Malpractice was the jury’s verdict last March against a San Francisco doctor who denied surgery to a PWA with severe bone degeneration, claiming that his CD4 count of 217 would put him at grave risk of infection. Four medical experts testified that there is no evidence showing greater postoperative complications for patients with low CD4s.
Most AIDS docs would agree, but with a caveat: The trend in your CD4 counts is one of many factors that you should weigh when deciding whether or not to submit to the knife. “I also want to know the trends in patients’ viral load, platelets and clotting factor, plus how long they’ve been positive, whether they’re taking HIV drugs, their side effects and general health,” says Jeffery Brande, MD, a plastic and reconstructive surgeon in New York City. “A person with 400 T-cells and active diarrhea may be a poorer surgery candidate than a healthy person with only 100 T-cells.”
In emergencies, you may need the knife to slice no matter what. But there is a slew of less-than-dire but uncomfortable and/or unsightly HIV-related conditions—anal warts, hemorrhoids, skin eruptions and lipodystrophy—for which surgery is either one of several treatments or an option that can be postponed.
For PWAs, the desire to reverse collapsing looks is only natural: Lipodystrophy and facial wasting can punch holes in your self-esteem. Brande says that surgery to reshape distorted body parts often provides a psychological boost, which may in turn improve general health. But getting reimbursement can be tough. “Insurers generally consider this surgery ‘cosmetic,’ although some cover it in severe cases,” he says.
With other options for reducing fat redistribution uncertain or expensive (small studies show some benefit from recombinant human growth hormone, or Serostim, which can cost up to $30,000 a year), some PWAs have opted for liposuction, a form of plastic surgery. “From the start, I had side effects from protease inhibitors,” says Los Angeles PWA Nora Drake. “I was like eggs on legs with a belly and a hump. I looked like a kidney bean.” Because the lipoma on her upper back was intergrown with the muscle, surgeons removed only 60 percent (two pounds of fat), most of which grew back later. Brande notes, however, that this type of regrowth has happened to only one of his many patients with lipodystrophy.
Sucking out blubber may sound neat and tidy, but there can be dangerous complications, such as uncontrollable bleeding or fat entering the bloodstream and traveling to the lungs. In fact, dozens of healthy people nationwide die from liposuction each year. And because of the heightened risk of hemorrhaging, removal of deep abdominal fat is not recommended.
“The real danger with surgery is the postoperative risk of infection: abscesses in abdominal surgery cases, or staph and strep infections,” explains Michael Liguori, MD, an internist in New York City. “Infection rates might be 2 to 3 percent among HIV negatives vs. 5 percent in the HIV population.”
Last January, after POZ deputy editor Jeff Hoover—HIV positive for 13 years and in good health—underwent knee surgery, things didn’t go well. “Within a week, my lower leg and foot swelled up, turned bright red and were incredibly painful,” he says. His doctors were divided on whether it was cellulitis (a skin infection) or hematoma (blood accumulation in the tissues). “There was never any resolution, so I was given heavy antibiotics for a week just in case it was HIV-related cellulitis,” Hoover says.
Stephen Goldstone, MD, a surgeon in New York City who operates on many PWAs, says that he hasn’t seen any postoperative infections. Rather, he notes, “Weight loss can be compounded by surgery if the patient is not eating properly, which can affect healing. Any kind of surgery stresses the body and you might see a rise in viral load immediately afterward.”
One risk during surgery itself—especially for women—can be unwanted extra procedures. In 1997, Lucy Mario (name changed), age 41 and HIV positive for 13 years, suffered severe bleeding from the uterus. Mario’s doctors pushed her to have not only her uterus removed, but also her ovaries, claiming that they were probably diseased as well. Mario said no. “I needed to produce natural hormones and didn’t want to get thrown into early menopause,” she says. “The gynecologist was really angry, but we made him sign a paper requiring a pathology report showing specific damage before any removal of ovaries.” The ovaries stayed put, and massive amounts of antibiotics got Mario through repeated postoperative infections. Today, she reports, “My ovaries are pink, healthy and happy, and I produce plenty of estrogen.”
Assertiveness can also prevent other problems. When Hoover was hospitalized, the nurses wouldn’t let him take his own HIV drugs, and several times they forgot to administer them. Such forgetfulness could result in forced drug holidays for a patient who is delirious, seriously injured or unconscious. Liguori ex-plains, “The general procedure is that nurses administer meds. But that can be superceded by a doctor’s order allowing the patient to take his own meds. Discuss this with your doctor.”
