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Surgery in Patients with HIV
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Introduction
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Surgery in the Management of Clinical Problems of HIV Infection
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transparent imageLymphadenopathy
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transparent imageImmune Deficiency-Associated Thrombocytopenic Purpura
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transparent imageThoracic Surgery
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transparent imageAbdominal Lymphadenopathy and Organomegaly
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transparent imageBiliary Tract Disease
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transparent imageIntracranial Mass Lesions
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transparent imageVascular Access
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transparent imageAnorectal Surgery
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transparent imageSolid Organ Transplantation in People with HIV
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Estimation of Operative Morbidity and Mortality
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Occupational Risk of HIV Transmission
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transparent imageRisk After Occupational Exposure
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transparent imageHIV Seroprevalence of Surgical Patient Populations
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transparent imageHIV Transmission from Provider to Patient
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Prevention Strategies
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transparent imageInfection-Control Precautions
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transparent imageChanges in Surgical Technique
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transparent imageMandatory Preoperative HIV Testing
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transparent imageNonoperative Treatment of HIV-Infected Patients
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Risk and Responsibility
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References
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Related Resources
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Introduction
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More than 40 million people worldwide, including up to 1 million Americans, are infected with HIV. Surgical treatment of HIV-infected patients is necessary for problems both related and unrelated to HIV infection. This chapter discusses a) the treatment of surgical problems directly related to HIV, b) the morbidity and mortality of surgery in HIV-infected patients, c) the risk of occupational transmission of HIV to the surgical team, and d) strategies for prevention of perioperative HIV transmission.

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Surgery in the Management of Clinical Problems of HIV Infection
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Lymphadenopathy
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Generalized lymphadenopathy is a common symptom of HIV infection. Lymph node biopsy specimens were obtained almost daily at San Francisco General Hospital during the early years of the HIV epidemic. Fine-needle aspiration (FNA) of enlarged lymph nodes usually provides sufficient diagnostic information.(1) Open lymph node biopsy should be reserved for two situations: to provide sufficient tissue to classify a lymphoma diagnosed by FNA, and to investigate a clinically suspicious FNA-negative lymph node that continues to enlarge or that occurs in a patient with an unexplained systemic illness. FNA is also useful for diagnosis of HIV-associated infections such as tuberculosis, Mycobacterium avium complex (MAC), and lymphadenitis.(2)

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Immune Deficiency-Associated Thrombocytopenic Purpura
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The relationship between HIV infection and thrombocytopenic purpura was first described in 1986 by Abrams et al.(3) This condition can occur in asymptomatic HIV-infected patients or in patients with advanced HIV disease. Patients with HIV-associated immune thrombocytopenic purpura (HIV-ITP) do not respond as well to steroid therapy as do HIV-negative patients with idiopathic thrombocytopenic purpura. Combination antiretroviral therapy has resulted in increased platelet production.(4) However, some HIV-infected patients may require splenectomy to control refractory thrombocytopenia.(5)

The results of splenectomy are good in HIV-infected patients without clinical manifestations of advanced HIV disease.(6) A significant rise in both the platelet count and the CD4-cell count occurs after splenectomy.(7) Splenectomy is also effective in HIV-infected hemophiliac patients with ITP.(8) In contrast, the morbidity and mortality have been considerable after splenectomy in patients with advanced HIV disease with ITP.(9) Elective splenectomy is rarely indicated in patients with advanced HIV disease. Splenectomy does not appear to increase the rate of progression from HIV seropositivity to clinical AIDS nor does it appear to accelerate the rate of immunologic deterioration of a patient who already has a diagnosis of AIDS prior to surgery.(10)

