CD4 Count is Still a Valid Indicator of Outcome in HIV-Infected Patients Undergoing Major Abdominal Surgery in the Era of Highly Active Antiretroviral Therapy

Weight loss and mortality in people living with HIV: a systematic review and meta-analysis

BACKGROUND

In the first reported cases of human immunodeficiency virus (HIV) infection, people living with HIV (PLHIV) suffered weight loss, which was an independent predictor of mortality. Highly active antiretroviral therapy (HAART) has changed this scenario for ideal weight, overweight, and even obesity. However, some PLHIV, even on HAART, continue to lose weight. Thus, the guiding question of the study was: do PLHIV hospitalized using HAART with weight loss have higher mortality than hospitalized PLHIV using HAART without weight loss?

METHOD

A systematic review and meta-analysis of prospective cohort studies published in English, Spanish, or Portuguese, searched in the MedLine, Embase, and LILACS databases from March 2020, until October 2023, reported by MOOSE. We analyzed the methodological quality and risk of bias using the Joanna Briggs Institute Critical Appraisal Tool for Cohort Studies; used the risk ratio (RR) to calculate the probability of hospitalized PLWH who lost weight dying, applied the random effect model and created the funnel plot. We used the inverse variance test estimated by the Mantel-Haenszel method, considering a 95% confidence interval (CI), heterogeneity (I2), total effect size (Z), and significance value of p < 0.05. We performed a sensitivity analysis with meta-regression and meta-analyses on subgroups to diagnose influence and outliers. The quality of evidence and strength of recommendation were analyzed using the Grading of Recommendations Assessment, Development, and Evaluation system (GRADE).

RESULTS

We included 10 of the 711 studies identified, totaling 1,637 PLHIV. The studies were from South Africa (1), Canada (1), China (1), Brazil (1), Cameroon (1), Ethiopia (1), Thailand (1), Colombia (1), and Tanzania (2), from 1996 to 2017. The average age of the participants was 33.1 years old, and the male was predominant. The leading causes of hospital admission were related to co-infections, and the average hospitalization time was 20.5 days. The prevalence of death in hospitalized PLHIV using HAART who lost weight was 57.5%, with a 1.5 higher risk of dying (RR: 1.50, 95% CI: 1.03, 2.19, p = 0.04) than hospitalized PLHIV who did not lose weight.

CONCLUSION

We concluded, with a very low confidence level, that that weight loss significantly increased the risk of death in hospitalized PLWH using HAART.

TRIAL REGISTRATION AND FUNDING

PROSPERO International Prospective Register of Systematic Reviews CRD42020191246 https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020191246 .

Safe performance of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with HIV infection

Background

Patients with HIV (PHIV) are living longer with the adoption of anti‐retroviral therapy. As such, more patients are presenting with advanced cancer diagnoses, including peritoneal surface malignancies. The objective of this study was to assess the safety of CRS/HIPEC in this cohort of patients.

Case

Five PHIV were identified, four of whom underwent CRS/HIPEC. Primary sites of disease were low‐grade appendiceal mucinous tumors in three patients and peritoneal mesothelioma in the other. Operative time ranged from 7 to 14 h. One patient developed a Clavien grade II complication postoperatively. There was no instance of neutropenia identified. One patient died of disease 19 months after surgery; the remaining three patients are alive 11, 21, and 33 months postoperatively.

Conclusion

This study demonstrates that CRS/HIPEC can be performed in PHIV without prohibitive complications and operative recovery approximates that of non‐HIV patients. Though more study is needed, HIV should not preclude a patient from being offered CRS/HIPEC.

Guidelines for Perioperative Care in Elective Abdominal and Pelvic Surgery at Primary and Secondary Hospitals in Low-Middle-Income Countries (LMIC's): Enhanced Recovery After Surgery (ERAS) Society Recommendation

Background

This is the first Enhanced Recovery After Surgery (ERAS®) Society guideline for primary and secondary hospitals in low–middle-income countries (LMIC’s) for elective abdominal and gynecologic care.