While Vinny Allegrini may not be perfect, parts of him are excellent. “My arms, legs, chest and shoulders were in good shape, but my middle section looked like it didn’t belong to the rest of the body,” says the 50-year-old New Yorker, who has had AIDS for four years, with a pre-surgery CD4 count of 150. “When my belly button became severely distended from lipodystrophy, my internist said I should have surgery.”
All went well under the knife, but two days later, Allegrini was rushed to the emergency room with a 104-degree fever. Suspecting postoperative complications, his doctor gave him a CAT scan, colonoscopy and lung X-rays, but to no avail. “My T-cells plummeted, and for six weeks I felt like someone had pulled the plug,” he recalls. “I had no energy. The doctor concluded that it was probably just intestinal flu, but I am sure it was the anesthesia.”
Indeed, many PWAs believe that anesthesia caused their postoperative blues. To reduce problems, anesthesia doses should be adjusted based on the person’s weight and any current use of cigarettes, alcohol or medications. James Spencer, MD, a New York City anesthesiologist, explains that HIV meds, particularly indinavir (Crixivan) and nelfinavir (Viracept), can prolong the action of some anesthesia drugs. “They compete for metabolism in the liver, but as long as there’s no liver damage from HIV, drugs or hepatitis, it shouldn’t be a problem,” he says. “If serious damage is present, then anything but emergency surgery should be put off.” And there have been anecdotes of harmful interactions between anesthesia drugs and such herbs as St. John’s Wort and gingko biloba. So give advance warning to both surgeon and anesthesiologist about any treatments you take—prescription, over-the-counter, herbal or nutritional.
Avoiding anesthesiologists “who are more interested in high-volume turn-over,” Brande now works with Spencer, who carefully monitors patients, maintaining the minimal dosage so that they remain in a light sleep. According to Brande, this method has resulted in less nausea, quicker recoveries and “zero complication rates” for patients. He adds, “James touches you the whole time. As you’re falling asleep, he’ll stroke your hair and say things like, ‘Are you on the beach, where you want to be?’ He stays with you until you wake up. We try to make the experience as nontraumatic as possible.”
METAL AND METTLE
One point that you human pin-cushions might miss: If you have metal objects skewering ears, tongue, navel, nipples or oh-so-private parts (or wear items of jewelry), be sure to remove them before an operation. “During surgery we use electric currents and have to ground the patient,” Goldstone writes in Ins and Outs of Gay Sex: A Medical Handbook for Men (Dell/New York City). “You run the risk of conducting electricity through those intimate parts and burning something.” Ouch! Another no-no in surgery is clothing made of silk or nylon, which are flammable.
Attitude matters. “When you take a car trip, you don’t worry that you’re going to have a wreck,” Brande says. “Some patients come in petrified, but those who are at ease fare better. As the HIV population becomes healthier, the dangers from surgery are lessening.”
Yet some surgeons say that PWAs sometimes jump too readily into extensive and unnecessary cosmetic reconstruction. “It is possible to have too much plastic surgery,” Goldstone says. “Any operation carries some risk, which must always be balanced with need. You’re trying to improve your outward appearance, not remake yourself into something you never were.”
Whatever you decide, try to find a surgeon who has worked with PWAs. Goldstone says, “Surgery decisions should be a three-way dialogue among the patient, the surgeon and the HIV caregiver. But if a doctor says you shouldn’t have surgery because of your HIV status, go for another opinion.”
HURRY UP AND HEAL
While surgery may leave you dependent on the kindness of strangers, you can help along the healing process by attending to a few basics, both before and after the operation:
Diet. Eat plenty of protein and calories to speed recovery.
Micronutrients. A potent multivitamin/mineral can provide the nutrients believed to hasten wound healing and boost immunity against infections (vitamins A, E and C and the mineral zinc), minimize scarring (zinc and E), and restore energy and vigor (vitamin B-12). Another scar-reducing tip: After the wound closes up, break open a capsule of vitamin E and spread it over the incision.
Amino acids. The combination of arginine and lysine (one gram of each, four times a day on an empty stomach) can stimulate the brain to release growth hormone, accelerating wound healing and inhibiting loss of muscle mass after surgery.
Plant extracts. Bach Flower Rescue Remedy (a nontoxic liquid available at health food stores) can help release the stress of surgery.