ORIGINAL ARTICLES

Role of thoracic surgery in patients suffering from Acquired Immune Deficiency Syndrome

S.H. AHMED
Department of Surgery, Bronx-Lebanon Hospital Center, Bronx, New York, USA

Introduction Material and method Results

Discussion Conclusion References

Background and purpose: To study the role of thoracic surgery in patients suffering from Acquired Immune Deficiency Syndrome (AIDS) in a South Bronx community with a high incidence of the disease. Methods: A retrospective analysis of medical records of patients who underwent thoracic surgery at Bronx-Lebanon hospital, New York, over a three year period between 1996-1998. Results: The thoracic surgeons at Bronx-Lebanon Hospital in New York operated upon a total of 210 patients. Of these, 39 were operated upon for AIDS-related illnesses, comprising 17% of the operative workload. The indications of surgery in these patients were variable, ranging from infections to tumours. Fifteen patients were operated on for pericardial effusion. Ten were operated on for empyema, which had failed to resolve with thoracostomy alone and necessitated decortication. Tumours also formed a significant portion of the surgical workload. Three patients had Kaposi’s sarcoma of the lung and three had a primary lymphoma in the lung. The mortality rate was high (46%). Conclusion: The data suggest that surgical intervention in AIDS-related chest diseases is unable to alter the course of the disease. Earlier detection and intervention of these complications may improve outcome in some patients.

Keywords: Acquired Immune Deficiency Syndrome (AIDS), thoracic surgery

J.R.Coll.Surg.Edinb., 46, October 2001, 257-260

INTRODUCTION

The epidemic of Acquired Immune Deficiency syndrome (AIDS) has brought a change in the pattern of diseases that different specialists manage. The hospital where the present study was conducted provides health care in the South Bronx area of the city, which has a high prevalence of AIDS. Such patients have an increased incidence of respiratory disorders throughout the course of their illness. They also develop cardiac problems such as pericardial effusions. As a result these various disorders, patients may need thoracic surgery and intervention to make a diagnosis and carry out treatment.

MATERIAL AND METHOD

The medical records of all patients who were treated at the Cardiothoracic Unit at Bronx-Lebanon Hospital Center between July 1996 and June 1998 were reviewed. Those patients who had AIDS were studied in detail. All patients were referred from the Medical Services for surgical evaluation and treatment.

Thirty-nine patients had AIDS, according to the criteria established by the Center for Disease Control; they were HIV+, had a low CD4+ count and suffered from opportunistic infections or tumours.¹

All patients with empyema thoraces underwent intercostal underwater suction drainage as the initial mode of treatment. This was inserted in the most dependant part of the chest, using 36F chest tube. In all of these patients, intercostal drainage failed to resolve the empyema after 2 weeks. Thoracotomy and decortication, therefore, was required. Postoperatively, all patients were treated in the intensive care unit.

Patients who were referred with pericardial effusion had an echocardiogram done which estimated the volume of effusion to be more than 300 mls. The operation was carried out under local anesthesia using an extra peritoneal approach through an upper midline incision. Approximately 2.5 x 2.5 cm of pericardium was excised and a size 36 Foley catheter was left in the pericardial space. It was removed when drainage was reduced to less than 30 mls per day. Patients who had segmental resection on part of the lung removed had this performed using the linear stapler. All patients were followed by serial chest radiography and clinical evaluation. Antibiotics were changed according to culture and sensivity. The patients whose histological diagnosis was Kaposi’s sarcoma or lymphoma were referred for chemotherapy.

RESULTS

A total of 210 patients were operated upon during this 3-year period. Thirty-nine patients had AIDS-related problems. This formed 17% of the thoracic operative workload. There were 23 males and 16 females ranging in age from 26-53 years; the majority of patients were between 31-40 years of age. All patients had AIDS as defined by the Center for Disease Control with low CD4+ counts, opportunistic infections or tumours, and positive uman immunodeficiency virus (HIV) tests. Twenty-three of the thirty-nine patients had a CD4+ count of less than 100; the range was 2-519 (Table 1).

Table 1: Level of CD4+ cells in the blood of patients with AIDS

In all patients, risk factors in the form of intravenous drug use or unprotected sex were present. No patient had blood transfusion as a risk factor. Patients had evidence of opportunistic infections as detailed in Table 2.

Table 2: Various types of opportunistic infections encountered

In all patients, a chest radiograph was the initial investigation, which pointed towards a surgical problem related to AIDS. Depending on the findings on chest radiography, 17 patients had a computerised tomography (CT) scan that helped in confirming diagnosis. Blood cultures were positive in 24 patients. The organisms grown were variable (Table 3). More than one organism was obtained from some of the patients. The indications for surgery are detailed in Table 4. One patient who was operated on for empyema developed a gastro-pleural fistula, which subsequently was found to be due to a gastric lymphoma. The operations performed are given in Table 5.

The patients who underwent thoracotomy and decortications for empyema had a thoracocentesis to establish the diagnosis. Subsequently, closed tube thoracostomy was carried out in all patients.

The median time between admission and surgery was 32 days. This was due to patients developing an AIDS-related chest complication requiring surgical intervention while in the hospital or had a delay in diagnosis.

