AIDS, EMERGENCY OPERATIONS, AND INFECTION-CONTROL

Acquired immunodeficiency syndrome (AIDS) caused by the human immunode ficiency virus (HIV) may turn out to be the largest lethal epidemic of infection ever. The estimated global number of HIV-infected adults in 1993 was 13 million, with projections of up to 40 million by the year 2009. Human immunodeficiency virus infections and AIDS are relevant t o surgeons with respect to the surgical management of AIDS patients in general, the treatment of the increasingly long list of surgical comp lications specific to AIDS patients in particular, and the risks of pa tient-to-surgeon and surgeon-to-patient HIV transmission. Because of m igration of individuals and populations throughout the world, even sur geons practicing in relatively unaffected regions should be familiar w ith the potential surgical implications of AIDS. Ethical consideration s arise, as well. Are surgeons obliged to operate on HIV-positive or A IDS patients? Some surgeons adhere strictly to the Hippocratic Oath, w hereas others reserve the right to be selective on whom they operate, except in emergencies. Other common ethical considerations in the AIDS patient are similar to those arising in the terminal cancer case: whe ther to operate or not; whether to provide advanced support such as to tal parenteral nutrition or hemodialysis. Answers are not simple and r equire close collaboration between the surgeon, the AIDS specialist, a nd involved members of other specialties. Emergency operations become necessary to treat AIDS independent disease such as acute cholecystiti s and appendicitis or AIDS-related life-threatening conditions such as gastrointestinal bleeding, obstruction, perforation, or ischemia comp licating Kaposi's sarcoma, lymphoma, and cytomegalovirus or disseminat ed nontuberculous mycobacterial infections. Delays and errors in diagn osis are frequent. Poor nutritional state with weight loss, low serum albumin, and leukocyte count prevails in most patients requiring emerg ency operations and account for a high mortality. By applying solid ju dgment and selecting management appropriately, the surgeon has the abi lity to prolong life and to improve the quality of life for these unfo rtunate patients, and to do so with extremely minimal risk to himself and his team.