HIV/AIDS手术切口愈合与CD<sub>4</sub><sup>+</sup>T淋巴细胞计数的关系

http://dx.doi.org/10.3760/cma.j.issn.0254-6450.2014.12.005
中华医学会主办。

文章信息

杨涤, 赵红心, 郜桂菊, 魏凯, 张俐, 韩宁, 肖江, 李鑫, 王芳, 梁洪远, 张伟, 吴亮. 2014.

Yang Di, Zhao Hongxin, Gao Guiju, Wei Kai, Zhang Li, Han Ning, Xiao Jiang, Li Xin, Wang Fang, Liang Hongyuan, Zhang Wei, Wu Liang. 2014.

HIV/AIDS手术切口愈合与CD₄⁺T淋巴细胞计数的关系

Relationship between CD₄⁺ T lymphocyte cell count and the prognosis (including the healing of the incision wound) of HIV/AIDS patients who had undergone surgical operation

中华流行病学杂志, 2014, 35(12): 1333-1336

Chinese Journal of Epidemiology, 2014, 35(12): 1333-1336

http://dx.doi.org/10.3760/cma.j.issn.0254-6450.2014.12.005

文章历史

投稿日期：2014-06-05

引用本文

杨涤, 赵红心, 郜桂菊, 魏凯, 张俐, 韩宁, 肖江, 李鑫, 王芳, 梁洪远, 张伟, 吴亮. 2014. HIV/AIDS手术切口愈合与CD₄⁺T淋巴细胞计数的关系[J]. 中华流行病学杂志, 35(12): 1333-1336 复制到剪切板

Yang Di, Zhao Hongxin, Gao Guiju, Wei Kai, Zhang Li, Han Ning, Xiao Jiang, Li Xin, Wang Fang, Liang Hongyuan, Zhang Wei, Wu Liang. 2014. Relationship between CD₄⁺ T lymphocyte cell count and the prognosis (including the healing of the incision wound) of HIV/AIDS patients who had undergone surgical operation[J]. Chinese Journal of Epidemiology, 35(12): 1333-1336. 复制到剪切板

HIV/AIDS手术切口愈合与CD₄⁺T淋巴细胞计数的关系

杨涤, 赵红心 , 郜桂菊 , 魏凯, 张俐, 韩宁, 肖江, 李鑫, 王芳, 梁洪远, 张伟, 吴亮

首都医科大学附属北京地坛医院感染中心, 北京 100015

收稿日期:2014-06-05

基金项目：美国NIH项目(1R01MH092225-01); 北京市朝阳区艾滋病和病毒性肝炎等重大传染病综合防治示范区建设研究(2012ZX10004-904)

通信作者: 赵红心,Email:13911022130@163.com;郜桂菊,Email:guiju.gao@163.com

摘要：目的探讨HIV/AIDS手术预后及切口愈合与CD₄⁺T淋巴细胞计数的关系.方法以北京地坛医院2008年1月至2012年12月手术治疗的234例HIV/AIDS住院患者为研究对象,采用回顾性分析的方法,对患者的年龄、性别、发现抗HIV(+)时间、手术时CD₄⁺T淋巴细胞计数、是否为急诊手术、手术部位、切口分类、术后切口愈合级别、切口感染情况、术后并发症及预后进行分析.统计学采用Wilcoxon 秩和检验、χ²检验、Kruskal-Wallis H检验和Spearman相关分析,比较不同的切口愈合级别的患者CD₄⁺T淋巴细胞计数水平的差异、不同CD₄⁺T淋巴细胞计数水平的甲级愈合率和HIV/AIDS相关因素与手术切口愈合率的关系.结果 (1)共有234例患者,男性125例,女性109例,性别比为1.15:1,平均年龄(36.17±11.56)岁.发现抗HIV(+)时间为0～204个月.CD₄⁺T淋巴细胞计数M为388.5 cell/μl.其中23.93%患者CD₄⁺T 淋巴细胞计数<200 cell/μl.(2)急诊手术占7.26%.发病部位涉及23个器官,48种疾病.Ⅰ类切口占21.37%,Ⅱ类切口49.57%,Ⅲ类切口29.06%.86.32%切口为甲级愈合,11.97%为乙级愈合,1.71%为丙级愈合.4.27%患者出现术后并发症.术后出现并发症与未出现并发症患者的CD₄⁺T淋巴细胞计数差异无统计学意义(P>0.05),两组患者感染HIV的时间差异无统计学意义(P>0.05).甲级愈合与乙、丙级愈合的CD₄⁺T淋巴细胞计数水平差异无统计学意义(P>0.05).不同CD₄⁺T淋巴细胞计数水平的甲级愈合率差异无统计学意义(P>0.05).手术切口愈合情况与CD₄⁺T淋巴细胞计数水平、抗病毒治疗时间长短、HIV感染时间无明显相关性(P>0.05).结论严格把握手术适应症和禁忌症,对需要手术的HIV/AIDS进行手术治疗,总体预后良好.低CD₄⁺T淋巴细胞计数并不是手术的绝对禁忌.切口愈合情况与CD₄⁺T淋巴细胞计数、抗病毒治疗时间长短及HIV感染时间无明显相关性.

