Complications of surgery in HIV-infected patients

Improved outcomes following gastrointestinal surgery among people living with HIV in the HAART-era: A scoping review

BACKGROUND

This study aimed to review the varied 1-4 gastrointestinal (GI) system surgical outcomes among people living with Human Immunodeficiency Virus (PLWH) in the HAART-era.

METHODS

MEDLINE and EMBASE were searched for primary publications on GI surgery outcomes exclusively in HAART-treated HIV patients. NSQIP-reported complications (NRCs), all-cause complications (ACC) and HIV disease parameters were extracted.

RESULTS

12 studies met study inclusion criteria, examining bowel (4), bariatric (5), cholecystectomy (1), appendectomy (1), and other general abdominal operations (1). The NRC rate was 0%, ≥44.4% and 13.3% in bariatric, bowel and appendix surgeries, respectively. Over half of NRCs were infectious. HAART-treated patients had lower ACC, LOS, and sepsis versus untreated-HIV, and higher ACC, LOS and reoperation rates versus HIV-negative patients.

CONCLUSION

HAART use is associated with markedly improved NRC outcomes post GI surgery among PLWH; however, these remained inferior to those documented among HIV uninfected individuals.

Postoperative Outcomes following a Multidisciplinary Approach to HIV-positive Breast Cancer Patients

Improvements in human immunodeficiency virus (HIV) treatment resulted in drastic increases in the lifespan of HIV-positive individuals, resulting in higher rates of non-AIDS-defining cancers. We describe our postoperative outcomes in HIV+ breast cancer (BC) patients, highlighting our multidisciplinary experience with this high-risk population.

Metabolic factors and post-traumatic arthritis may influence the increased rate of surgical site infection in patients with human immunodeficiency virus following total hip arthroplasty

BACKGROUND

The impact of CD4+ T-cell count and highly active antiretroviral therapy (HAART) on the rate of surgical site infection (SSI) in patients with human immunodeficiency virus (HIV) undergoing total hip arthroplasty is still unclear. The goals of this study were to assess the rate of perioperative infection at a large tertiary care referral center and to identify risk factors in HIV+ patients undergoing total hip arthroplasty (THA).

METHODS

This study was a prospective, observational study at a single medical center from 2000-2017. Patients who were HIV+ and underwent THA were followed from the preoperative assessment period, through surgery and for a 2-year follow-up period.

RESULTS

Sixteen of 144 HIV+ patients (11%) undergoing THA developed perioperative surgical site infections. Fourteen patients (10%) required revision THA within a range of 12 to 97 days after the initial surgery. The patients' mean age was 49.6 ± 4.5 years, and the most common diagnosis prompting THA was osteonecrosis (96%). Patients who developed SSI had a lower waist-hip ratio (0.86 vs. 0.93, p = 0.047), lower high density lipoprotein cholesterol (45.8 vs. 52.5, p = 0.015) and were more likely to have post-traumatic arthritis (12.5% vs. 0%, p = 0.008). Logistic regression analysis demonstrated that current alcohol use and higher waist-hip ratio were significant protectors against infection (p < 0.05). No other demographic, medical, immunologic parameters, or specific HAART regimens were associated with perioperative infection.

CONCLUSIONS

Immunologic status as measured by CD4+ cell count, HIV viral load, and medical therapy do not appear to influence the development of SSI in HIV+ patients undergoing THA. Metabolic factors and post-traumatic arthritis may influence the increased rate of infection in HIV+ patients following THA.

Wounds in patients with HIV

Highly active antiretroviral therapy has dramatically reduced morbidity and mortality among patients who are HIV-positive. A retrospective review of the authors' data separated subjects into cohorts based on HIV status and matched them for age and gender. The authors' data reveal a higher fraction of venous ulcers compared with a lower fraction of pressure ulcers in the seropositive population.