Methods

The ERAS LMIC Guidelines group was established by the ERAS® Society in collaboration with different representatives of perioperative care from LMIC’s. The group consisted of seven members from the ERAS® Society and eight members from LMIC’s. An updated systematic literature search and evaluation of evidence from previous ERAS® guidelines was performed by the leading authors of the Colorectal (2018) and Gynecologic (2019) surgery guidelines (Gustafsson et al in World J Surg 43:6592–695, Nelson et al in Int J Gynecol Cancer 29(4):651–668). Meta-analyses randomized controlled trials (RCTs), prospective and retrospective cohort studies from both HIC’s and LMIC’s were considered for each perioperative item. The members in the LMIC group then applied the current evidence and adapted the recommendations for each intervention as well as identifying possible new items relevant to LMIC’s. The Grading of Recommendations, Assessment, Development and Evaluation system (GRADE) methodology was used to determine the quality of the published evidence. The strength of the recommendations was based on importance of the problem, quality of evidence, balance between desirable and undesirable effects, acceptability to key stakeholders, cost of implementation and specifically the feasibility of implementing in LMIC’s and determined through discussions and consensus.

Results

In addition to previously described ERAS® Society interventions, the following items were included, revised or discussed: the Surgical Safety Checklist (SSC), preoperative routine human immunodeficiency virus (HIV) testing in countries with a high prevalence of HIV/AIDS (CD4 and viral load for those patients that are HIV positive), delirium screening and prevention, COVID 19 screening, VTE prophylaxis, immuno-nutrition, prehabilitation, minimally invasive surgery (MIS) and a standardized postoperative monitoring guideline.

Conclusions

These guidelines are seen as a starting point to address the urgent need to improve perioperative care and to effect data-driven, evidence-based care in LMIC’s.

Perioperative Antiretroviral Regimen for HIV/AIDS Patients Who Underwent Abdominal Surgery

BACKGROUND

A short interruption of antiretroviral therapy (ART) and reduced oral bioavailability of antiretroviral medications could occur in perioperative human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) patients who undergo abdominal surgery. Therefore, we focused on the changes in HIV viral load and CD4⁺ T lymphocyte count in HIV/AIDS patients after surgery and explored whether the perioperative use of intravenous antiretroviral drugs is beneficial in lowering the viral load and increasing the safety of the surgery.

METHODS

We prospectively collected data from HIV/AIDS patients who underwent abdominal surgery at our institution from January 2019 and April 2019. According to the use of different antiretroviral medications during the perioperative period, the HIV/AIDS patients were divided into four groups: Group I: Patients continued their original antiretroviral medications; Group II: Patients received their original antiretroviral medications plus intravenous administration of the fusion inhibitor albuvirtide (ABT); Group III: Patients received ABT alone; and Group IV: Patients did not receive ART. The primary outcomes considered were the changes in HIV load and CD4⁺ T lymphocyte count and the postoperative complications in the four groups.

RESULTS

A total of 64 HIV/AIDS patients were enrolled, and their data were analyzed descriptively. There were no differences between group I and group II in terms of the changes in viral load. The viral load continued to decrease in group III within 30 days after surgery, especially from D7 to D30 (t = 2.179, p = 0.043). However, the viral load showed an upward trend after surgery in group IV. There were statistically significant differences between the two groups in the changes in viral load after surgery (p = 0.022). However, there were no statistically significant differences between group III and group IV in the postoperative changes in the CD4⁺ T lymphocyte count. Seven out of 64 patients had postoperative infective complications. The incidence of complications from high to low was as follows: group IV > group I > group III > group II (p < 0.05).

CONCLUSIONS

A short perioperative interruption of ART may have a small impact on viral load in HIV/AIDS patients on virologic suppression after abdominal surgery. For patients with a detectable viral load, an intravenous injection of ABT in the perioperative period can reduce the viral load quickly, lower the occurrence of postoperative complications, and increase operation safety for both the HIV/AIDS patient and the surgeons.

