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SURGICAL TECHNOLOGY INTERNATIONAL II.
$245.00 - Online Edition
Surgical Technology International II contains 66 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.
1993 - ISBN: 0-9638866-0-6
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Sections
General Surgery
Liver Xenotransplantation
Ignazio Roberto Marino, MD, Andreas G. Tzakis, MD, John J. Fung, MD, PhD, Satoru Todo, MD, Howard R. Doyle, MD, Rafael Manez, MD, Thomas E. Starzl, MD, PhD, Pittsburgh, Pennsylvania
Abstract
During the past 30 years orthotopic liver transplantation has become a highly successful form of surgical treatment. The significant advances achieved in this field have led to an increased demand for organs and created a wide gap between organ availability and orgall supply. A wider availability of organs for transplantation would allow an expansion rather than a contraction of the indications for transplantation, and, at the same time a relaxation of the patient selection criteria. All these facts clearly justify the renewed interest observed in the last decade in xenotransplantation. The original concept of xenografting, meaning the transplantation of cells, tissues, or organs between different species, is so ancient that it is easily recognizable in Greek and Roman mythology. The centaur Chiron, the teacher of Esculapius, and the Chimera are legendary examples of discordant xenogeneic creatures. However, it is only during this century that scientists have been able to bring this idea into the clinical arena. The early efforts were prompted by the shortage of humans organs at a time when there were few alternatives for treating end-stage organ failure.
During the past 30 years orthotopic liver transplantation has become a highly successful form of surgical treatment. The significant advances achieved in this field have led to an increased demand for organs and created a wide gap between organ availability and orgall supply. A wider availability of organs for transplantation would allow an expansion rather than a contraction of the indications for transplantation, and, at the same time a relaxation of the patient selection criteria. All these facts clearly justify the renewed interest observed in the last decade in xenotransplantation. The original concept of xenografting, meaning the transplantation of cells, tissues, or organs between different species, is so ancient that it is easily recognizable in Greek and Roman mythology. The centaur Chiron, the teacher of Esculapius, and the Chimera are legendary examples of discordant xenogeneic creatures. However, it is only during this century that scientists have been able to bring this idea into the clinical arena. The early efforts were prompted by the shortage of humans organs at a time when there were few alternatives for treating end-stage organ failure.
Transplantation Immunology
Vasyl Warvariv, MD, Sharon Inokuchi, MD, Carlos O. Esquivel, MD, PhD, San Francisco, California
Abstract
The replacement of diseased or damaged organs by transplantation became a reality in 1954, when a kidney was transplanted from one monozygotic twin to another. Barring technical difficulties, a graft between genetically identical (syngeneic) individuals is readily accepted and is termed an isograft. An allograft is a transplant between allogeneic (genetically not-identical) members of a given species, whereas a xenograft crosses species lines. Allografts and xenografts provoke a strong immunological response which, unless suppressed, leads to rejection and graft loss. Immunological processes involved in rejection include humoral (B-cell) and cellular (T-cell) components that are both antigen specific and non-specific. 45 years ago Peter Medawar and his colleagues established that rejection has an immunological basis. From studies of skin grafts between animals, they demonstrated that transplantation immunity was actively acquired, systemically propagated and highly specific. Previous exposure to donor antigens was shown to lead to the sensitization of the recipient and resulted in a markedly accelerated rejection upon re-exposure to the same antigens. Also at this time, the possibility of transplantation tolerance, or specific allograft unresponsiveness was first described in an animal bone marrow chimera model. The greatest challenge in clinical transplantation today is to develop in the organ recipient a state of immunologic non-responsiveness to the organ while preserving the ability for immune surveillance and function necessary for life.
The replacement of diseased or damaged organs by transplantation became a reality in 1954, when a kidney was transplanted from one monozygotic twin to another. Barring technical difficulties, a graft between genetically identical (syngeneic) individuals is readily accepted and is termed an isograft. An allograft is a transplant between allogeneic (genetically not-identical) members of a given species, whereas a xenograft crosses species lines. Allografts and xenografts provoke a strong immunological response which, unless suppressed, leads to rejection and graft loss. Immunological processes involved in rejection include humoral (B-cell) and cellular (T-cell) components that are both antigen specific and non-specific. 45 years ago Peter Medawar and his colleagues established that rejection has an immunological basis. From studies of skin grafts between animals, they demonstrated that transplantation immunity was actively acquired, systemically propagated and highly specific. Previous exposure to donor antigens was shown to lead to the sensitization of the recipient and resulted in a markedly accelerated rejection upon re-exposure to the same antigens. Also at this time, the possibility of transplantation tolerance, or specific allograft unresponsiveness was first described in an animal bone marrow chimera model. The greatest challenge in clinical transplantation today is to develop in the organ recipient a state of immunologic non-responsiveness to the organ while preserving the ability for immune surveillance and function necessary for life.
