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The newspaper of The Johns Hopkins University May 9, 2005 | Vol. 34 No. 33
 
Scalpel-Free Surgery Could Reduce Risk of HIV and Hepatitis Exposure

By Trent Stockton
Johns Hopkins Medicine

While the incidence of disease from HIV and hepatitis is increasing in the United States, little is known about their prevalence in patients undergoing surgery. Now, researchers have shown that nearly 40 percent of surgeries at The Johns Hopkins Hospital occur in patients who tested positive for a blood-borne germ.

"While these rates are alarming, they are not entirely unexpected. General precautions have been in effect for some time to prevent the spread of disease to health care workers in the operating room," says Martin A. Makary, assistant professor of surgery and public health at Johns Hopkins and lead author of a report in the May issue of Annals of Surgery.

"Given the high incidence of these infections, however, we have developed new strategies such as 'sharpless' surgery — a surgical technique which uses high-technology alternatives to needles and knives. We advocate using these techniques whenever possible in high-risk settings to further protect health care workers from accidental transmission," Makary says.

Sharpless surgical techniques include laparoscopy, electrocautery to replace scalpel incisions, and skin clips or glue instead of sewing to close or repair wounds.

Previous studies have shown that health care workers are injured in about 7 percent of operations. As many as 87 percent of surgeons will receive an injury that breaks the skin — thus allowing for possible disease transmission — at some point in their career. There are an estimated 40,000 new cases of HIV each year, and hepatitis C is increasing at an even faster rate, according to the report. The study concludes that by studying the rates of HIV and hepatitis B and C among patients presenting for surgery, a more accurate incidence of disease is measured within a community, bypassing the selection bias of traditional statistics of known infected patients presenting to primary care clinics. Furthermore, the authors report that blood-borne pathogens are associated with certain types of operations.

The researchers also found that the operations associated with the greatest risk of infection — lymph-node biopsy, soft-tissue-mass excision and abscess-drainage cases — were often assigned to the most inexperienced surgeons in training, placing them at greatest risk.

"Sharpless surgical techniques combined with traditional precautions and early education for surgery trainees are the most practical ways to reduce the risk of infection to health care workers," Makary says.

The researchers studied 709 consecutive adult general surgery operations performed between July 2003 and June 2004 in the community surgical service at The Johns Hopkins Hospital including inpatient, emergency department and outpatient surgical procedures. Data were collected on HIV, hepatitis B and hepatitis C test results; type of operation; and the patient's age, sex and history of intravenous drug use.

The researchers found that 38 percent of all operations involved a blood-borne pathogen, and almost half (47 percent) of all men tested positive for at least one infection. HIV accounted for 26 percent of infections, hepatitis B for 4 percent, hepatitis C for 35 percent and co-infection with HIV and hepatitis C for 17 percent.

In addition, blood-borne pathogen infection was found in up to 65 percent of patients with a history of intravenous drug use and in as many as 71 percent of patients undergoing a soft-tissue abscess procedure or lymph-node biopsy.

While the patients in this study tend toward low socioeconomic status and increased substance use, most university hospitals in the United States are located in urban areas and serve a similar patient population, Makary says.

Other authors on the report are Eric S. Weiss, Theresa Wang, Dora Syin, Peter Pronovost, David Chang and Edward Cornwell III.

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