Compromised Gut Associated Lymphoid Tissue is a Risk Factor for Postoperative Septic Complications in HIV-Seropositive Trauma Patients

Background

The gut associated lymphoid tissue (GALT) is an important part of the immune system and compromised in HIV treatment-naïve as well as in HIV-seropositive patients on antiretroviral treatment (ART) due to HIV-induced changes. The influence of the impaired GALT on the postoperative complication rate after surgery for penetrating abdominal trauma has not been investigated and the hypothesis that the HIV-induced changes of the GALT contribute to septic complications postoperatively was tested.

Material and methods

This prospective study included patients who required a small bowel resection due to abdominal gunshot wounds. A bowel specimen was obtained in the index operation, and the T-lymphocytic quantity in the specimen was analyzed via immunohistochemistry to scrutinize whether these lymphocyte numbers had an impact on the postoperative outcome. Septic and postoperative complications were documented during the in-hospital course and the first month after discharge.

Results

In total, 62 patients were included in the study of which 38 patients were HIV-seronegative and 24 were HIV-seropositive. HIV-seropositive patients had a significantly lower quantity of CD4 + T cells in the GALT compared to the HIV-seronegative patients (p = 0.0001), which was also associated with a significantly higher rate of septic complications in the postoperative course. In the HIV-seropositive group, no significant differences were detected for T-lymphocytic quantity in the GALT between the HIV-treatment naïve and antiretroviral treatment groups.

Conclusion

The compromised GALT in HIV-seropositive patients may predispose these patients to postoperative septic complications. Antiretroviral therapy does not result in an adequate immune reconstitution in this tissue.

Does Living With Human Immunodeficiency Virus Increase Pelvic Reconstructive Surgery Perioperative Complication Risk? A Multicenter Retrospective Cohort Study

OBJECTIVE

To determine if women with human immunodeficiency virus (HIV) undergoing pelvic reconstructive surgery (PRS) have an increased risk of perioperative and postoperative complications compared with HIV-negative controls.

STUDY DESIGN

Multicenter, retrospective matched cohort study of patients with and without HIV infection who underwent PRS between 2006 and 2016. Cases were identified using International Classification of Disease, 9th edition Clinical Modification and 10th edition Clinical Modification and current procedural terminology (CPT) codes encompassing HIV diagnoses and pelvic reconstructive surgeries. Controls were identified as patients without HIV who underwent similar procedures, performed by the same surgeon during the same 1-year period as surgeries performed on patients with HIV. Cases were matched to controls at a ratio of 1:3. The primary outcome was composite complication rate within 1 year of surgery.

RESULTS

Sixty-three patients with HIV and 187 controls were identified. There was no difference in the composite complication rate between women with HIV and HIV-negative women (36.5% vs 30.0%, P = 0.15) over 1 year. However, 19.1% of patients with HIV compared with 5.4% controls had Clavien Dindo Grade I complications (P = 0.002), and 11.1% of HIV patients had urinary retention within 6 weeks of surgery compared with 3.2% of controls (P = 0.02). After multivariable logistic regression used to adjust for confounders, living with HIV was not associated with an increased risk of complications.

CONCLUSIONS

Patients living with HIV are not at an increased risk of complications within 1 year of PRS compared with patients without HIV.

The Effect of Bariatric Surgery on Patients with HIV Infection: a Literature Review

Obesity among human immunodeficiency virus (HIV)-infected individuals is on the rise. Bariatric procedures such as Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) alter the GI tract. Whether this alteration has any impact on the absorption of highly active antiretroviral therapy (HAART), thus affecting HIV disease markers such as CD4 cell count or viral load (VL), is not yet known. We conducted this review to look into the outcomes of bariatric surgery procedures, RYGB, SG and adjustable gastric band (AGB) and its effects on the CD4 cell counts and VL and HAART therapy. A literature search was conducted between January and April 2017, by two independent reviewers, using Pubmed and Google Scholar. The terms 'bariatric surgery and HIV', 'obesity surgery and HIV', 'gastric bypass surgery and HIV', 'sleeve gastrectomy and HIV' and 'gastric band and HIV' were used to retrieve available research. Of the 49 papers reviewed, only 12 reported the outcomes of patients with HIV undergoing bariatric surgery and were therefore included in this review. Six papers assessed patients undergoing RYGB only (N = 18), 3 papers reported on SG only (N = 18) and 3 papers reported on case mix, including 7 cases of RYGB, 4 cases of SG and 11 cases of AGB. Data is limited; however, based on the available data, bariatric surgery is safe in HIV-infected individuals and does not have any adverse impact on HIV disease progress. Additionally, there was no difference in HIV-related outcomes between SG and RYGB.