Beta Cell Replacement Therapy in the 1990's
Mark M. Levy, MD, Kenneth L. Brayman, MD, PhD, Philad Elphia, Pennsylvania, David E.R. Sutherland, MD, PhD, Minneapolis, Minnesota
Abstract
The goal of pancreatic beta cell replacement therapy is to restore normoglycemia in insulinopenic Type I diabetics patients. Pancreas transplantation is now considered a therapeutic option for Type I diabetic patients. It can no longer be considered an experimental procedure. Although a number of techniques have been applied in an attempt to restore normal glucose metabolism in Type I diabetic patients, pancreatic transplantation is the only therapy that consistently achieves normal glycosylated hemoglobin levels, an accomplishment rarely if ever achieved with frequent insulin injections or insulin pump therapy. Restoration of normoglycemia can be accomplished by either selectively transplanting isolated pancreatic islet cells or by transplanting the pancreas, usually as a composite graft of duodenum and whole pancreas. At this time, the likelihood of achieving independence from insulin is greater with a whole pancreas transplant than with an islet transplant. However, considerable progress in the field of islet transplantation has been made. This chapter will review the state of pancreas and islet transplantation.
The goal of pancreatic beta cell replacement therapy is to restore normoglycemia in insulinopenic Type I diabetics patients. Pancreas transplantation is now considered a therapeutic option for Type I diabetic patients. It can no longer be considered an experimental procedure. Although a number of techniques have been applied in an attempt to restore normal glucose metabolism in Type I diabetic patients, pancreatic transplantation is the only therapy that consistently achieves normal glycosylated hemoglobin levels, an accomplishment rarely if ever achieved with frequent insulin injections or insulin pump therapy. Restoration of normoglycemia can be accomplished by either selectively transplanting isolated pancreatic islet cells or by transplanting the pancreas, usually as a composite graft of duodenum and whole pancreas. At this time, the likelihood of achieving independence from insulin is greater with a whole pancreas transplant than with an islet transplant. However, considerable progress in the field of islet transplantation has been made. This chapter will review the state of pancreas and islet transplantation.
Technical Aspects of Intestinal Transplantation
Hiroyuki Furukawa, MD, Kareem Abu-Elmagd, MD, Jorge Reyes, MD, Bakr Nour, MD Andreas Tzakis, MD, Satoru Todo, MD, Thomas E Starzl, MD, PhD, Pittsburgh, Pennsylvania
Abstract
Since the advent of the potent immunosuppressive agent FK 506, intestinal transplantation has become a feasible therapeutic option for patients with irreversible intestinal failure. In this chapter, we present our clinical experience with intestinal transplantation, focusing on the technical aspects of both the donor and recipient operations.The logistics of the operative procedure have been described previously.
Since the advent of the potent immunosuppressive agent FK 506, intestinal transplantation has become a feasible therapeutic option for patients with irreversible intestinal failure. In this chapter, we present our clinical experience with intestinal transplantation, focusing on the technical aspects of both the donor and recipient operations.The logistics of the operative procedure have been described previously.
Human Fetal Surgery
Marc H. Hedrick, MD, Michael R. Harrison, MD, San Francisco, California
Abstract
The ability to "see" the fetus before birth with routine obstetrical sonography, has changed the management of many congenital anomalies. Although most correctable malformations diagnosedprenatally, are best cared for by appropriate medical or surgical therapy after planned delivery at term, fetal intervention in selected casesmay be advantageous.
The ability to "see" the fetus before birth with routine obstetrical sonography, has changed the management of many congenital anomalies. Although most correctable malformations diagnosedprenatally, are best cared for by appropriate medical or surgical therapy after planned delivery at term, fetal intervention in selected casesmay be advantageous.