Total laparoscopic intestinal vaginoplasty as neovaginal reconstruction in an HIV-positive transgender woman

A 46-year-old, HIV-positive transgender woman of South American ethnicity consulted our outpatient clinic to discuss the possibilities of a surgical, secondary neovaginal reconstruction because of complete stenosis of her inverted penile skin-lined neovagina. She was taking abacavir/lamivudine and nevirapine as antiretroviral therapy. We successfully performed a total laparoscopic sigmoid vaginoplasty without any complications. There was no short-term morbidity and no complications were reported after 15 months of follow-up. To our knowledge, this is the first report of laparoscopic sigmoid vaginoplasty as vaginal reconstruction in a HIV-positive transgender woman. Worldwide, transgender women have a high burden of HIV infection. This report shows that intestinal vaginoplasty is a feasible surgical option for HIV-positive transgender women in need of vaginal reconstruction. Because patients are again able to engage in penetrative sexual intercourse, we emphasise the importance of practicing safe sex and early initiation of adequate antiretroviral therapy in this patient population.

Understanding the experiences of doctors who undertake elective surgery on HIV/AIDS patients in an area of high incidence in South Africa

This study investigates the experiences of doctors who perform elective surgical procedures in an area of South Africa with a high incidence of HIV and AIDS. A qualitative study approach was adopted. Interviews were individually conducted with 15 doctors. The transcribed interviews were read four times, each with a different data-collection purpose, and follow-up interviews were carried out when it was necessary to complete the data set. Surgical doctors from two semi-urban hospitals and one rural hospital in northern KwaZulu-Natal province took part in the study. The analysis of the interviews rendered four areas of concern in the experiences of doctors who perform surgery on HIV/ AIDS patients. These were: personal factors, patient factors, factors relating to the structure of the health system, and factors concerning protocols for the treatment of patients with HIV or AIDS. Although the doctors were altruistic in their approaches to operating on HIV/AIDS patients, they commonly mentioned the increased levels of stress they experience as a result of a multiplicity of issues surrounding the treatment and care of an HIV/AIDS patient specifically. The public health system has not made special arrangements to deal with the increased patient loads in hospitals as a result of the HIV epidemic, and this will have to be addressed as the number of HIV/AIDS patients increases.

Wound infection rates in elective plastic surgery for HIV-positive patients

BACKGROUND

Human immunodeficiency virus (HIV)-positive patients suffer from a unique set of aesthetic challenges, frequently requiring plastic and reconstructive surgical intervention. This study was designed to evaluate the overall wound infection rates for elective surgery in this patient population, focusing specifically on differences between transdermal (both open and minimally invasive) and transoral procedures.

METHODS

Charts were reviewed for all patients with an International Classification of Diseases, Ninth Edition code of V08 (asymptomatic HIV infection, CD4 count >200 cells/microl) who underwent surgery by the senior author (S.P.D.) at this tertiary care hospital between January 1, 2000, and October 1, 2007 (39 patients, 98 procedures). Indication for surgery, type of procedure performed, wound infection rates, length of follow-up, status of HIV infection, and HIV treatment status were all documented. Data were collected according to internal review board protocol. Infection rates were compared between study groups and with the existing surgical literature.

RESULTS

Statistical analysis revealed no significant difference in wound infection rate between open and minimally invasive procedures when a transdermal approach is used (10 percent and 0 percent, respectively; p > 0.05). However, there was a significantly increased infection rate in transoral surgery when compared with these two groups (71 percent; p < 0.001).

CONCLUSIONS

These findings indicate that there is a greatly increased risk of wound infections for HIV-positive patients undergoing transoral surgery when compared with transdermal surgery and historical norms.

Is impaired immunity a consequence of surgery in patients infected by the human immunodeficiency virus?

BACKGROUND

Surgery affects immune function adversely in a variety of clinical settings. To date, there are no data assessing immune function in patients infected with the human immunodeficiency virus (HIV) who have had surgery.

METHODS

A retrospective review was performed of 67 patients, of whom 46% were female, who underwent surgery while being treated for HIV infection. These patients were identified from a database collected over a ten-year period. The CD4(+) cell counts were analyzed according to the degree of immunosuppression (> or =500, 200-499, and <200 cells/mm(3), respectively). Viral titers also were assessed.

RESULTS

Of the 17 patients with CD4(+) cell counts >500/mm(3) prior to surgery, 64.7% had unchanged counts after surgery (95% confidence interval [CI] 32.9%, 81.6%), whereas 35.2% of patients had lower CD4(+) counts after surgery (95% CI 14.2%, 61.7%). In patients with preoperative CD4(+) counts between 200 and 500/mm(3), 9.7% (95% CI 2.0%, 25.8%) had their counts decrease to <200 cells/mm(3), whereas in 29% (95% CI 14.2%, 48.0%) of patients, the counts increased to within the normal range. In the most immunosuppressed group (CD4(+) counts <200/mm(3)), 15.8% of patients (95% CI 3.4%, 39.6%) had their CD4(+) counts increase to the intermediate range. In the majority of patients, the viral titers remained unchanged, whereas 18.8% (n = 6) (95% CI 7.2%, 36.4%) had a decline in their titers.

