SURGERY & AIDS

Prof.Amarjit Singh Lukram

MS MNAMS FICS FACS
Imphal
Kakatiya Medical College
Warangal
 Two main considerations
for the surgeon

 Precautions must be applied universally to

prevent contamination and possible infection of
medical staff
 All surgical staff should be trained to recognize
the symptoms and signs of HIV disease.
John Jellis, Head of Orthopedics,Univ Teaching Hosp, Zambia
“ Every patient cannot be tested
for HIV before treatment. Even if
this were possible, viremic
patients in the ‘window period’ of
very early infection, who are
probably the most
infectious,would test negative”. -
CDCP
 Objectives

 Precautionary measures
 Assessment of patient for surgery
 Guidelines for HIV disease needing
surgery
 Barrier Protection
Mandatory
 Blood, Bloody body fluids
 Amniotic fluids
 Pericardial, Peritoneal, Pleural fluids
 Synovial fluids
 Cerebro-spinal fluid
 Vaginal Secretions, Seminal fluid
Morb Mortal Wkly Rep 37:377, 1988
 Fluids considered safe
 Saliva
 Sputum
 Tears
 Sweat
 Vomitus
 Urine, Stool
 US OCCUPATIONAL SAFETY & HEALTH
ADMINISTRATION GUIDELINES

 Wear gloves: Venipuncture

Canulation
Catheterization
Endotracheal intubations
 Wear mask and protective eyewear or visor
 Wear a gown during inspection/dressing of
wounds
 William Halsted 1889

Berger in Paris
1897
 Surgeon’s Attire in the OR
 Double gloving – reduces manual
dexterity
 Gowns – impervious sleeves and fronts
 Spectacles or visor – to protect eyes
 Footwear – blood proof
 Sterile cotton gloves over latex for
orthopedic operations
(sharp wires snapping on cotton sparing the skin)
 Behaviour modification
 Needles not to be bent or recapped
 Avoid palpation of sutures in the depth
 Surgical incisions: adequate / minimum
retraction
 Suture needles handled by instruments
 Wound retraction with instruments only
 Instrument tray – a kidney dish
 Risk of Transmission
 0.3% following percutaneous exposure
Curr Probl Surg 29:197, 1992
 Seroconversion – 1 of the surgery team every 8 yrs
N Eng J Med 322: 1778, 1990
 HIV transmission – 1 in every 250 contam. Needle
stick Surgical Technology International II:1993, 220
 Surgeon to patient – 1 per 83,000 hr of surgery
J Am Coll Surg 184:403, 1997
Risks factors for transmission

 Volume of the innoculum

 Quantity of virus in the source
 Depth of penetration
 Type of needle – hollow bore needle
 Response to Occupational
Exposure

 Cleanse wound immediately

 Report exposure
 Evaluate the patient for HIV HBV HCV
 Baseline serology for the Surgeon
 Counseling
 Chemo prophylaxis
 Chemo prophylaxis

 Decision to institute chemo prophylaxis

 Prophylaxis regimen:
(a) Zidovudine, 200 mg tid
(b) Lamivudine, 150 mg bid
(c) Indinavir, 800 mg tid
 Start medication promptly – 4 weeks
 Drugs for HIV disease

1. Nucleoside-analogue Reverse Transcriptase

Inhibitors (NRTI)
2. Non-nucleoside Reverse Transcriptase
Inhibitors (NNRTI)
3. Protease Inhibitors
 Assessment of HIV Positive
Patients

 Clinical Assessment – quick & thorough

 Assess for emergency surgery
 Positive serology – no indication for stage
 Common HIV Related
Symptoms

 Recurrent URTI
 Frequent fever
 Weight loss
 Persistent diarrhea
 Tuberculosis
 Herpes Zoster
 Physical Examination

 Typical skin lesions

 Symmetrical lymphadenopathy – Typical of HIV
post cervical, occipital, axillary, epitrochlear
 Asymmetrical Enlargement – HIV associated
lesions tuberculosis, kaposi’s sarcomas,lymphoma
Typical skin lesion
Kaposi’s
sarcoma
 Serological Testing

