Complications of Surgery for HIV Patients

OAKLAND, Calif., Dec. 19 -- HIV-infected patients having surgery were more likely to develop post-op pneumonia or to die within 12 months than matched non-infected patients, researchers here reported.

A pre-op viral load of 30,000/mL or more was associated with almost three times the rate of complications, according to a report in the December issue of Archives of Surgery.

Although complication rates were higher for those with a CD4 cell count of less than 50/L, counts above this level did not affect outcomes, said Michael Horberg, M.D., of the Kaiser Permanente Medical Care Program -- Northern California, and colleagues.

To our knowledge, this study is the largest analysis of surgical outcomes for HIV-infected patients compared with matched non-infected patients in the modern era of highly active antiretroviral therapy (HAART), Dr. Horberg said.

In the study, 332 HIV-infected patients were matched 1:1 with HIV-non-infected patients (mean age, 46.7 years; male 91%) who had a variety of surgical procedures from 1997 to 2002. The pairs had similar comorbidities, length of hospital stay, and number of postoperative surgical visits (P>0.05 for all variables).

More than 95% of the patients were followed by means of health-plan records for 12 postoperative months or until their deaths. Data were analyzed using the Fisher exact test and logistic regression.

Most of the operations (80.8%) were abdominal or pelvic procedures; 8.4% were cardiac or breast operations; and 10.8% were orthopedic procedures. There were no neurological, urologic, or otolaryngology procedures.

No difference was found for urgency or need for surgery, as most procedures were elective, and the matched pairs were comparable for surgical risk, aside from any risk attributable to HIV or AIDS.

Among HIV-infected patients, the median years with HIV infection was 8.4 years and the median CD4 count was 379/?L. Of these patients 61.5% had an HIV RNA level less than 500 copies per milliliter, and 68% were receiving HAART.

Among the various complications, only pneumonia stood out. Eight (2.4%) HIV-infected patients developed pneumonia versus one (0.3%) non-infected patient (P=0.04), the researchers reported.

Other complications were no more frequent among the infected than the non-infected patients (11.1% versus 10.2%; P=0.79).

However, there were 10 deaths within the 12 months among the HIV-infected patients versus two deaths (0.3%) among the non-infected patients (P=0.02). The cause of death varied among the HIV patients and, in addition to pneumonia, included, for example, renal failure secondary to bladder carcinoma, CNS toxoplasmosis, infected amputated leg, and metastatic rectal carcinoma discovered at operation.

Although none of the deaths appeared related to the surgery, two patients died 30 days or earlier after being operated on (multiple organ failure secondary to lymphoma, and sudden death presumed secondary to arrhythmia). Other surgical outcomes were comparable for HIV-infected and non-infected patients, the researchers said.

Among HIV-infected patients, a viral load of 30,000 copies/mL or higher was associated with increased complications (adjusted odds ratio, 2.95; P=0.007), while patients with a CD4 count less than 50/?L had a higher complication rate. However, for those with counts above this level, CD4 counts were not a factor, the researchers said.

HAART use 180 days before surgery did not appear effective in reducing post-operative complications (11.9% vs. 13.8%, P=0.69).

These results indicate that a higher HIV viral load seems to be a greater predictor of surgically related complications than either the CD4 cell count or the presence or absence of HAART, the researchers said.

The study's limitations included possible selection bias in the observational cohort analysis. Sicker patients may have been less likely to have surgery. Further, HIV-infected patients with post-op complications may have been brought to the medical centers more frequently than non-infected patients with similar complications, the investigators said.

In addition, 20 pairs were not available for analysis, and some HIV-infected patients (9%) did not have CD4 cell counts and HIV viral loads measured. Furthermore, there were fewer patients with lower CD4 cell counts, resulting in wider confidence intervals for the proportion with any complications and for the odds ratio from the logistic regression model in sub-group analyses, the researchers noted.

"Patients with HIV are living longer and regaining a substantial amount of immune function. Many HIV-infected patients will require surgical attention because of a variety of disorders. In many cases, HIV serostatus should not be a criterion when determining the need for surgery if patients have adequate viral control," Dr. Horberg's team concluded.