This article describes a 27-year-old patient with acquired immunodeficiency syndrome (AIDS) who underwent emergency sigmoid colostomy, Hartmann\u27s pouch, and presacral drainage for rectal perforation. Three months later, he underwent uneventful elective colostomy closure, a procedure previously unreported in an AIDS patient. He remained without gastrointestinal symptoms for 14 months after colostomy closure until he died from central nervous system toxoplasmosis. A diagnosis of AIDS alone should not preclude colostomy closure in AIDS patients

Holt, R W

Kenkel, J M

Pasquale, Michael D, MD, FACS, FCCM

English

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Lehigh Valley Health Network LVHN Scholarly Works Department of Surgery Elective colostomy closure in an AIDS patient. Michael D. Pasquale MD, FACS, FCCM Lehigh Valley Health Network, michael.pasquale@lvhn.org J M Kenkel R W Holt Follow this and additional works at: https://scholarlyworks.lvhn.org/surgery  Part of the Other Medical Specialties Commons, and the Surgery Commons Published In/Presented At Pasquale, M. D., Kenkel, J. M., & Holt, R. W. (1994). Elective colostomy closure in an AIDS patient. Journal Of The National Medical Association, 86(6), 469-471. This Article is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by an authorized administrator. For more information, please contact LibraryServices@lvhn.org. CASE REPORTSELECTIVE COLOSTOMY CLOSUREIN AN AIDS PATIENTMichael D. Pasquale, MD, Jeffrey M. Kenkel, MD, and Richard W. Holt, MD, MPHWashington, DCThis article describes a 27-year-old patient withacquired immunodeficiency syndrome (AIDS)who underwent emergency sigmoid colos-tomy, Hartmann's pouch, and presacral drain-age for rectal perforation. Three months later,he underwent uneventful elective colostomyclosure, a procedure previously unreported inan AIDS patient. He remained without gastroin-testinal symptoms for 14 months after colos-tomy closure until he died from central nervoussystem toxoplasmosis. A diagnosis of AIDSalone should not preclude colostomy closurein AIDS patients. (J Nati Med Assoc.1 994;86:469-471.)Key words * acquired immunodeficiency syndrome(AIDS) * gastrointestinal symptoms * colostomy closureAcquired immunodeficiency syndrome (AIDS) wasfirst recognized as a distinct clinical entity in 1981.1The causative agent, human immunodeficiency virus 1(HIV-1), was isolated in 1983.2 By June 1, 1992, morethan 225 000 cases of AIDS had been reported to theCenters for Disease Control.3 By the year 2000, anestimated 6 million people will be afflicted worldwide.4Given these numbers, it is highly likely that most, if notall, surgeons now practicing will be involved at sometime in the treatment of AIDS patients.l14 This articledescribes elective colostomy closure in an AIDSpatient.From Georgetown University Surgery Section, DC GeneralHospital, and the Department of Surgery, Georgetown Univer-sity Medical Center, Washington, DC. Requests for reprintsshould be addressed to Dr Richard W. Holt, GeorgetownUniversity Surgery Section, DC General Hospital, 19th &Massachusetts Ave, SE, Washington, DC 20003.CASE REPORTA 27-year-old homosexual black male with AIDSwas admitted for elective colostomy closure. He wasnoted to be HIV positive in 1986, and his firstopportunistic infection occurred in August 1989 whenhe was treated for Pneumocystis carinii pneumonia. Hesubsequently was maintained on prophylactic zidovud-ine and trimethoprim-sulfamethoxazole.In November 1990, he presented to the hospitalcomplaining of left lower quadrant abdominal pain,fever, and diarrhea. There was marked tenderness in theleft lower quadrant. Computerized tomography of theabdomen and pelvis revealed free air in the perirectaltissues. On further questioning, he admitted to havingreceptive anal intercourse on the previous evening. Adiagnosis of rectal perforation was made, and surgicalconsultation was obtained. Emergent exploratory lapa-rotomy with sigmoid colostomy and Hartmann's pouchwas performed along with presacral drainage. Hispostoperative course was unremarkable, and he wasdischarged on postoperative day 10.He was readmitted 3 months later for electivecolostomy closure. His Karnofsky performance statuswas 90%. Admission laboratory values were significantfor a white blood cell count of 2500 cells/dL, a