 Minor surgery – Clinical assessment adequate

 Major surgery – Clinical assessment + HIV test

Surgery International 27:11, 2003

 Clinical Staging
Stage 0
 HIV-positive but no symptoms or signs
Clinical Stage I
 Asymptomatic
 Persistent generalized lymphadenopathy

Clinical Stage II
 Weight loss (<10% body weight)
 Minor mucocutaneous manifestations
 Recurrent upper respiratory tract infection
 Herpes zoster within last 5 years
 Clinical Staging - contd
Clinical Stage III
 Weight loss ( > 10% body weight)
 Unexplained chronic diarrhoea (>1 month)
 Unexplained prolonged fever (>1 month)
 Oral candidiasis & hairy leucoplakia
 Pulmonary tuberculosis (within past year)
 Severe bacterial infections
 Clinical Staging - contd
Clinical Stage IV
 AIDS: the HIV wasting syndrome
 Severe opportunistic infections
 Extra-pulmonary tuberculosis
 Lymphoma
 Kaposi’s sarcoma
 HIV encephalopathy
 WHO Epidemiological Record 1990;65:221-8
 Clinical Staging -
Importance
 Choice of operative procedure
 Conservative Treatment Vs Radical surgery
 Stage 0 : infection rate doubled
 Stage I-III: infection rate trebled
 Stage IV : infection rate overwhelming
 (AIDS)
 CD4 Cell Count
( Major Surgery )

 CD4 count > 500/mm3 : Normal immune system

 CD4 count 200-500/mm3: Definite immune compro.
 CD4 count <200/mm3 : Severe loss of immune func.
Babina Diagnostic Centre
 Guidelines for Surgical
Procedures
Reactive Hyper. Tuberculosis

FNAC

Kaposi’s sarcoma Metastatic L.N.

Common Surgical Problems
 Abscesses
 Peritonitis
 Empyema
 Perianal disease
 Necrotizing fasciitis
 Osteomyelitis
 Implants
 Tumors
 Abscesses

 Common in HIV + people

 Polymyositis in young people
 Breast abscess in non-lactating women
Drainage
IV Antibiotics
 Peritonitis
 Appendicitis
 Gynecological pelvic abscess
 Primary peritonitis
Drainage
Lavage
Antimicrobials
Oral Kaposi’s
Sarcoma
 Extravasation
of RBCs
diagnostic

Kaposi’s Sarcomas
 Empyema

 Insidious & usually tubercular

 Under water seal drainage – Inadequate
 (try with 21 Fr gauge needle in10 ml syringe)
 Open drainage – Right option
 Thoracostomies – Skin to pleural suture
 Perianal Diseases

 Avoid radical surgery

 Always spread of pre existing infection
 Very slow healing of wounds
 Drainage only
 No dissection
 No exploration
 No surgery for R-V fistula
 Necrotizing Fasciitis

 Excision of all infected tissues

 Hyperbaric oxygen chamber
 Osteomyelitis

 Commonly femur & tibia – Bilateral affection

 Skiagram: osteopenia little periosteal reaction
 Disease progression inevitable despite therapy
 poor healing
 severe bleeding
 pathological fracture
 Above knee amputation – Last resort
Osteomyelitis
 Implants

 Avoid implants in recent # fracture

 Avoid prosthetic joint replacement
 Once infected - impossible to eradicate
 Late infection of implant : Remove implants
 Tumors

 Surgery seldom indicated

 Biopsy only - if FNAC is inconclusive
 Chemotherapy – treatment of choice
 Hemorrhage & Intussusception: Surgery
 High amputation for Kaposi’s sarcoma
 CMV
Cholecystitis
 Conclusion
 Precautions applied universally to protect all medical
staff.
 Surgical staff must educate themselves to recognize
the signs, symptoms of HIV disease.
 Patient’s HIV status should influence the surgeon to
tailor treatment options to the greater benefit of the
patient.
Thank you