Stereotactic Core Breast Biopsy a Replacement for Surgical Breast Biopsy
Fred Burbank, MD, Mission Viejo, California, Steve H. Parker, MD, Englewood, Colorado
Abstract
In 1988 two separate technologies were joined together by a team of radiologists in Denver, Colorado: a stereotactic breast biopsy system and an automated biopsy gun system. With the union of these two technologies, a new era in early breast cancer diagnosis began, stereotactic core breast biopsy. Any lesion that can be seen by mammography can be accurately biopsied with the stereotactic core breast biopsy. The accuracy of the procedure depends upon highly developed mammography skills and is, consequently, an advanced radiology procedure. Accuracy is equal to or greater than accuracy with traditional localization and open, surgical breast biopsy.
In 1988 two separate technologies were joined together by a team of radiologists in Denver, Colorado: a stereotactic breast biopsy system and an automated biopsy gun system. With the union of these two technologies, a new era in early breast cancer diagnosis began, stereotactic core breast biopsy. Any lesion that can be seen by mammography can be accurately biopsied with the stereotactic core breast biopsy. The accuracy of the procedure depends upon highly developed mammography skills and is, consequently, an advanced radiology procedure. Accuracy is equal to or greater than accuracy with traditional localization and open, surgical breast biopsy.
An Update on Mammography
Robert Mclelland, MD, Etta D. Pisano, MD, M. Particia Braeuning, MD, Chapel Hill, North Carolina
Abstract
For at least 7% of breast cancers there are no known causal factors other than gender and aging. Other possible risk factors include hormonal, genetic, nutritional, morphologic, environmental (chemical, pesticides, food additives), irradiation, and viruses. Japanese women have much less breast cancer than women in the U.S.A. and after age 45, their incidence levels off or falls, whereas ours continues to rise. Furthermore, within a generation or two of moving to the U.S.A., Japanese women have a similar incidence to ours! What are we doing that increases our risk for this disease? It would certainly suggest that the other risk factors are involved and much research continues to explore this. Screening with mammography and breast physical examination is the cornerstone of earlier detection, improved survival and reduced mortality from breast cancer. A variety of studies and improvement in stage trends support this. Despite this, overall mortality from breast cancer remains unchanged. However, increasing incidence with stable mortality would suggest there is some reduction in overall mortality. Some other reasons for no reduction in overall mortality include: I. The variable biological forms and natural history of the disease. Assuming an average 100 days doubling time, cancer has been present in a woman's breast if not elsewhere for 6-7 years or longer before it is potentially detectable by mammography or breast physical examination. The extent of disease, cell type and grade, and host resistance are all important survival factors. Not enough breast cancers are at an early stage when diagnosed and treated. Not enough eligible women are being routinely screened with optimum mammography and breast physical examination. There is too much reliance on breast self-examination and breast physical examination alone for detection.
For at least 7% of breast cancers there are no known causal factors other than gender and aging. Other possible risk factors include hormonal, genetic, nutritional, morphologic, environmental (chemical, pesticides, food additives), irradiation, and viruses. Japanese women have much less breast cancer than women in the U.S.A. and after age 45, their incidence levels off or falls, whereas ours continues to rise. Furthermore, within a generation or two of moving to the U.S.A., Japanese women have a similar incidence to ours! What are we doing that increases our risk for this disease? It would certainly suggest that the other risk factors are involved and much research continues to explore this. Screening with mammography and breast physical examination is the cornerstone of earlier detection, improved survival and reduced mortality from breast cancer. A variety of studies and improvement in stage trends support this. Despite this, overall mortality from breast cancer remains unchanged. However, increasing incidence with stable mortality would suggest there is some reduction in overall mortality. Some other reasons for no reduction in overall mortality include: I. The variable biological forms and natural history of the disease. Assuming an average 100 days doubling time, cancer has been present in a woman's breast if not elsewhere for 6-7 years or longer before it is potentially detectable by mammography or breast physical examination. The extent of disease, cell type and grade, and host resistance are all important survival factors. Not enough breast cancers are at an early stage when diagnosed and treated. Not enough eligible women are being routinely screened with optimum mammography and breast physical examination. There is too much reliance on breast self-examination and breast physical examination alone for detection.