关键词： HIV感染者/AIDS患者手术

Relationship between CD₄⁺ T lymphocyte cell count and the prognosis (including the healing of the incision wound) of HIV/AIDS patients who had undergone surgical operation

Yang Di, Zhao Hongxin , Gao Guiju , Wei Kai, Zhang Li, Han Ning, Xiao Jiang, Li Xin, Wang Fang, Liang Hongyuan, Zhang Wei, Wu Liang

The Infectious Diseases Center, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China

Abstract: Objective To explore the relationship between CD₄⁺T lymphocyte cell count and prognosis as well as healing of the surgical incision in HIV/AIDS patients who had received operation. Methods Data were collected and analysed retrospectively from 234 HIV/AIDS patients hospitalized at the Beijing Ditan hospital who underwent operation between January 2008 and December 2012. Following factors were taken into consideration that including:age,gender,time and where that anti-HIV(+) was diagnosed,CD₄⁺T lymphocyte cell count at the time of operation,part of the body that being operated,typology of incision,different levels of healing on the surgical incision,infection at the incision site,post-operative complications and the prognosis,etc. Wilcoxon rank sum test,χ² test,Kruskal-Wallis H test and Spearman rank correlation were used for statistical analysis to compare the different levels on healing of the incision in relation to the different CD₄⁺T lymphocyte cell counts. Rates of level A healing under different CD₄⁺T cell counts were also compared. Results 1)Among the 234 patients including 125 males and 109 females,the average age was 36.17±|11.56 years old. Time after discovery of anti-HIV(+) was between 0 and 204 months. The medium CD₄⁺T cell count was 388.5 cell/μl| 23.93% of the patients having CD₄⁺T lymphocyte cell counts as <200 cell/μl. 2)7.26% of the operations were emergent. There were 23 different organs affected at the time of operation,due to 48 different kinds of illness. 21.37% of the operations belonged to class Ⅰ incision,49.57% was class Ⅱ incision and 29.06% was class Ⅲ incision. 86.32% of the incisions resulted in level A healing,12.51% resulted in level B and 1.71% in level C. 4.27% of the patients developed post-operative complications. Differences between level A healing and level B or C healing in terms of CD₄⁺T lymphocyte cell count were not significant (P>0.05). There was no statistically significant difference on the CD₄⁺T lymphocyte count in patients with or without postoperative complications. Difference of the HIV infection time was also not statistically significant between the two groups of patients. Rate of level A healing for the different CD₄⁺T lymphocyte cell count was not significant (P>0.05). Healing of the incision did not show significant correlation with CD₄⁺T lymphocyte cell count,duration of antiretroviral therapy or the time that HIV infection was discovered (P>0.05). Conclusion As long as both the in/exclusion criteria were strictly followed,prognosis for operation on HIV/AIDS seemed to be generally good. Low CD₄⁺T lymphocyte cell count should not be taken as a exclusion criteria for operation on HIV/AIDS patients.

Key words: HIV/AIDS Surgery

截止2011年底，我国存活HIV/AIDS约78万人^[1]。随着HIV感染者逐渐增加，其并发外科疾病也越来越多，手术风险的评估及预后已引起关注。本研究旨在通过分析北京地坛医院5年来HIV/AIDS手术病例，评价手术预后及切口愈合情况与CD4⁺T淋巴细胞计数的关系。材料与方法

1. 研究对象：以北京地坛医院2008年1月至2012年12月进行手术治疗的234例HIV/AIDS住院患者为研究对象，所有患者均经省级疾病预防控制中心（CDC）确证为抗HIV-1（+）。

2. 研究方法及相关定义：采用回顾性分析的方法，对患者年龄、性别、发现抗HIV（+）时间、手术前CD4⁺T淋巴细胞计数、是否为急诊手术、手术部位、切口分类、术后切口愈合级别、切口感染情况、术后并发症及预后进行分析。采用单克隆免疫荧光抗体染色技术，应用流式细胞仪测定外周血CD4⁺T淋巴细胞计数。所有患者均经严密的术前评估，除外手术禁忌症。切口分类：Ⅰ类为清洁切口，Ⅱ类为可能污染的切口，Ⅲ类为污染切口。切口愈合等级：甲级为愈合优良；乙级为愈合欠佳，但未化脓；丙级为切口化脓，需切开引流。

3. 统计学分析：应用SPSS 17.0软件进行统计学分析。计量正态分布资料用x±s表示，偏态分布资料用M（QR）表示。偏态资料采用Wilcoxon 秩和检验，计数资料采用χ²检验，多组等级资料比较采用Kruskal-Wallis H检验，等级资料的相关分析采用Spearman相关分析。P＜0.05为差异有统计学意义。结果

1. 基本情况：共有234例患者，男性125例，女性109例，性别比为1.15 ∶ 1，年龄9～67（36.17±11.56）岁。发现抗HIV（+）时间为0～204个月。所有患者均于术前1周内检测了CD4⁺T淋巴细胞计数，CD4⁺T淋巴细胞计数为14～1 468 cell/μl，M＝388.50（230.25～516.75）cell/μl。其中23.93%（56/234）患者CD4⁺T淋巴细胞计数＜200 cell/μl。