Postoperative CD4 counts predict anastomotic leaks in patients with penetrating abdominal trauma

INTRODUCTION

The influence of trauma- and surgical stress-induced decrease of CD4 count on anastomotic leaks after penetrating abdominal trauma has to date not been investigated. A prospective study was performed to explore the effect of CD4 count 24 h after surgery on the anastomotic leak rate and to identify risk factors for anastomotic leaks.

METHODS

This was a prospective study including 98 patients with small or large bowel resection and subsequent anastomosis due to penetrating abdominal trauma. Univariate analysis identified risk factors for the development of anastomotic leak and also investigated the predictive value of the CD4 count for this complication.

RESULTS

Of the 98 patients 23 patients (23%) were HIV-infected. The overall leak rate was 13%. Univariate analysis including all potential risk factors with p-values<0.05 identified six factors leading to a significantly higher rate of anastomotic complications: postoperative CD4 count<250 cells/μl, postoperative albumin <30 g/L, penetrating abdominal trauma index≥25, gunshot wound as mechanism of injury, blood transfusion requirement >6units and delayed anastomosis after damage control surgery. Survival rates were analysed with the χ² test and did not show a significantly higher mortality rate in patients with low CD4 count. The negative impact of trauma and subsequent surgery on the cell mediated immunity was demonstrated by the fact that 55 (73%) of the HIV-negative patients had a CD4 count less than 500 cells/μl 24 h postoperatively. HIV-infection had no significant influence on the leak rate, however all HIV infected patients that developed an anastomotic leak died.

CONCLUSION

A low post-operative CD4 count is a predictor for anastomotic leaks irrespective of HIV-serostatus. Low postoperative serum albumin, high injury severity, gunshot wound as mechanism of injury, blood transfusion requirement >6 units and delayed anastomosis were further risk factors for anastomotic complications. Postoperative CD4 count and serum albumin should be considered in the decision making process of performing an anastomosis or diverting stoma for patients after "clip and drop" of the bowel as part of damage control surgery.

Perioperative outcomes in human immunodeficiency virus-infected patients - the PRO HIV study

It is estimated that a quarter of patients with HIV/AIDS undergo at least one surgical procedure in their life time. Surgical outcomes in these patients from developing countries are poorly characterized and surgeons are often concerned about poor surgical outcomes, especially when their CD4 cell counts are less than 200 cells/µl. This study evaluated the surgical outcomes of HIV-infected patients undergoing various surgical procedures over a six-year period in a large tertiary care hospital from South India. Two hundred and ninety-three patients underwent 374 surgical procedures during the study period. The median duration of HIV prior to surgery was 1.9 years (range 0-18.8 years). Two-thirds (58%) were on highly active antiretroviral therapy (HAART) at the time of surgery with the median duration of this treatment being 38 months (n = 194). About one-third (35%) of surgical procedures were performed as an emergency. Abdomino-pelvic surgeries were the most common (225, 60%). Adverse surgical outcome defined as death or post-operative infection was seen in 25 (6.6%). The post-operative infection rate was 5% (20/374). The most common of these was surgical site infection observed in nine (60%) followed by pneumonia in five patients (33%) and urinary tract infection in one patient. Day 30 mortality was 2% (n = 8) and a quarter of these were reported to be related to post-operative infectious complications. On multivariate analysis, only preoperative haemoglobin of less than 10 g/dl was significantly associated with a poor surgical outcome. HIV-related parameters such as CD4 cell counts, duration of HIV infection and HAART regimen did not seem to contribute towards an adverse surgical outcome.

The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide. The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important. In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs. The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.