Chemotherapy and Hormonal Therapy for Breast Cancer
Debasish Tripathy, MD, San Francisco, California
Abstract
Significant incremental advances in the use of systemic hormonal therapy and chemotherapy for the treatment of breast cancer have occurred in the past few years. Benefits of systemic therapy can be broadly divided into two major categories. The first is the favorable impact of systemic adjuvant therapy on recurrence and survival following primary surgical therapy for early stage disease. In this setting, both hormonal therapy and chemotherapy are effective. The results of recent trials as well as an overview analysis of randomized studies, have been able to further delineate, although not unequivocally, for which populations of patients a given type of therapy is most efficacious. Additionally, a more precise estimate of the reduction in odds of relapse and death afforded by a given therapy and within a defined patient subgroups is now possible, and these may be helpful in guiding clinical decision-making. Second, the treatment of advanced metastatic disease remains challenging due to the inability to induce long-term remissions or cures despite common initial responsiveness to hormonal therapy or chemotherapy. Over the last decade, only a few new drugs have been approved for the treatment of breast cancer, although several promising chemotherapeutic and biological agents are under scientific and clinical development. The use of therapy in this setting is therefore currently aimed at improving symptoms and quality of life. The use of conventional and novel chemotherapeutic agents at escalated doses with the use of hematopoietic growth factors, peripheral stem cells or autologous marrow support in terms of improved response rates and the potential to prolong survival, achieve long-terms remissions or cures, and improve quality of life is under active investigation.
Significant incremental advances in the use of systemic hormonal therapy and chemotherapy for the treatment of breast cancer have occurred in the past few years. Benefits of systemic therapy can be broadly divided into two major categories. The first is the favorable impact of systemic adjuvant therapy on recurrence and survival following primary surgical therapy for early stage disease. In this setting, both hormonal therapy and chemotherapy are effective. The results of recent trials as well as an overview analysis of randomized studies, have been able to further delineate, although not unequivocally, for which populations of patients a given type of therapy is most efficacious. Additionally, a more precise estimate of the reduction in odds of relapse and death afforded by a given therapy and within a defined patient subgroups is now possible, and these may be helpful in guiding clinical decision-making. Second, the treatment of advanced metastatic disease remains challenging due to the inability to induce long-term remissions or cures despite common initial responsiveness to hormonal therapy or chemotherapy. Over the last decade, only a few new drugs have been approved for the treatment of breast cancer, although several promising chemotherapeutic and biological agents are under scientific and clinical development. The use of therapy in this setting is therefore currently aimed at improving symptoms and quality of life. The use of conventional and novel chemotherapeutic agents at escalated doses with the use of hematopoietic growth factors, peripheral stem cells or autologous marrow support in terms of improved response rates and the potential to prolong survival, achieve long-terms remissions or cures, and improve quality of life is under active investigation.
Intraoperative Radiotherapy Experimental and Clinical Results, Future Prospects, H.J. Hoekstra MD, PhD, H. Heymans MD, J. Oldhoff MD, PhD, B.G. Szabo MD, PhD, Groningen, the Netherlands
Abstract
During the last two decades increasingly complex surgical techniques have been developed to improve the resection rate in the surgical treatment of cancer. There is an enormous growth in the development of new chemotherapeutic agents, and in the insight in chemotherapy treatment regimens. Since growth factors became available, high dose intensive chemotherapy combined with autologous bone marrow transplant can be performed with a low morbidity and mortality rate. Within radiation oncology technical advances in methods of radiation therapy, including the use of computerized planning (3D) treatment and conformal treatment have decreased the radiation-induced morbidity. To increase the radiation effect, e.g to improve local control, without increasing radiation toxicity, hyper fractionation, radiation-sensitizers, and radiation-protectors were clinically investigated. New radiation techniques and equipment like brachytherapy (BT) units and intraoperative radiotherapy (IORT) became available. All these new techniques are today also used in the treatment of cancer as a combined modality treatment, with the idea to improve the local control rate, the disease free-, and overall survival without increasing or inducing treatment morbidity, and more over to prevent multilating surgical procedures.
During the last two decades increasingly complex surgical techniques have been developed to improve the resection rate in the surgical treatment of cancer. There is an enormous growth in the development of new chemotherapeutic agents, and in the insight in chemotherapy treatment regimens. Since growth factors became available, high dose intensive chemotherapy combined with autologous bone marrow transplant can be performed with a low morbidity and mortality rate. Within radiation oncology technical advances in methods of radiation therapy, including the use of computerized planning (3D) treatment and conformal treatment have decreased the radiation-induced morbidity. To increase the radiation effect, e.g to improve local control, without increasing radiation toxicity, hyper fractionation, radiation-sensitizers, and radiation-protectors were clinically investigated. New radiation techniques and equipment like brachytherapy (BT) units and intraoperative radiotherapy (IORT) became available. All these new techniques are today also used in the treatment of cancer as a combined modality treatment, with the idea to improve the local control rate, the disease free-, and overall survival without increasing or inducing treatment morbidity, and more over to prevent multilating surgical procedures.