CD4count of 61.63 cells/UL (normal = 500-1200), a CD8count of 225.4 cellslUL (normal = 200-800), and aT4/T8 ratio of 0.27 (normal= 1.0 or greater). Zidovud-ine was discontinued 2 days prior to admission. Inanticipation of colostomy closure, a barium enema hadbeen performed several weeks prior to admission andrevealed no extravasation or stricture in the rectum orcolon. Standard bowel preparation was accomplishedwith one gallon of Golytely (PED 3350 and electro-lytes, Braintree Laboratories, Braintree, Massachusetts)orally along with tap water enemas. Cefoxitin, 1 g IV,was given preoperatively and continued for two dosesJOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 86, NO. 6 469COLOSTOMY CLOSURE IN AIDS PATIENTpostoperatively. A functional end-to-end stapled anas-tomosis was performed. The postoperative course wasagain uncomplicated, and he was discharged onpostoperative day 7 tolerating a regular diet and havingformed bowel movements.At 10 months postcolostomy closure, he requiredchest tube placement and brief hospitalization for aspontaneous pneumothorax. Two months thereafter, hedeveloped cutaneous manifestations of Kaposi's sar-coma but was without gastrointestinal symptoms. Thepatient died 14 months after colostomy closure due tocentral nervous system toxoplasmosis.DISCUSSIONEstimates of increasing numbers of HIV-infectedpersons along with advances in their treatment, mostnotably the use of zidovudine, make it likely that mostsurgeons will be involved in the treatment of HIV-infected patients.4'5 Guidelines for the surgical treat-ment of patients with AIDS are still in the early stagesof definition.6 It is important that these guidelines befurther defined with regard to abdominal surgery, as upto 4.3% of AIDS patients will require laparotomy.7Prior to recommending surgery to any patient, asurgeon must weigh the potential benefits of theoperation against its morbidity and mortality. Morbidityand mortality are of special concern in immunocompro-mised patients. Several authors have stated that the risksassociated with major abdominal surgery in the AIDSpatient are prohibitive.8'9 Studies to date involve limitednumbers of patients and have not stratified patients withrespect to manifestations of their disease.6'10Our case represents the first reported case of anelective colostomy closure in a patient with AIDS.Colostomy closure is a common operative procedure,with a morbidity rate varying from 9.6% to 33% and areported mortality rate of 0% to 2.2%.1 1,12 Complica-tions are most often related to wound infection, with themajor factor affecting the morbidity rate being theinterval of time between formation of the colostomyand its closure.13 Currently, an interval of at least 90days is recommended.13 A study by Buehrer et a114 onhemophiliacs revealed no significant difference in thewound infection rates between HIV- 1-positive andHIV-1-negative patients. Although no significant dif-ferences in morbidity or mortality have been describedwith regard to the material or methods used to performcolostomy closure, in the case presented here, staplingdevices were used to reestablish gastrointestinal conti-nuity to decrease the risk of needle injury to operatingroom personnel.'3Perioperative mortality following major abdominalprocedures in AIDS patients has ranged from 9% forsolely elective cases to 70% for emergency cases.6'7'15In all instances, death has been attributable to progres-sion of AIDS in combination with overwhelmingsepsis.6'15 Specific prognostic factors have not beenfully elucidated. Wexner et a19 noted that preoperativewhite blood cell counts <5000/mm3 correlated withdecreased wound healing in AIDS patients undergoinganorectal procedures. Other authors have shown nosignificant relationship between hematologic indicesand morbidity or mortality.6 Indeed, Schecter et al°reported that asymptomatic patients with HIV infectiondid not have significantly increased morbidity andmortality when compared with equally fit non-HIV-infected patients. To date, the only consistent predictorof outcome postoperatively in AIDS patients is thefailure of more than one organ system.6We agree with Deziel et al,6 LaRaja et al,7 andWilson et a115 that celiotomy does not jeopardizesurvival in AIDS patients and thus should not bewithheld for fear of unfavorable outcomes. Electiveintra-abdominal procedures, however, should be re-served for those patients without multisystem organfailure as perioperative mortality is excessive in thatgroup.6'8 Although randomized prospective studies toconfirm this are lacking, the Karnofsky performancestatus scale may be used as a guideline to select thosepatients who will best tolerate intra-abdominal proce-dures. 