Patients infected with the human immunodeficiency virus (HIV) may require surgery to treat infections and diseases associated with the condition. HIV infects white blood cells called CD4 cells. Since white blood cells are the main component of the immune system, HIV patients have an increased risk of developing infections.
With the introduction of highly active antiretroviral therapy (HAART), a combination of anti-HIV drugs, HIV patients are able to live longer lives. As a result, it is possible for HIV patients to require surgical interventions for long-term conditions.
Common complications of surgery include bleeding, infections, and nerve damage. It has been suggested that HIV patients may have an increased risk of surgical complications (especially infections) because they have weakened immune systems. However, there is currently no scientific data on the prevalence of surgical complications among HIV patients compared to non-infected patients.
Researchers believe that the risks of surgical complications for HIV patients can be predicted in a way similar to the method used in HIV-negative patients. Prior to surgery, healthcare providers should perform a physical examination, detailed medical history, and laboratory testing to determine the patient's overall health. Healthcare providers must also consider possible interactions between the patient's anti-HIV drugs (antiretrovirals) and medications, such as pain relievers, that are used before, during, and after surgical procedures.
It remains unclear whether a patient's CD4 cell count influences their risk of surgical complications. Healthy individuals have a CD4 cell count between 600 and 1,200 cells per microliter of blood. The lower the CD4 count, the weaker the patient's immune system. Some studies have found no correlation between low CD4 cell counts and surgical complications, while others have found an increase in complications with lower CD4 counts. Further research is needed before a firm conclusion can be made.
Acquired immune deficiency syndrome, acquired immunodeficiency syndrome, AIDS, antiretroviral therapy, antiretrovirals, appendicitis, ART, biopsy, CD4 cells, endoscope, endoscopic sphincterotomy, HAART, highly active antiretroviral therapy, HIV, human immunodeficiency virus, immune, immune defense system, immune system, immunocompromised, immunodeficiency, prostate cancer, prostate surgery, splenectomy, surgery, surgical, thoracic surgery, weakened immune system, white blood cells.
types of surgery
Infections associated with HIV may require surgical diagnostic tests. For instance, a laparoscopy is a diagnostic procedure that involves surgery. During this procedure, the patient receives general anesthesia and a small incision is made in the abdomen. A viewing tube called a laparoscope is then inserted through the incision. This allows the healthcare provider to view the inside of the abdomen. This procedure has been used to diagnose conditions, including a bacterial infection called abdominal tuberculosis. Because there is a slight risk of bleeding and infection, this procedure should only be performed when all other diagnostic tests are inconclusive.
Appendicitis (inflamed appendix) requires the surgical removal of the organ. In most cases, feces block the inside of the appendix, causing it to swell. Bacterial or viral infections in the digestive tract, which are common among HIV patients, may lead to enlarged lymph nodes. The swollen lymph nodes then squeeze the appendix, causing obstruction. HIV-positive and HIV-negative patients generally experience the same symptoms, including severe abdominal pain, nausea, and vomiting. However, the condition may be more difficult to diagnose in HIV patients. Since HIV destroys the white blood cells, HIV patients do not have high levels of white blood cells, which is a characteristic of appendicitis. This may lead to a delay in diagnosis and surgery, resulting in an increased risk of death.
Anorectal (related to the anus and/or rectum) diseases are common among HIV patients and may require surgery.
Condylomas are wart-like growths around the anus, vulva, or tip of the penis. HIV patients who have the human papillomavirus (HPV) typically develop these warts in the perianal region. The warts may be flat or cauliflower shaped. Small warts may spontaneously resolve. Lesions can be removed at a doctor's office with a scalpel, by electrosurgery, laser ablation, or liquid nitrogen. While these procedures have been shown to be safe for HIV patients, surgical removal of the warts does not cure the virus or prevent future outbreaks.
HIV patients who have hemorrhoids may need to have them surgically removed. The procedure, called hemorrhoidectomy, is considered safe for HIV patients. However, wound healing may be delayed in patients with low CD4 cell counts.
