Abstract
Screening for HIV infection before surgery is controversial. Many surgical societies and countries recommend screening, mostly for subgroups in a population [1]. Here we present a case of periampullary carcinoma, who was detected to be HIV positive on screening before surgery and underwent successful resection. A 44-year-old Indian woman presented with jaundice for 6 months. Her serum bilirubin was 2.5/1.9 mg/dl (total/conjugated), alkaline phosphatase was 307 IU/dl and CA 19-9 was 25.5 U/ml. She was found to be HIV positive during work up in another hospital. Her CD 4 count was 604 cells/ml. CT scan showed an ill-defined periampullary tumor. She developed isoflurane induced refractory hypotension on her first visit to operation room. After cardiac re-evaluation she was operated with using sevoflurane as anesthetic agent. Classical Whipple’s pancreatoduodenectomy and feeding jejunostomy were done. Postoperatively, except for delayed gastric emptying, she recovered well, her nasogastric tube was removed on day 9, and she was discharged on day 11. Her biopsy report showed a 2-cm well-differentiated papillary adenocarcinoma of periampullary region with no perineural/lymphovascular invasion. Her retropancreatic margin, bile duct margin and stomach margin were free of tumor. Peripancreatic (4), common hepatic artery (1) and aortocaval lymphnodes (4) were also free of tumor. She was doing well 3 months after surgery. Although controversial, many countries recommend screening for HIV before surgery, especially in high-risk population. There are arguments against routine screening, like mental trauma and social ostracism. But at the same time, the universal precaution for all patients is not practically feasible in almost all government hospitals and most of the private hospitals in India. As the risk to the health care provider and patient’s spouse is real and the treatment provided in our country for HIV is free, there may be justification in routine screening for all patients undergoing surgery. The influence of surgery on the course of HIV or vice versa is not clear for periampullary cancer. Literature search (English language, Pubmed) revealed only one case of pancreatoduodenectomy for periampullary carcinoma reported from Switzerland with good outcome [2]. CD4 count of less than 200 cells/ml is considered to be a predictor for complications for HIV patients undergoing surgery, but other reports suggest that there is no correlation between CD 4 count and operative complications [2, 3]. This case supports the view that major abdominal surgery like pancreatoduodenectomy can be undertaken with good outcome in the HIV positive patient.
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