ANORECTAL SURGERY IN PATIENTS INFECTED WITH HUMAN-IMMUNODEFICIENCY-VIRUS - FACTORS ASSOCIATED WITH DELAYED WOUND-HEALING

Objective A review of ail anorectal operations in patients infected wi th human immunodeficiency virus (HIV) was performed to assess the inci dence, variety, and clinical course of anorectal disease in these pati ents and to identify factors influencing wound healing. Summary Backgr ound Data Anorectal disease is the most common indication for surgical intervention in patients infected with HIV. The cause and management of HIV-related anorectal conditions, which differ significantly from n on-HIV-related diseases, are not clear. There also is considerable var iation in the reported results of surgical procedures, including wound healing. St. Vincent's Hospital, Sydney, is situated in an area with the highest concentration of individuals infected with HIV in Australi a. Methods The medical records of ail identified patients infected wit h HIV who had an anorectal operation at St. Vincent's General Hospital between January 1, 1988, and January 31, 1995, were reviewed retrospe ctively. Logistic regression, Mann-Whitney U test, and Fisher's exact tests were used for analysis. Results One thousand five hundred two pa tients with acquired immune deficiency syndrome (AIDS), equivalent to 26.8% of all known patients with AIDS in Australia at this time, were admitted to this hospital during the T-year period. One hundred one pa tients infected with HIV underwent 161 anorectal operations. All patie nts were male homosexuals (98 patients, 97%) or bisexuals (3 patients, 3%), with intravenous drug use an additional risk factor in 5 patient s (5%). Thirty-seven percent of patients had more than one operation. Seventy-two percent of patients were Centers for Disease Control (CDC) group 4 (AIDS) at operation, 27% were group 2, 1% was group 3, and no ne were group 1. Accurate information about wound healing was availabl e for 74% of first operations, and univariate and multivariate logisti c analyses of these showed that when the CD4+ T-lymphocyte count was < 50 cells/mu L, healing was significantly retarded (p = 0.016). The Cen ters for Disease Control group, patient age, and serum albumin were no t significant predictors of wound healing; The interval between HIV di agnosis and operation was not associated with impaired wound healing, but recognition of AIDS more than 1 year before operation was associat ed with significantly better wound healing compared with those in whom AIDS developed within the year before operation (p = 0.025). In the p atients for whom accurate wound healing information was available, onl y 40% had healed their wounds by 3 months after operation. Wound heali ng was worst for patients with chronic fissures, only 16% of whom had healed their wounds at 3 months. The wound healing rate was worse for repeat operations than for first operations. Ten percent of patients h ad anorectal malignancies, none of which were diagnosed clinically bef ore or during operation. Conclusions Wound healing is a significant pr oblem after anorectal operations in patients infected with HIV, especi ally when the CD4 count is <50/mu L. Although there seems to be little or no benefit from more invasive operations in some cases, thorough e xamination with adequate biopsies is required in all cases. The best m anagement of anorectal disease in patients infected with HIV still is unclear.