Out of 15 specimens of pericardial fluid, nine were positive on bacterial culture; six grew staphylococcus aureus. Of the 10 specimens sent for culture after surgery for lung abscess/empyema, 14 grew bacterial organisims. Most of these were gram-negative organisms of mixed flora. The post-operative mortality was high. Eighteen of the thirty-nine (46%) died within 30 days of surgery. In most patients it was attributed to the nature of their illness and advanced stage of the disease. One patient died of post-operative myocardial infarction and another from established acute renal failure. The mean CD4+ count in the group of patients who died was 70.5 (standard deviation 52.6), compared with 233.2 (standard deviation 150.6) in the group who were alive at the end of the 30 days post-operatively. This difference was statistically significant (p< .001 by independent samples t-test for unequal variances).

The patients stay in the hospital ranged from 6 to 180 days; the mean was 50 days. This was due to the chronic nature of the disease and the fact that the patients continued to develop a range of problems as a consequence of major immunosupression.

DISCUSSION

Patients with HIV infection have an increased incidence of respiratory disorders throughout the course of their disease. The risk increases as the disease progresses, and is markedly increased in persons who have CD4+ counts of less than 200 per cubic millilitre.² In patients with HIV disease, respiratory complaints must be taken seriously and evaluated promptly. Patients should be instructed to report clinical features such as cough and shortness of breath.³ This may reduce the frequency of complications of pneumonia, such as empyema and lung abscess. Commonly, patients with HIV infection have systemic symptoms such as fever, malaise and weight loss for weeks to months before developing pulmonary symptoms.⁴ The empyema is usually secondary to a para pneumonic effusion. It is usually thick and difficult to aspirate when patients are seen for treatment.⁵ This may be the reason why intercostal chest-tube drainage failed to deal with the problem.

Table 3: Types of organisms grown from blood cultures taken from patients

Intravenous drug use is common among such a group of patients.6 The disease can be severe and pleural involvement so extensive that thoracotomy and decortication may become necessary. Empyema associated with AIDS carries a very high mortality, as has been shown in other series.⁵

In most cases, without HIV disease, open lung biopsy has a high diagnostic yield. However, the role of this procedure in HIV disease is still debated. ^7,8 It is helpful in patients who have no diagnosis despite full bronchoscopic evaluation, including bronchoalveolar lavage and transbronchial biopsy.⁸ The procedure has been used to diagnose lymphocytic interstitial pneumonia and non-specific interstitial pneumonia, both of which may resemble opportunistic infections.⁹ Spontaneous pneumothorax has been described frequently in patients with pneumocystis carinii pneumonia (PCP) and pulmonary tuberculosis. Spontaneous pneumothorax may also be the presenting feature of PCP. ¹⁰ It may also occur after procedures such as transbronchial biopsy. ^11,12

Mediastinal lymphadenopathy may occur with Kaposi’s sarcoma, lymphoma and infections, particularly tuberculosis and fungal infections. ¹³ It is established that the two most common pulmonary neoplastic processes, Kaposi’s sarcoma and non-Hodgkin’s lymphoma, occur when there is severe immune compromise. ¹⁴ Kaposi’s sarcoma may cause parenchymal infiltration and large pleural effusions leading to hypoxia. It may also present as a solitary nodule, as one of the patients did in our study. It may also present as ill-defined nodular lesions throughout both lung fields. ^15,16 It can be fatal in patients with lung involvement. Systemic chemotherapy is at present the most effective treatment. A recent Phase II trial of liposomal daunorubicin has shown promising results.¹⁷ There is no specific manifestation of HIV-related lung lymphoma. Solitary pulmonary lesions, pleural effusions and infiltration of the intra-thoracic adenopathy may occur. ¹⁸ In most patients it is a high grade B-cell non-Hodgkin’s lymphoma. ¹⁹

Since HIV infection was first recognised in 1981, case reports have been described, documenting both clinical and autopsy evidence of cardiac abnormalities. The most common cardiac abnormality has been pericarditis; on occassions large pericardial effusions, often with cardiac tamponade have been described. ²⁰ In some of these reports, the aetiology of the pericardial effusions was unknown. Other series have also reported opportunistic infections as a cause in some cases. ^21,22,23 In a series of 25 cases reported by Galli and Cheitlem (1992), no identifiable aetiology was found. ²⁴

The survival of patients with advanced HIV disease and pericardial effusion is significantly shorter than survival for all patients with advanced disease without effusion. ²⁵ If a patient has an increase in the cardiac size on a chest radiograph or clinical signs of heart failure, an echocardiogram should be performed to differentiate between pericardial effusion and heart failure. Among HIV-infected patients with cardiac abnormalities, the incidence of alcohol, cocaine and injection drug use is high. This has been observed in other studies as well. ²⁶

Table 4: Clinical indications for surgical procedures carried out

Table 5: Operative procedures done on patients with AIDS

CONCLUSION

Thoracic surgery in patients with HIV carries a high mortality. This may be due to the advanced underlying immunodeficiency in such patients rather than the surgical problems or the surgical procedures carried out. Thoracic surgical intervention, therefore, should be used with caution in patients with AIDS. Earlier detection and treatment of complications may improve outcome.

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Copyright date: 11th July 2001

Correspondence: S.H. Ahmed, Sage Memorial Hospital, PO Box 1090, Ganado, Arizona 86505, USA
E-mail: Syedhaseen@aol.com