Wittmann M M, Wittmann A, Wittmann D H
Department of Surgery, University of Colorado Health Center, Denver, USA.
Infect Control Hosp Epidemiol. 1996 Aug;17(8):532-8. doi: 10.1086/647364.
Acquired immunodeficiency syndrome (AIDS) caused by the human immunodeficiency virus (HIV) may turn out to be the largest lethal epidemic of infection ever. The estimated global number of HIV-infected adults in 1993 was 13 million, with projections of up to 40 million by the year 2000. Human immunodeficiency virus infections and AIDS are relevant to surgeons with respect to the surgical management of AIDS patients in general, the treatment of the increasingly long list of surgical complications specific to AIDS patients in particular, and the risks of patient-to-surgeon and surgeon-to-patient HIV transmission. Because of migration of individuals and populations throughout the world, even surgeons practicing in relatively unaffected regions should be familiar with the potential surgical implications of AIDS. Ethical considerations arise, as well. Are surgeons obliged to operate on HIV-positive or AIDS patients? Some surgeons adhere strictly to the Hippocratic Oath, whereas others reserve the right to be selective on whom they operate, except in emergencies. Other common ethical considerations in the AIDS patient are similar to those arising in the terminal cancer case: whether to operate or not; whether to provide advanced support such as total parenteral nutrition or hemodialysis. Answers are not simple and require close collaboration between the surgeon, the AIDS specialist, and involved members of other specialties. Emergency operations become necessary to treat AIDS independent disease such as acute cholecystitis and appendicitis or AIDS-related life-threatening conditions such as gastrointestinal bleeding, obstruction, perforation, or ischemia complicating Kaposi's sarcoma, lymphoma, and cytomegalovirus or disseminated nontuberculous mycobacterial infections. Delays and errors in diagnosis are frequent. Poor nutritional state with weight loss, low serum albumin, and leukocyte count prevails in most patients requiring emergency operations and account for a high mortality. By applying solid judgment and selecting management appropriately, the surgeon has the ability to prolong life and to improve the quality of life for these unfortunate patients, and to do so with extremely minimal risk to himself and his team.
由人类免疫缺陷病毒（HIV）引起的获得性免疫缺陷综合征（AIDS，艾滋病）可能会成为有史以来最大的致命性感染流行疾病。据估计，1993年全球感染HIV的成年人数量为1300万，预计到2000年将增至4000万。就总体上对艾滋病患者的外科治疗、尤其是治疗艾滋病患者特有的越来越多的外科并发症，以及患者与外科医生之间和外科医生与患者之间HIV传播的风险而言，人类免疫缺陷病毒感染和艾滋病与外科医生密切相关。由于世界各地的个人和人群迁移，即使是在受影响相对较小地区执业的外科医生也应该熟悉艾滋病在外科方面的潜在影响。同时也出现了伦理方面的考量。外科医生有义务为HIV阳性或艾滋病患者做手术吗？一些外科医生严格遵守希波克拉底誓言，而另一些医生则保留选择手术对象的权利，紧急情况除外。艾滋病患者的其他常见伦理考量与晚期癌症病例中的类似：是否进行手术；是否提供诸如全胃肠外营养或血液透析等高级支持。答案并不简单，需要外科医生、艾滋病专家以及其他相关专科的成员密切合作。对于诸如急性胆囊炎和阑尾炎等与艾滋病无关的疾病，或诸如胃肠道出血、梗阻、穿孔，或使卡波西肉瘤、淋巴瘤、巨细胞病毒或播散性非结核分枝杆菌感染复杂化的缺血等与艾滋病相关的危及生命的情况，进行急诊手术是必要的。诊断延误和失误很常见。大多数需要急诊手术的患者营养状况较差，体重减轻、血清白蛋白低和白细胞计数低，这是导致高死亡率的原因。通过运用可靠的判断力并适当选择治疗方法，外科医生有能力延长这些不幸患者的生命并改善其生活质量，同时将对自身及其团队的风险降至极低。