16CONCLUSIONThere is no evidence that the outcome of surgery isdifferent for healthy HIV-infected individuals than it isfor non-HIV infected persons, even when dealing withdisease unrelated to AIDS.10 The patient described hereillustrates that both emergency and elective intra-abdominal procedures may be performed in functionalAIDS patients with good results. Thus, the diagnosis ofAIDS alone should not preclude such surgery.Literature Cited1. Nugent P, O'Connell TX. The surgeon's role in treatingacquired immunodeficiency syndrome. Arch Surg. 1986;121:1117-1120.2. Barre-Sinoussi F, Chermann J-C, Rey F, Nugeyre MT,Chamaret S, Gruest J, et al. Isolation of a T lymphotropicretrovirus from a patient at risk of acquired immune deficiencysyndrome. Science. 1983;220:868-870.3. Centers for Disease Control. AIDS Weekly SurveillanceReport. June 1992.4. Williams RA, Wilson SE. Surgical intervention andprecautions in AIDS patients. AIDS Updates. 1991;4:1.470 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 86, NO. 6COLOSTOMY CLOSURE IN AIDS PATIENT5. Moore RD, Hidalgo J, Sugland BW, Chaisson RE.Zidovudine and the natural history of the acquired immunodefi-ciency syndrome. N Engl J Med. 1991;324:1412-1416.6. Deziel DJ, Hyser MJ, Doolas A, Beines SD, Blaauw B,Kessler HA. Major abdominal operations in acquired immu-nodeficiency syndrome. Am Surg. 1990;56:445-450.7. LaRaja RD, Rothenberg RE, Odom JW, Mueller SC. Theincidence of intra-abdominal surgery in acquired immunodefi-ciency syndrome: a statistical review of 904 patients. Surgery.1 989;105:175-179.8. Burack JH, Mandel MS, Bizer LS. Emergency abdominaloperations in the patient with acquired immunodeficiencysyndrome. Arch Surg. 1989;124:285-286.9. Wexner SD, Smithy WB, Milsom JW, Daily TH. Thesurgical management of anorectal diseases in AIDS andpre-AIDS patients. Dis Colon Rectum. 1986;29:719-723.10. Schecter WR Surgery of AIDS and related conditions.In: Sim AJW, Jeffries DJ, eds. AIDS and Surgery. Oxford,England: Blackwell Scientific Publications; 1990:38-42.11. Garnjobst W, Leaverton GH, Sullivan ES. Safety ofcolostomy closure. Am J Surg. 1978;1 36:85-89.12. Knox AJS, Birkett FDH, Collins CD. Closure of colos-tomy. BrJ Surg. 1971;58:669-672.13. Parks SE, Hastings PR. Complications of colostomyclosure. Am J Surg. 1985;149:672-675.14. Buehrer JL, Weber DJ, Meyer AA, Becherer PR, RutalaWA, Wilson B, et al. Wound infection rates after invasiveprocedures in HIV-1 seropositive versus HIV-1 seronegativehemophiliacs. Ann Surg. 1990;21 1:492-498.15. Wilson SE, Robinson G, Williams RA, Stabile BE, ConeL, Sarfeh J, et al. Acquired immune deficiency syndrome(AIDS): indications for abdominal surgery, pathology, andoutcome. Ann Surg. 1989;210:428-434.16. Mor V, Laliberte L, Morris JN, Wiemann M. TheKarnofsky performance status scale: an examination of itsreliability and validity in a research setting. Cancer.1 984;53:2002-2007.You can help us raise the cure rateforcolorecal cancer."If everyone over 50 hadcheckups for colorectal cancer,the cure rate could be as highas 75%," says Dr. LaSalle D.Leffall, Jr., past president,American Cancer Society "Youcan't cure it if you don't knowyou have it." Your doctor can... ~perform the digital and.. ..... ...... ... .. ..*:::... :..... proctoscopic exams, and you~~~~~~take care of the simple stool---................. blood test at home.Colorectal cancer warningsigns are a change in bowelhabits and blood in the stool.Checkup Guidelines formen and women over 50without symptoms:edigital exam annually*stool blood test annually*procto exam every 3 to 5years after 2 negative tests1 year apart.No one facescancer alone.JOURNALFTHENATON ,AAERALCGATIERSCL W6JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 86, NO. 6 471

Elective colostomy closure in an AIDS patient.

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Elective colostomy closure in an AIDS patient.

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