CONCLUSIONS

Surgery does not affect immune function adversely in HIV-infected patients, as judged by CD4(+) cell counts or viral titers.

Inguinal Lymph Node Biopsy in Patients Infected with the Human Immunodeficiency Virus Is Safe

BACKGROUND AND PURPOSE

The incidence of postoperative complications in human immunodeficiency virus (HIV)-infected patients remains controversial. Published data suggest that these patients are at higher risk for postoperative surgical site infections (SSIs) than are uninfected patients if the site is contaminated. To determine the incidence of postoperative SSI in HIV-infected patients undergoing aseptic surgery at uncontaminated sites, we performed a prospective case series analysis. We hypothesized that the rate of postoperative SSI would be low for this aseptic procedure, irrespective of CD4(+) lymphocyte counts. Additionally, we monitored the rates of other complications, namely, hematoma, dorsal vein thrombosis, epididymitis, lymphocele, and suture extrusion.

METHODS

From May 1, 2000, through January 31, 2006, we performed 137 sterile inguinal lymph node biopsies in 44 HIV-infected patients as part of a funded study evaluating the role of peripheral lymphatic tissue in the pathophysiology of HIV infection. Postoperatively, we followed all patients for a minimum of 30 days.

RESULTS

Postoperatively, we noted one instance each (0.7%) of infection, dorsal vein thrombosis with epididymitis (0.7%), and lymphocele and two cases each (1.4%) of hematoma and suture extrusion. The CD4(+) count at the time of biopsy did not correlate with postoperative complications.

CONCLUSIONS

Inguinal lymph node biopsy in HIV-infected patients is safe, irrespective of CD4(+) lymphocyte count.

Impact of highly active antiretroviral therapy on outcome of cholecystectomy in patients with human immunodeficiency virus infection

BACKGROUND

Highly active antiretroviral therapy (HAART) reduces virus proliferation and significantly decreases the rate of septic and opportunistic complications in patients infected with human immunodeficiency virus (HIV). Although surgery is performed routinely on patients receiving HAART, the effect of this treatment on surgical outcome has not been examined in detail.

METHODS

This retrospective study reviewed 54 consecutive patients with HIV infection who underwent surgical cholecystectomy: 31 patients were on HAART, 13 on nucleoside analogue reverse transcriptase inhibitors (NRTIs) and ten were receiving no specific therapy. Characteristics of HIV-1 infection, laboratory investigations, characteristics of the gallbladder disease, type of operation, postoperative course, morbidity and mortality were recorded. Univariable analysis and unconditional logistic regression were performed to determine factors related to postoperative complications and death.

RESULTS

The three groups were similar in terms of HIV-1 infection characteristics. In univariable analysis HAART and laparoscopic cholecystectomy were associated with a significantly lower complication rate, whereas only HAART was shown to be protective by logistic regression analysis. A low HIV RNA load and a high CD4(+) cell count were significant predictors of uncomplicated surgical outcomes.

CONCLUSION

HAART significantly reduces the risk of complications after cholecystectomy in patients with HIV infection or acquired immune deficiency syndrome.

Is acute appendicitis another inflammatory condition associated with highly active antiretroviral therapy (HAART)?

OBJECTIVE

To report the occurrence of acute appendicitis as a possible manifestation of the immune restoration inflammatory syndrome (IRIS) following the commencement of highly active antiretroviral therapy (HAART) in HIV patients.

DESIGN

Case-note review of HIV patients on HAART with acute appendicitis.

METHODS

Review of HIV markers, antiretroviral therapy and abdominal ultrasound results of four HIV patients with acute appendicitis and the histopathology reports on the appendix in two of the patients.

RESULTS

From a population of approximately 350 HIV patients on HAART, we found four patients who developed acute appendicitis within 6 months of commencing or changing HAART.

CONCLUSION

Acute appendicitis occurring in HIV patients on HAART may represent a variant of IRIS. Further immunohistopathological and epidemiological evaluation will be needed to define this relationship fully.