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Thoracic Surgery
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HIV-infected patients with advanced disease may present with pulmonary infiltrates caused by a variety of opportunistic infections as well as Kaposi sarcoma (KS) and lymphoma. Pneumocystis jiroveci pneumonia (PCP) is the most frequent opportunistic infection, but bacterial pneumonias, MAC infection, tuberculosis, and fungal pulmonary infections are also common. Often more than one pathogen is involved in the etiology of pulmonary infiltrates.(11-14) Examination of induced sputum specimens is an excellent diagnostic test for PCP,(15) and sensitivity is improved if patients with negative induced sputum are further evaluated by bronchoalveolar lavage with or without transbronchial biopsy.(16) Obtaining a lung specimen by open biopsy is seldom indicated and rarely yields a diagnosis of a treatable condition.(17) Occasionally, a relatively fit patient with pulmonary lymphoma may benefit from an open lung biopsy to provide enough tissue for diagnosis and classification. The use of video-assisted thoracic surgery in the management of pneumothorax and empyema has simplified treatment in the HIV-infected patient.(18)

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Abdominal Lymphadenopathy and Organomegaly
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HIV-infected patients may present with abdominal discomfort related to organomegaly and intraperitoneal and/or retroperitoneal lymphadenopathy caused by opportunistic infections and neoplasia. Computed tomography (CT)-guided FNA has largely replaced diagnostic exploratory laparotomy as the diagnostic procedure of choice because it usually permits diagnosis of MAC infection, KS, and lymphoma.(19,20) Laparotomy is rarely necessary to evaluate organomegaly or lymphadenopathy and should generally be reserved for therapeutic procedures, such as drainage of pus, resection of neoplasm, and relief of obstruction.

In one retrospective study, only 8% of HIV-infected patients presenting to the emergency department (ED) with abdominal pain required abdominal surgery, and HIV-associated opportunistic infections accounted for only 10% of ED diagnoses in patients presenting with abdominal pain and advanced HIV disease.(21)

HIV-infected patients with appendicitis have clinical symptoms and signs similar to appendicitis patients without HIV risk factors. However, as HIV-infected patients with appendicitis often do not have leukocytosis, normal white blood count may delay diagnosis and appendectomy, resulting in increased morbidity.(22)

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Biliary Tract Disease
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Opportunistic infections can involve the gallbladder and common bile duct of HIV-infected patients. Cryptosporidium, Salmonella, cytomegalovirus, and MAC have been identified in biopsy specimens of the ampulla of Vater in patients who presented with right upper quadrant pain, fevers, or elevated alkaline phosphatase levels.(23,24) However, most HIV-infected patients with biliary tract disease have cholelithiasis.(25) Acute cholecystitis typically requires cholecystectomy.(26) Extrahepatic biliary obstruction due to sclerosing cholangitis or ampullar stenosis or both is a well-described phenomenon in HIV-infected patients. This obstruction is usually managed by endoscopic sphincterotomy without laparotomy.(27) Extrahepatic biliary obstruction may also be caused by external compression of the common bile duct by enlarged portal lymph nodes or by lymphoma of the common bile duct.(28)

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Intracranial Mass Lesions
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Patients with advanced HIV disease may develop intracranial mass lesions due to toxoplasmosis, brain abscess, or primary central nervous system (CNS) lymphoma.(29) Toxoplasma abscesses are the most common lesions. A 3-week empiric trial of pyrimethamine and sulfadiazine for all patients with advanced HIV disease and intracranial mass lesions is the first step. A CT-guided stereotactic needle biopsy should be performed if some or all of the masses fail to respond to empiric therapy.(30) A shorter therapeutic trial and earlier biopsy may be required for rapidly expanding lesions.(31) The use of positron emission tomography combined with Toxoplasma serologic screening may also identify patients who will benefit from earlier biopsy.(32,33)

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Vascular Access
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Vascular access for patients requiring long-term chemotherapy is achieved using tunneled Silastic catheters placed percutaneously or by cutdown into the subclavian or internal jugular vein, or, less commonly, subcutaneously implantable diaphragms connected to Silastic catheters. The advantage of these systems is not having an external catheter passing through the skin. Disadvantages are that they require percutaneous puncture of the diaphragm for each chemotherapy infusion, and an operation is needed for removal if the catheter becomes infected. Nosocomial infection rates for HIV-infected patients appear to be higher than those for the general population.(34) Nosocomial infection rates for HIV-infected dialysis patients are significantly higher than those for HIV-negative dialysis patients, particularly if there is a history of intravenous drug use.(35)