Biliary tract surgery
The biliary tract is a system of organs and ducts that are involved in the production and transportation of bile from the liver to the small intestine. Bile, which is stored in the gallbladder, helps breakdown fats from digested food. Opportunistic infections associated with HIV, including cytomegalovirus and mycobacterium avium complex (MAC), may infect the gallbladder and bile duct. The most common cause of biliary tract disease is cholelithiasis, also called gallstones.
Gallstones develop when liquid in the gallbladder (called bile) hardens and becomes stone-like. Sometimes gallstones are too large for the patient to excrete in the urine. The stone becomes stuck inside the tubes in the gallbladder. In such cases, surgery is necessary to remove the gallstone. A procedure called endoscopic sphincterotomy is most often performed. During the procedure, which is performed at a hospital, the patient receives general anesthesia. Then, a thin, flexible tube called an endoscope is inserted through the patient's anus. Additional surgical tools are inserted through the tube to remove the gallstone.
In general, this procedure is considered safe and effective for HIV patients with gallstones that cannot be passed naturally. It is estimated that five to 10% of all patients (HIV-positive and HIV-negative) experience complications from endoscopic sphincterotomy. It is unknown whether this risk is higher among HIV patients. Common complications include inflammation of the pancreas (pancreatitis), inflammation of the bile ducts (cholangitis), bleeding, and passage of bacteria into the bloodstream.
Patients with HIV may develop brain lesions as a result of toxoplasmosis (a parasitic infection), brain abscesses (infection in the brain), or cancer of the central nervous system (brain and spinal cord).
Brain surgery is a serious and risky procedure for all patients, not just those who have HIV. It remains unclear whether HIV patients have an increased risk of developing complications during or after brain surgery. Complications of brain surgery may include bleeding, infection, brain tissue damage, blood vessel damage, loss or impairment of mental functions (e.g. memory, speech), nerve damage, and muscle paralysis or weakness. Brain surgery should only be performed if the potential health benefits outweigh the risks. Patients should make educated decisions about surgery after discussing the potential risks with their healthcare providers.
Toxoplasmosis is the most common cause of brain lesions in HIV patients. In rare cases, especially if patients do not respond to treatment, a brain biopsy may be necessary to confirm a diagnosis. During this surgical procedure, the patient receives anesthesia so he/she cannot feel pain. The neurosurgeon drills a small hole into the patient's skull and inserts a thin needle to remove a small tissue sample from the brain. The sample is then analyzed in a laboratory to check for the presence of the disease-causing parasite. A brain biopsy is an invasive procedure that is associated with serious health risks, including brain injury, and therefore should only be performed when all other diagnostic procedures are inconclusive.
Although a cesarean section (surgical delivery of a baby), also called a C-section, can reduce the risk of HIV transmission to the newborn during birth, it is not typically necessary in patients who undergo antiretroviral therapy. However, mothers who have high levels of the virus in their blood may reduce the risk of transmitting the virus to their babies if they undergo a C-section.
Patients should discuss the potential risks and benefits of a C-section. It has been suggested that HIV patients may have an increased risk of experiencing complications of C-sections because they have weakened immune systems. However, there is insufficient evidence comparing the prevalence of surgical complications among HIV-positive and HIV-negative patients.
One study found that HIV-negative women who had C-sections were twice as likely to be re-hospitalized after giving birth than women who had vaginal deliveries. Most of these hospitalizations were for uterus infections.
The same researchers concluded that, on average, women who undergo C-sections lose about twice as much blood than women who had vaginal deliveries.
Until recently, people who had HIV were not considered good candidates for organ transplantations. Many patients were denied transplants under the assumption that they had shorter life expectancies and less favorable survival rates than other patients in need of transplants. However, now that patients are living longer lives, many groups are reconsidering whether HIV patients should be transplant candidates.
Although the United Network for Organ Sharing (UNOS) does not consider HIV infection a contraindication for organ transplantation, the decision to perform transplantation in an HIV-positive individual rests with individual centers. Some centers will not provide organ transplants to good candidates who are HIV-positive.
Some health insurance companies are reluctant to cover transplantation in HIV-positive candidates because they consider it to be an experimental procedure. Currently, only a few medical centers worldwide perform organ transplants in HIV-positive patients.
