HIV, Tuberculosis and the Thoracic Surgeon

HIV, Tuberculosis and the Thoracic SurgeonMany of our patients present with concomitant HIV infections. As most of our patients are presenting with inflammatory or malignant disease, the co-existence of Human Immunodeficiency Virus infection with possible immuno-suppression is taken into account in assessing suitability and appropriateness of major surgery. Patients with life-threatening haemoptysis or infective complications are all treated with no account of immune status providing they do not have clinically overt AIDS. Patients requiring elective major surgery are all counselled about HIV blood tests and consent is obtained before these tests are performed. If the test if positive, then a CD4 assay is performed to assess adequate immunocompetance before proceeding. A CD4 count of over 200 is considered adequate to withstand major surgery with prospect of medium term survival. In patients who are on Anti-Retro-viral therapy, we accept patients for surgery in the abscence of other Contra-indications provided they have been on ARV therapy for a minimum of three months regardless of the CD4 count. In children less than 18 months we are happy to accept a CD4 /total lymphocyte ratio of > 20% or agian if on ARV’s for more than three months. For children over 18 months a CD4/Total lymphocyte ratio of >15% or on ARV’s for more than 3 months. We have performed surgery for first time and redo valve replacement and coronary artery surgery, transposition of the great vessels, resection of carcinoma of the oesophagus, trans-empyema pneumonectomy and resection for multi-drug resistant tuberculosis in HIV positive patients. We have now performed major surgery on well over 150 HIV +ve patients with results almost equivalent to non-HIV patients in patients and presented our initial results at the Aids 2000 congress in Durban. Patients who were not on ARV therapy with low CD4 counts were noted to have a higher incidence of complications and death.

Tuberculosis rather than decreasing in our province, appears to be static and we are seeing patients who have developed massive haemoptysis in the acute phase. Many later suffer pulmonary damage developing extensive bronchiectasis complicated by recurrent chest infection, or formation of aspergillomata usually in the upper lobe or apical lower lobe lung segments. The major part of the pulmonary surgery at King George V Hospital is for resection of lungs destroyed by Tuberculosis. Some of these patients are young children although at last their need for surgery does seem to be decreasing and this surgery is now performed at IALCH due to the lasck of facilities at KGV for children to have surgery.

Until the primary health care system can adequately treat TB, (until recently more than 50% of patients have failed to complete treatment), we are doomed to go on treating these terrible but mainly avoidable complications.

Improvement in treatment and follow up is occuring with tracing of contacts by the primary health care system and institution of DOTS (Directly Observed Treatment). Education both by the local and National media is vital to help local communities in the ongoing fight against TB.

Multi-drug resistant (MDR TB) has become a major problem. Many patients can be helped if they have surgically resectable disease and many operations are now being performed in this group to help with steralizing the lungs.

Extremely Drug Resistant TB (XDR TB) has made major headlines over the last year. It appears to have its highest incidence in KZN. We have now performed resectio for such disease limited to one lobe but it is too early to report the longterm results of this surgery. Again avoidance of the disease would seem the most logical way to deal with a medically almost incurable disease and most of these patients are being treated as inpatients in an effort to halt spread.