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Anorectal Surgery
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Anorectal procedures are the most common operations performed in HIV-infected homosexual male patients. Extensive anal condylomata, fistula in ano, hemorrhoids, and perirectal abscess are all indications for surgery.(36,37) Rubber band ligation and open hemorrhoidectomy (38,39) are safe procedures, although wound healing may be delayed in patients with low CD4 T-lymphocyte counts.(40) Squamous cell carcinoma of the anus occurs in HIV-infected patients, often in association with anal condylomata.(41) Excision, cautery, and laser ablation of condylomata and intraepithelial neoplasia are safe methods of treatment.(42,43) Treatment considerations are the same for HIV-positive and HIV-negative patients. Anorectal KS usually requires no specific therapy.(44)

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Solid Organ Transplantation in People with HIV
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Patients with HIV have traditionally been excluded from solid organ transplantation out of concerns that further immunosuppression in a potentially immunosuppressed patient would be dangerous. However, in the setting of effective antiretroviral therapy, people with HIV are dying less frequently from progression to AIDS, but more often from comorbid conditions, which may affect both the liver and kidney. Based on the increasing demand for solid organ transplantation, combined with decreased morbidity and mortality in patients with HIV, transplant centers are cautiously proceeding with transplantation in selected patients with well-controlled HIV infection. The improvements in effective prophylaxis against opportunistic infections that affect both HIV and transplant recipients has provided further rationale for embarking on transplantation in this challenging group of patients. Finally, the immunosuppressive medications commonly used to suppress the alloimmune response may actually have antiretroviral qualities that may make their use in people with HIV less risky than expected.(45,46)

Patients with HIV are commonly coinfected with hepatitis C virus (HCV) and hepatitis B virus (HBV) because of their similar routes of transmission. As a result, end-stage liver disease has emerged as a leading cause of morbidity and mortality in people infected with HIV in the era of combination antiretroviral therapy.(47) Similarly, it has been estimated that 4-7% of HIV-positive patients have end-stage renal failure and have a higher mortality on dialysis than HIV-negative patients.(48,49) For these reasons, transplant centers across the country have begun to proceed with solid organ transplantation. The initial trials have selected patients with well-controlled HIV disease, as defined by undetectable HIV viral loads, CD4 counts greater than 100/mm3 for liver transplants and 200/mm3 for kidney transplants, and no history of opportunistic infections.

Early data from initial trials dispute the convention that HIV is a strict contraindication to transplantation. Early graft and patient survival has been equivalent to that seen in HIV-negative recipients.(50) Of equal significance, solid organ transplantation has not been found to increase progression of HIV disease or development of opportunistic infections. Patient management post-transplant can be complicated by the complex interactions of the antiretroviral regimen with immunosuppressive regimens, requiring close monitoring of drug levels and dosage adjustment.(51) There have been some reports of rapid recurrence of hepatitis C following liver transplantation in people with HIV,(52) but other reports suggest that the recurrence is no different than in HIV-negative recipients.(53) Further liberalization of the transplantation selection criteria for people with HIV will be dependent on continued follow-up of these initial trials, but early results are promising.

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Estimation of Operative Morbidity and Mortality
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No prospective data are available on operative morbidity and mortality in HIV-positive and HIV-negative patients. In one retrospective study, investigators found a high incidence of serious wound complications after anorectal surgery and urged nonoperative treatment for most anorectal diseases in HIV-infected patients.(54) The experience at San Francisco General Hospital and elsewhere indicates that most HIV-infected patients who require anorectal surgery benefit from surgical treatment and their wounds heal.(37,55) A study of laparotomy in HIV-infected patients showed no increase in wound complications.(56)

Despite a scarcity of hard data, we believe it is possible to predict the risk of surgery for an HIV-positive person in much the same way as risk is assessed for an HIV-negative person. Routine history taking, physical examination, and laboratory tests probably provide adequate information about wound healing. An otherwise fit HIV-positive person with good muscle mass probably has the same risk of wound complications as an HIV-negative person.