Recent legislation in California and a ruling in Arizona may help increase HIV patients' access to transplant surgery. In October 2005, an administrative law judge declared that Medicaid had to pay for a liver transplant for an Arizona woman who was HIV-positive. In the same month, California Governor Arnold Schwarzenegger signed a law that prohibits health insurance companies from denying coverage for organ transplants in HIV patients solely on the basis of their HIV-status. The law is the first of its kind to target such denials.
The limited number of transplants that have been performed in HIV patients have produced encouraging results. However, organ transplants for patients with HIV/AIDS have not gained widespread medical support, and there are still concerns regarding the long-term prognosis for HIV-positive transplant recipients.
Until recently, scientific evidence on the safety and efficacy of surgical procedures for HIV patients with prostate cancer was inconclusive. Currently, it appears that HIV patients who have prostate cancer do not have an increased risk of developing complications from surgery when compared to HIV-negative patients. Studies have found that HIV patients can safely undergo prostate surgery, as long as they are otherwise healthy. HIV patients should not undergo surgery unless they have reasonably stable CD4 cell counts, an indicator of how the health of the immune system.
Splenectomy (surgical removal of the spleen)
Idiopathic thrombocytopenic purpura, also called immune thrombocytopenic purpura, occurs when the body's immune system mistakenly destroys platelets (blood cells that help with clotting) in the spleen. In general, HIV patients do not respond as well to corticosteroid treatment as HIV-negative patients. Some HIV patients require a splenectomy (surgical removal of the spleen) to treat this condition.
In general, this procedure has been shown to be safe and effective for HIV patients who do not have advanced HIV. After surgery, most patients experience an increase in both their platelets counts and their CD4 cell counts.
According to one study, which involved 21 HIV patients, splenectomy did not increase the risk of patients progressing to AIDS.
Thoracic (chest) surgery
Since HIV infects and destroys immune cells in the body, HIV patients are vulnerable to a multitude of infections. Lung infections, which may be caused by Pneumocystis jiroveci pneumonia (formerly called Pneumocystis carinii pneumonia, PCP), mycobacterium avium complex (MAC), tuberculosis, and fungal infections often require invasive diagnostic procedures, such as bronchoalveolar lavage or an open lung biopsy. Like any surgical procedure, there are potential heath risks. It remains unclear whether HIV patients are more likely to develop complications than HIV-negative patients.
Bronchoalveolar lavage: A bronchoalveolar lavage (BAL) is commonly performed to determine whether patients have lung infections, such as PCP. During the procedure, a thin, flexible tube, called a bronchoscope, is passed through the mouth or nose and into the lungs. Saline is squirted into a small part of the lung and then collected for analysis. Common complications include infection and bleeding.
Transbronchial biopsy: During a transbronchial biopsy, a bronchoscope is inserted through the patient's mouth or nose and into the lungs. Then, tiny forceps are inserted into the hollow tube of the bronchoscope. A small amount of lung tissue is removed for analysis. Patients may need to stay overnight at the hospital after the procedure is performed.
Pneumothorax, an accumulation of air between the outer lining of the lung and the chest wall that causes the lung to collapse, occurs in about two percent of transbronchial biopsies. There is also a risk of bleeding and infection after the procedure.
Open lung biopsy: An open lung biopsy is a diagnostic procedure with 100% sensitivity and specificity because it provides the greatest amount of tissue for diagnosis. However, since a lung biopsy is the most invasive test, it should only be performed when all other diagnostic tests are inconclusive. The procedure is performed in a hospital while the patient is under general anesthesia. A tube will be placed through the mouth and into the airway that leads to the lungs. After cleaning the skin, the surgeon makes a cut in the chest area and removes a small piece of lung tissue. The wound is closed with stitches. A chest tube may be left in place for one to two days to prevent the lung from collapsing. The tissue sample is taken to a laboratory for analysis.
Complications are more likely to occur in patients who have lung diseases or severe breathing problems. Complications associated with open lung biopsies include infection, bleeding, pneumothorax, spasms of the bronchial tubes, and irregular heartbeat.