Immunotherapy for Cancer
Stanley P.L. Leong, MD, San Francisco, California
Abstract
The study of the immune system on the cellular and molecular level has made significant strides over the past several decades. The role of immune system against infection is self-evident. Although the role of the immune system in the immune surveillance of cancer has not been proven, the immune system is believed to play an interactive role in the regulation of tumor growth. Immunotherapy is the application of the immune system to fight against the tumor. Although immunotherapeutic approaches have been tried in many types of cancer, both malignant melanoma and renal cell carcinoma seem to show occasional, but definitive response to immunotherapy. The fact that immune eradication of tumor is most efficient when the tumor burden is minimal speaks for the fact that immunotherapy may be most effective for control of microscopic disease. Therefore, to maximize the effect of immunotherapy, the tumor burden needs to be reduced, hopefully to microscopic level either by surgery or in combination with chemotherapy and radiation therapy. Also, new strategies are needed to develop more potent vaccines and stimulate effector cells to eradicate tumor cells under the most optimal conditions.
The study of the immune system on the cellular and molecular level has made significant strides over the past several decades. The role of immune system against infection is self-evident. Although the role of the immune system in the immune surveillance of cancer has not been proven, the immune system is believed to play an interactive role in the regulation of tumor growth. Immunotherapy is the application of the immune system to fight against the tumor. Although immunotherapeutic approaches have been tried in many types of cancer, both malignant melanoma and renal cell carcinoma seem to show occasional, but definitive response to immunotherapy. The fact that immune eradication of tumor is most efficient when the tumor burden is minimal speaks for the fact that immunotherapy may be most effective for control of microscopic disease. Therefore, to maximize the effect of immunotherapy, the tumor burden needs to be reduced, hopefully to microscopic level either by surgery or in combination with chemotherapy and radiation therapy. Also, new strategies are needed to develop more potent vaccines and stimulate effector cells to eradicate tumor cells under the most optimal conditions.
Current Treatment of Primary Tumors of the Liver in Japan
Tomoo Tajima, MD, Yutaka Tanaka, MD, Hiroyasu Makuuchi, MD, Toshio Mitomi, MD, Isehara, Kanagawa, Japan
Abstract
The number of patients dying from primary malignant tumors of the liver in Japan has steadily increased during the last two decades. There are several epidemiological and clinical characteristics of primary malignant tumors of the liver in Japan, among which are: (I) hepatocellular carcinomas (hepatomas) which comprise approximately 90% of the cases; (2) high association of hepatoma with viral hepatitis and with consequent liver cirrhosis (over 85%); and (3) male predominance (5-6 to 1 male-to-female ratio). In recent years, more and more smaller hepatomas are being detected due to the efficient and liberal use of ultrasonography on high risk patients, and hepatic resections of limited extent such as segmentectomy and subsegmentectomy are now becoming increasingly common surgical procedures. This article will present an overview of current status of treatment of patients with hepatoma in Japan, and the information contained may prove to be useful for clinical management of Western patients, though some of their epidemiological features differ significantly from those of Japanese patients.
The number of patients dying from primary malignant tumors of the liver in Japan has steadily increased during the last two decades. There are several epidemiological and clinical characteristics of primary malignant tumors of the liver in Japan, among which are: (I) hepatocellular carcinomas (hepatomas) which comprise approximately 90% of the cases; (2) high association of hepatoma with viral hepatitis and with consequent liver cirrhosis (over 85%); and (3) male predominance (5-6 to 1 male-to-female ratio). In recent years, more and more smaller hepatomas are being detected due to the efficient and liberal use of ultrasonography on high risk patients, and hepatic resections of limited extent such as segmentectomy and subsegmentectomy are now becoming increasingly common surgical procedures. This article will present an overview of current status of treatment of patients with hepatoma in Japan, and the information contained may prove to be useful for clinical management of Western patients, though some of their epidemiological features differ significantly from those of Japanese patients.
Development and Testing of A Bioartificial Liver.