Data regarding the value of CD4 counts in predicting postoperative wound and septic complications after anorectal surgery are controversial. The incidence of bacterial infectious complications was independent of CD4 T-cell counts in a retrospective study of 56 HIV-positive trauma patients treated at Bellevue Hospital in New York City.(57) Two subsequent studies have also shown no correlation between HIV serologic and immune status as independent variables and surgical complications.(58,59) Results of other studies, however, suggest a direct correlation exists between the CD4 cell counts and postoperative sepsis.(60,61)

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Occupational Risk of HIV Transmission
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During a prospective observational study of 1,307 consecutive patients at San Francisco General Hospital, accidental exposure of surgical personnel to patients' blood occurred during 84 procedures (6.4%). Parenteral exposure occurred during 23 procedures (1.7%). The risk of exposure was highest when procedures lasted more than 3 hours, when blood loss exceeded 300 mL, and when major vascular or intra-abdominal gynecologic surgery was performed.(62)

The level of awareness of the occupational risk of HIV transmission at San Francisco General Hospital is high, and strict infection-control precautions are generally taken during surgery. The risk of exposure is reportedly much higher at other institutions.(63-66) The possibility of exposure of the mucous membranes of the upper respiratory tract to aerosolized blood during certain surgical procedures has been investigated. Although data are incomplete, surgical masks may not offer adequate protection during certain operative procedures.(67)

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Risk After Occupational Exposure
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The risk of HIV transmission after injury with a hollow needle contaminated with HIV-infected blood is 0.3%.(68-70) The risk after injury with a suture needle is unknown. Increases in risk of transmission are associated with several specific circumstances : 16-fold if the hollow needle injury was a deep soft tissue penetration, 5-fold if there is either visible blood on the needle or the procedure involved placement of the needle in an artery or vein, and 6-fold if the patient has advanced AIDS (and presumably a high viral titer). Prophylactic administration of zidovudine to the injured health care worker effects an 80 percent reduction in the risk of HIV transmission after hollow needlestick injury.(71)

Surgeons have multiple parenteral and cutaneous exposures over the course of their careers. Chambers developed a mathematical model to predict the risk of HIV seroconversion as a function of the number of needlestick injuries and the seroprevalence of the patient population (Chambers HF, personal communication). This model assumes a seroconversion rate of 0.3% per exposure to HIV-infected blood. The higher the HIV seroprevalence and the higher the number of needlesticks, the greater the risk of occupational HIV transmission.

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HIV Seroprevalence of Surgical Patient Populations
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In 1987, penetrating trauma victims in Baltimore were reported to have an HIV seroprevalence rate of 13%.(72,73) In 1988, the HIV seroprevalence rate among drug addicts in a Brooklyn hemodialysis unit was 89%.(74) At San Francisco General Hospital, 29% of patients going to the operating room had risk factors associated with HIV infection.(62) In a study from Westchester County, New York, 16.7% of all blood samples submitted for transfusion screening or cross-match had serologic evidence of blood-borne viral infection (HIV, HBV, HCV); 5.6% of the specimens were HIV positive.(75) Surgeons who work in large inner-city hospitals can be assumed to be working with patient populations with significant seroprevalence rates.

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HIV Transmission from Provider to Patient
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Since the onset of the epidemic, HIV transmission to patients has been associated with two health care providers, a Florida dentist(76,77) and a French orthopedist.(78) Since 1990, "at least 22,759 patients have received medical care from 53 U.S. health care providers with HIV infection (including 29 dental care workers and 15 surgeons and obstetricians)."(79) Retrospective reviews of these patients identified 113 HIV-infected patients, three of whom represented the infections associated with the two health care providers listed above. Provider-to-patient HIV transmission is therefore a possible but rare event. Infection control precautions should reduce the risk of both patient-to-provider and provider-to-patient transmission of blood-borne infections.