2. 手术情况及预后：急诊手术7.26%（17/234）。涉及23个手术器官，48种疾病。所有患者中，最多为肛肠科手术（24.36%，57/234），其次为妊娠剖宫产术（23.50%，55/234）；其余还包括颅脑、颜面五官、肝胆、胃肠、脊柱四肢等部位手术。4.27%（10/234）出现术后并发症，其处理情况及预后见表 1。术后出现并发症与未出现并发症患者的CD4⁺T淋巴细胞计数（cell/μl）分别为216（142.0～553.5）和396（239.5～541.5），差异无统计学意义（P＝0.194），两组患者感染HIV的时间分别为7.5（0.875～36.0）个月和12（2～48）个月，差异无统计学意义（P＝0.332）。切口分类：Ⅰ类切口占21.37%（50/234），Ⅱ类切口占 49.57%（116/234），Ⅲ类切口占29.06%（68/234）。切口愈合级别：甲级占86.32%（202/234），乙级占11.97%（28/234），丙级占1.71%（4/234）。甲级与乙、丙级愈合的CD4⁺T淋巴细胞计数差异无统计学意义（P＝0.081）。不同CD4⁺T淋巴细胞计数水平的患者切口甲级愈合率差异无统计学意义（P＝0.073），见表 2。

表 1 10例HIV/AIDS术后并发症及其预后与CD4⁺T淋巴细胞数的关系

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表 2 HIV/AIDS不同CD4⁺T淋巴细胞数患者切口甲级愈合率

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3. HIV/AIDS相关因素与手术切口愈合率的关系：手术切口愈合情况与CD4⁺T淋巴细胞计数水平、抗病毒治疗时间长短、HIV感染时间无明显相关性（P＞0.05）。不同手术部位的切口愈合情况差异有统计学意义（P＜0.05），见表 3。

表 3 HIV/AIDS不同手术切口愈合比较

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讨论

随着高效抗反转录病毒治疗的实施，HIV/AIDS存活期逐渐延长，其合并外科疾病的人数也明显增多，大部分需要手术解决，其中一部分需要急诊手术^{[2, 3, 4, 5, 6]}。目前这类患者在寻求手术治疗时遇到了诸多困难：其中很大原因是部分医生对患者进行手术存在顾虑，除担心医护人员的HIV职业暴露外，还担心患者术中或术后感染，影响手术效果，或增加患者感染率及死亡率，而不愿施行手术。

本研究显示，234例手术患者病变部位广泛，疾病种类较多，仅内科治疗不能解决所有问题，具有较严重的手术适应症。所有患者中，最多为肛肠科手术，这与目前我国的HIV感染途径以男男性行为传播比例的上升有关^[1]，易出现肛周尖锐湿疣、肛周脓肿有关。其次为妊娠剖宫产术，显示较多的HIV/AIDS有生育需求。为减少分娩过程中的母婴传播机会，尽可能采取剖宫产术^[7]。

CD4⁺T淋巴细胞计数＜200 cell/μl意味着机体处于极低的免疫状态，进入艾滋病阶段，易出现多种机会性感染及严重的HIV 相关并发症^{[7, 8]}。本研究中的患者CD4⁺T淋巴细胞计数M仅为388.5 cell/μl，近1/5的患者CD4⁺T淋巴细胞计数＜200 cell/μl，最少的1例仅为14 cell/μl，但术后极少数患者出现并发症。死亡病例中，1例因血管畸形出血，另1例因严重颅高压脑疝，均与低CD4⁺T淋巴细胞计数无直接关系。出现术后并发症与未出现术后并发症的患者，其CD4⁺T淋巴细胞计数水平差异无统计学意义，提示手术预后不能以CD4⁺T淋巴细胞计数水平预测。本研究显示，Ⅱ类和Ⅲ类切口占绝大部分，而大部分切口为甲级愈合，丙级愈合仅4例（1.71%），总体术后预后良好。多项研究显示，对HIV/AIDS施行手术，其中CD4⁺T淋巴细胞计数最低为1 cell/μl，术后均未出现严重并发症及机会性感染^{[9, 10, 11, 12]}。来自撒哈拉以南的Meta分析结果也显示，尚不能证实HIV感染者进行手术可能会增加切口感染率^[13]。目前，低CD4⁺T淋巴细胞计数对切口愈合及死亡率是否存在影响尚有争议^{[14, 15, 16]}，本研究显示，不同CD4⁺T淋巴细胞计数水平的切口甲级愈合率差异无统计学意义（P＞0.05）。评价HIV/AIDS的免疫水平及感染时间和抗病毒治疗时间的长短等相关因素与手术切口愈合情况也无明显相关性，因此，这些指标并不能作为手术禁忌症进行术前评价。但不同的手术部位，其切口的愈合情况可能不同，统计结果显示，头颈部手术甲级愈合率更高，而下腹部多为丙级愈合，可能与切口污染相关。

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