frequently the cause of abdominal procedures in patients with HIV and AIDS. The number of patients with known HIV infection who present for elective and emergency surgical procedures, as well as the high prevalence of documented HIV and HCV in patients with major penetrating wounds at St. Vincent's hospital, reinforces the need for all health care workers to practice strict universal precautions against body fluid exposure at all times.
| Identifer | oai:union.ndltd.org:ADTP/215809 |
| Date | January 2001 |
| Creators | Chambers, Anthony James, St. Vincent's Hospital, UNSW |
| Publisher | Awarded by:University of New South Wales. St. Vincent's Hospital |
| Source Sets | Australiasian Digital Theses Program |
| Language | English |
| Detected Language | English |
| Rights | Copyright Anthony James Chambers, http://unsworks.unsw.edu.au/copyright |
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