Introduction:
Over 40 million people are believed to be living with human immunodeficiency virus (HIV) across the world. It is an easily transmitted disease for which there is no cure. Healthcare professionals who treat these patients are at a higher risk of direct exposure to the virus. However, surgery is not contraindicated in HIV patients. Surgeries can be carried out safely by following the guidelines to prevent the spread of the infection. Though there are several issues during the surgery, like the risk of transmission and postsurgical complications like in wound healing, surgery is carried out if required.
Who Are HIV Patients?
HIV is a virus that affects the body's immune system, when not treated, causing acquired immunodeficiency syndrome. Individuals who test positive for HIV are known as HIV patients.
What Are the Effects of the Human Immunodeficiency Virus?
HIV attacks cells that help the body fight infections. There is no antidote for this virus; however, recent developments have successfully helped to control the damage caused by the virus. The patient has to live with the virus and is put on antiretroviral therapy, which lowers the levels of the virus in the body.
There are four stages of HIV infection.
Stage 1 - HIV infection detection.
Stage 2 - Asymptomatic stage.
Stage 3 - Symptomatic stage.
Stage 4 - AIDS (acquired immunodeficiency syndrome).
Till the early stages of HIV, antiretroviral therapy can help reduce the viral load within six months after the detection of the virus.
Can Blood Transfusion Be a Substitute for Surgeries in HIV Patients?
Cord blood transplantation (stem cell transplantation) serves as a cure for patients who have HIV along with cancers. In cases where surgery has to be done because of a disease related to certain organs, blood transfusion cannot be a substitute.
What Are the Factors to Note Before the Surgery for HIV Patients?
The patient's clinical condition determines the reason for surgery. The patient may require surgery due to pathological issues in the body rather than due to the HIV infection.
In certain cases, where there is a risk of delaying the surgeries, the patients might not be willing to undergo surgery. Counseling such patients and explaining the risks of delay are undertaken. The surgery should be delayed only if there is a positive affirmation that the patient's condition will not deteriorate during the delay. The patient should be willing to change the dosage of the antiretroviral medication as suggested by the physician.
What Are the Indications for Surgeries in HIV Patients?
- Most surgeries are performed on HIV patients for diagnostic purposes.
- As many lesions occur due to HIV infection.
- Intention to treat diseases resulting from HIV.
- Clinically advanced disease conditions.
- Emergency operations.
- When the patient's viral load is extreme, management is carried out after consulting an experienced HIV care provider.
What Are the Surgical Issues in HIV Patients?
Issues during and after surgery can arise even in major surgical interventions, but the risks associated with HIV infection can vary as described below:
Risk of Transmission - Transmission of viral diseases has always been a difficult surgical issue while performing major surgeries. Knifeless surgeries like diathermy and stapling procedures have taken over the common scalpel.
Preoperative Evaluations - Cardiovascular and pulmonary evaluations are carried out as patients with HIV have more comorbidities than those without HIV. Certain tests are carried out to evaluate the presence of HIV infection and its interactions, such as CD4 cell count, HIV viral load test, CBC (complete blood count), basic metabolic panel, prothrombin time, and LFT (liver function test).
What Are the Various Surgeries and Related Surgical Issues in Patients With HIV?
Patients infected with or without HIV need to undergo emergency or elective surgeries. Certain surgeries carried out on HIV patients are as follows:
- Exploratory laparotomy (surgery to open the abdomen to carry out further operation).
- Thyroidectomy (removal of a part or complete thyroid gland).
- Colorectal surgery (surgery related to intestines and rectum such as colectomies, abdominoperineal resections, and anterior resections).
- Thoracotomies (an incision made in the thoracic cavity to operate the area inside).
- Gynecological operations (includes removing defective ovaries or delivery of a baby).
- Prostatectomies (removing the prostate gland, which is located below the urinary bladder of a male).
- Mastectomies (removal of breasts) and other major procedures.
Intra-Abdominal Surgery:
- Symptoms ranging from an increase in the size of internal organs or enlargement of lymph nodes can be presented.
- CT (computed tomography) guided biopsy is carried out to decrease the surgical process of incising the abdominal region, draining the abscess, resectioning the cancerous organ, etc.
- Surgeries like appendicectomy to treat appendicitis, laparotomy to carry out abdominal surgeries, major amputations, cholecystectomy (the process of removing the gallbladder, hepato-biliary surgery (surgery related to the liver), pancreatic surgery, splenectomy (removal of the spleen), etc.
Anorectal Surgery:
- As the mode of HIV transmission is through contact with body fluids, anorectal diseases commonly occur, and hence it is the most common surgery performed in HIV patients. Adequate evaluation of biopsies for suspicious lesions should be carried out.
- These surgeries are well tolerated by patients, with fewer cases showing delayed wound healing.
- Anorectal surgery is carried out in treating cancers of the rectal region, rectal lymphomas, rectal sarcomas, etc.
Diagnostic Surgeries:
- Inflammation of the lymph nodes is the main symptom in HIV patients. Lymph nodes are a part of the body's immune system, which enlarge during infections.
- This surgery can be performed in two ways.
Open Biopsy - Where the lymph nodes are cut open and sent for further laboratory investigations.
Fine Needle Aspiration Cytology - A needle is used to aspirate the contents of the lymph nodes and the fluid is examined. These procedures can be performed safely without any postoperative complications.
What Are the Risks Related to Surgeries in HIV Patients?
There is a higher risk in intra-abdominal surgeries compared to anorectal and diagnostic procedures.
Surgical Site Infections - These are commonly occurring complications due to improper maintenance of the wound area.
Pneumonia - Inflammation of the lung due to infections.
Delayed Wound Healing - There can be a delay in wound healing due to infections or other factors like diabetes.
Sepsis - It is a life-threatening response of the body to an infection.
Hemorrhage - Release of blood from broken blood vessels.
Postoperative Mortality - Death after the surgery within 30 days.
Drug-To-Drug Interactions - Drugs used in the surgery may interact with the antiretroviral medications and cause adverse reactions.
Increased Hospital Stay - Hospital stay increases for a patient with HIV infection, as compared to a patient not infected with HIV, by around one week.
Conclusion:
Human immunodeficiency virus (HIV) has been associated with poor outcomes in critically ill patients. With the use of antiretroviral regimens, outcomes of surgeries in HIV patients have improved. HIV infection is one of the independent reasons for causing complications after surgeries. Current treatment regimens for HIV patients improve nutritional status, decrease bacterial infections and increase life expectancy. Surgical issues in HIV patients can be managed effectively with the prevalent medical expertise of healthcare practitioners.
