Clarke D L, Thomson S R, Bissetty T, Madiba T E, Buccimazza I, Anderson F
Department of General Surgery, Nelson R Mandela School of Medicine, University of Kwa-Zulu Natal, Congella, Durban, South Africa.
World J Surg. 2007 May;31(5):1087-96; discussion 1097-8. doi: 10.1007/s00268-007-0402-8.
Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) has resulted in a resurgence of abdominal tuberculosis in South Africa, and these patients often present to general surgeons. We describe a single-hospital experience in a region of high HIV prevalence.
A prospective database of all patients with suspected abdominal tuberculosis was maintained from January 2003 until July 2005.
There were 67 patients (20 men, 47 women) with an average age of 32 years (range 27-61 years). The erythrocyte sedimentation rate was universally elevated (105 +/- 23). Altogether, 23 patients were HIV-positive and 7 were HIV-negative. The status was unknown in the remainder. Chest radiographs demonstrated an abnormality in 17 patients (22%). Abdominal ultrasonography was performed in 59 patients and computed tomography in 12. Twelve laparotomies were performed, seven as emergencies. None in the elective laparotomy group died, whereas the mortality rate in the emergency group was 60%. Laparoscopy was insufficient for a variety of reasons. Two patients underwent appendectomy and two excision of a perianal fistula. Two patients underwent biopsy of a palpable subcutaneous node, which confirmed the diagnosis in both cases. A definitive diagnosis was achieved in all 12 patients subjected to laparotomy and at colonoscopic biopsy in 2, lymph node biopsy in 2, appendectomy in 2, perianal fistulectomy in 2, and percutaneous drainage in 2. In the remaining 47 patients the diagnosis was made on the basis of the clinical presentation and radiologic imaging. The patients were commenced on antituberculous therapy. The in-hospital mortality in this group was 10%. Therapy was continued at a centralized tuberculosis facility independent of the hospital. Surgical follow-up was poor, with only five (7%) patients completing the 6-month review at a surgical clinic.
A resurgence in tuberculosis during the HIV era produces a new spectrum of presentations for the surgeon. Emergency surgery is associated with high mortality. Bacterial and histologic evidence of infection are difficult to obtain, and indirect clinical and imaging evidence are used to commence a trial of therapy. A short-term clinical response is regarded as proof of disease. Lack of follow-up means that the efficacy of this strategy is unproven. Health policy changes are needed to enable appropriate surgical follow-up to determine the most effective management algorithm.
人类免疫缺陷病毒/获得性免疫缺陷综合征（HIV/AIDS）导致南非腹部结核病再度流行，这些患者常就诊于普通外科医生。我们描述了在一个HIV高流行地区一家医院的经验。
从2003年1月至2005年7月，对所有疑似腹部结核病患者建立前瞻性数据库。
共有67例患者（20例男性，47例女性），平均年龄32岁（范围27 - 61岁）。红细胞沉降率普遍升高（105±23）。其中23例患者HIV阳性，7例HIV阴性。其余患者情况不明。胸部X线片显示17例患者（22%）有异常。59例患者进行了腹部超声检查，12例进行了计算机断层扫描。实施了12例剖腹手术，7例为急诊手术。择期剖腹手术组无患者死亡，而急诊组死亡率为60%。由于各种原因，腹腔镜检查并不充分。2例患者接受了阑尾切除术，2例进行了肛周瘘管切除术。2例患者对可触及的皮下结节进行了活检，两例均确诊。所有12例接受剖腹手术的患者、2例经结肠镜活检、2例经淋巴结活检、2例经阑尾切除术、2例经肛周瘘管切除术以及2例经皮引流术的患者均确诊。其余47例患者根据临床表现和影像学检查确诊。患者开始接受抗结核治疗。该组患者的院内死亡率为10%。治疗在独立于医院的集中结核病治疗机构继续进行。手术随访情况不佳，只有5例（7%）患者在外科诊所完成了6个月的复查。
HIV时代结核病的再度流行给外科医生带来了一系列新的临床表现。急诊手术死亡率高。感染的细菌学和组织学证据难以获得，间接的临床和影像学证据被用于开始试验性治疗。短期临床反应被视为疾病的证据。缺乏随访意味着该策略的疗效未经证实。需要改变卫生政策，以便进行适当的手术随访，以确定最有效的管理方案。