Jacek Rozga, MD, PhD, Luis Podesta, MD, Allen Hoffman, MD, Elaine Lepage, Rn, Ms, Eugenio Morsiani, MD, Albert D. Moscioni, PhD, Achilles A. Demetriou, MD, PhD, Los Angeles, California
Abstract
Management of patients with acute severe liver failure is a major clinical challenge. We need to understand better normal and abnormal liver physiology, develop methods of assessing the degree of liver dysfunction, standardize methods of intervention and develop rational procedures to support the acutely failing liver until it either recovers or is replaced. Investigators have attempted to support animals and patients with liver insufficiency, utilizing various extracorporeal support systems including cross-circulation, whole liver blood perfusion, hemadsorption, hemodialysis, plasma exchange, total body wash-out, use of microsomal enzymes bound to artificial carriers and other. None of these therapeutic modalities succeeded in gaining wide clinical acceptance. Charcoal hemoperfusion has been used to treat severe acute liver failure with mixed results. Although there is clear experimental evidence that the technique has some beneficial effects, a controlled prospective clinical study failed to demonstrate significant clinical advantages. Other methods which relied primarily upon blood detoxification, showed limited success as well. Thus it appears that, at least for now, whole organ transplantation remains the only method with clinically-proven efficacy for treating severe acute liver failure. In attempting to develop systems for temporarily supporting patients until an organ becomes available for transplantation and because of the complexity and vast number of metabolic and other physiologic functions provided by the liver, it was felt that to provide effective ex vivo liver support, either utilization of whole organ perfusion or construction of a liver support system utilizing intact, viable, functioning isolated liver cells will be needed.
Management of patients with acute severe liver failure is a major clinical challenge. We need to understand better normal and abnormal liver physiology, develop methods of assessing the degree of liver dysfunction, standardize methods of intervention and develop rational procedures to support the acutely failing liver until it either recovers or is replaced. Investigators have attempted to support animals and patients with liver insufficiency, utilizing various extracorporeal support systems including cross-circulation, whole liver blood perfusion, hemadsorption, hemodialysis, plasma exchange, total body wash-out, use of microsomal enzymes bound to artificial carriers and other. None of these therapeutic modalities succeeded in gaining wide clinical acceptance. Charcoal hemoperfusion has been used to treat severe acute liver failure with mixed results. Although there is clear experimental evidence that the technique has some beneficial effects, a controlled prospective clinical study failed to demonstrate significant clinical advantages. Other methods which relied primarily upon blood detoxification, showed limited success as well. Thus it appears that, at least for now, whole organ transplantation remains the only method with clinically-proven efficacy for treating severe acute liver failure. In attempting to develop systems for temporarily supporting patients until an organ becomes available for transplantation and because of the complexity and vast number of metabolic and other physiologic functions provided by the liver, it was felt that to provide effective ex vivo liver support, either utilization of whole organ perfusion or construction of a liver support system utilizing intact, viable, functioning isolated liver cells will be needed.
General Surgery in the Patient With Aids
James R. Macho, MD, William P. Schecter, MD, San Franciso, California
Abstract
In 1993, it is estimated that 2 million americans are infected with the human Immunodeficiency Virus (HIV). The Acquired Immune Deficiency Syndrome (AIDS) represents the most severe manifestation of infection with the virus. In the patient with AIDS, helper T lymphocytes are depleted resulting in a defect in cell mediated immunity. The resulting state of profound immunosuppression leads to susceptibility to rare infections and tumors. Although opportunistic infections have been seen in patients on immunosuppressive therapy, those associated with AIDS are much more severe and extensive. Many patients present with symptoms that mimic acute surgical emergencies. In other cases, the presentation has been one of a more chronic disease state. Some of the diseases associated with AIDS are directly attributable to the effects of the HIV virus. In all of these categories, there are some patients who will benefit from surgical therapy. In many cases medical therapy will be more appropriate. The evaluation of these patients can represent a major diagnostic challenge to the surgeon. A familiarity with these disease processes is essential for timely diagnosis and appropriate treatment.
In 1993, it is estimated that 2 million americans are infected with the human Immunodeficiency Virus (HIV). The Acquired Immune Deficiency Syndrome (AIDS) represents the most severe manifestation of infection with the virus. In the patient with AIDS, helper T lymphocytes are depleted resulting in a defect in cell mediated immunity. The resulting state of profound immunosuppression leads to susceptibility to rare infections and tumors. Although opportunistic infections have been seen in patients on immunosuppressive therapy, those associated with AIDS are much more severe and extensive. Many patients present with symptoms that mimic acute surgical emergencies. In other cases, the presentation has been one of a more chronic disease state. Some of the diseases associated with AIDS are directly attributable to the effects of the HIV virus. In all of these categories, there are some patients who will benefit from surgical therapy. In many cases medical therapy will be more appropriate. The evaluation of these patients can represent a major diagnostic challenge to the surgeon. A familiarity with these disease processes is essential for timely diagnosis and appropriate treatment.