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Prevention Strategies
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Four methods for preventing perioperative HIV transmission are infection-control precautions, changes in surgical technique, mandatory preoperative HIV testing, and nonoperative treatment of HIV-infected patients.

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Infection-Control Precautions
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Blood should be treated as an infectious substance.(62) Contact of patients' blood with the skin and mucous membranes of health care workers is unacceptable. Protective eyewear, masks, and water-impermeable gowns, sleeves, and boots are standard equipment.(80) Wearing two pairs of latex gloves reduces the risk of exposure due to glove defects from approximately 17% to 5%.(62) During procedures involving open fractures, a pair of cloth gloves worn with latex gloves significantly reduces the risk of exposure.(81)

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Changes in Surgical Technique
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Reduction of the incidence of intraoperative exposure to blood requires caution and attention to detail. Avoidance of hand-to-hand passage of sharp instruments and increased use of staple devices instead of suturing are methods that reduce injury. Sharp instruments may be placed on a sterile Mayo stand positioned between the scrub nurse and the surgeon, although this practice requires continual diversion of the surgeon's attention from the operative field. Therefore, this method is good for short, low-risk procedures but may be impractical for longer procedures with the potential for significant blood loss.

Surgeons often use their fingers to protect underlying viscera, particularly when closing the abdomen. This practice is now outmoded and is potentially dangerous. Blunted needles are slowly gaining acceptance for fascial closure. The widespread use of laparoscopy has introduced the possibility of release of HIV-infected blood and peritoneal fluid into the operating room environment during pneumoperitoneal evacuation. Awareness of this potential problem can reduce the risk of HIV transmission.(82)

Surgical technique varies with each surgeon and should be based on what will achieve the best results for the individual patient, given the clinical circumstances. There are no prospective studies comparing risk of exposure among different surgical techniques, and such studies are needed before definitive recommendations can be made.

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Mandatory Preoperative HIV Testing
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In the debate surrounding the question of preoperative HIV testing of patients, opponents were concerned about civil rights implications of a positive HIV test result and feared that HIV-positive patients would receive different (ie, substandard) treatment. Supporters argued that members of the surgical team had the right to know of a potential risk for acquiring a fatal infection after exposure to a patient's blood.

Preoperative testing has become less of an issue because of studies showing that anti-HIV therapy and prophylaxis against opportunistic infection benefit patients in asymptomatic or minimally symptomatic stages of HIV infection. Thus, arguments for HIV testing in the patient's interest have supplanted arguments about the surgical team's right to know. Surgeons who plan to use different precautions during surgery for HIV-positive patients can order preoperative HIV testing after obtaining informed consent and arranging pre- and post-test counseling. Most patients will consent when offered the test, and the few who do not should be managed as if they were HIV positive. Knowledge of a patient's preoperative status offers little protection for the surgical team because HIV testing will not reveal risk from other infectious agents, including human T-lymphotropic virus types I and II, hepatitis viruses, and possible undiscovered infectious agents. It is reasonable to consider all patients to be potentially infected and infectious and to offer patients preoperative HIV testing if they have risk factors for infection or if they request the test. The results of the test, however, should not alter behavior in the operating room.

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Nonoperative Treatment of HIV-Infected Patients
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Surgeons planning treatment must weigh the risks to the patient against the potential benefits of surgery. The HIV epidemic has added a new weight to the scale: the risk to the surgical team. How this unquantified risk should affect the surgeon's decision is an unanswered question. Some surgeons believe they have the right to choose whether to treat HIV-infected patients. Arguments supporting this view include: a) the belief that all HIV-infected patients should be treated in specialized centers; b) the traditional right of physicians to decline to treat certain patients as long as prompt referral to another physician is made; and c) the responsibility of surgeons to protect themselves, their families, and their coworkers against occupationally acquired illness.

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Risk and Responsibility
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We believe that health professionals who are privileged to be members of the surgical team have a professional responsibility to provide the highest possible quality of care for their patients. If the surgeon weighs the risks and benefits to the patient and believes the procedure will have a positive effect on the patient's life, he or she should offer surgical treatment.(83)

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References

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