What is the optimal surgical approach for patients with hepatitis B surface antigen (HBsAg), hepatitis C virus (HCV), hepatitis A virus (HAV), hepatitis E virus (HEV), hepatitis D virus (HDV), and human immunodeficiency virus (HIV) infections, considering their viral load and liver function?

Surgical Management of Patients with Viral Hepatitis (HBV, HCV, HAV, HEV, HDV, HIV)

Surgery can and should proceed in patients with viral hepatitis infections when clinically indicated, as viral status is NOT an absolute contraindication to surgery, provided universal precautions are strictly followed and appropriate perioperative management is implemented. 1

Key Principle: Viral Load Does NOT Determine Surgical Candidacy

The decision to operate is based on liver function and disease severity, not viral titers. 2 The presence of detectable virus or high viral loads does not preclude surgery—what matters is:

• Degree of hepatic fibrosis/cirrhosis (assessed by non-invasive methods like FibroScan or liver biopsy) 2
• Liver synthetic function (ALT, AST, bilirubin, albumin, prothrombin time/INR) 1
• Presence of decompensated cirrhosis (ascites, encephalopathy, variceal bleeding) 2

Preoperative Assessment Algorithm

Step 1: Establish Complete Viral Profile

• HBV patients: Determine HBsAg, anti-HBc total, anti-HBc IgM, anti-HBs, HBeAg, and quantitative HBV DNA by PCR 1
• HCV patients: Confirm HCV RNA positivity and quantitative viral load 2
• HIV patients: Document CD4 count, HIV viral load, and current antiretroviral therapy status 2
• HDV patients (if HBsAg-positive): Test for anti-HDV and HDV RNA 2
• HAV/HEV: These cause acute self-limiting hepatitis and rarely impact surgical decisions unless causing acute liver failure 3, 4

Step 2: Assess Liver Disease Severity

• Measure liver enzymes (ALT, AST), bilirubin, albumin, and INR 1
• Evaluate for cirrhosis using FibroScan (liver stiffness measurement), APRI score, or FIB-4 index 2
• Classify disease stage:
  • Chronic hepatitis without cirrhosis: Standard surgical risk 2
  • Compensated cirrhosis: Increased risk, requires hepatology consultation 2, 1
  • Decompensated cirrhosis: Very high risk, surgery only if emergent 2

Step 3: Risk Stratification by Virus Type

Hepatitis B (HBsAg-positive):

• HBeAg-positive patients have higher infectivity (30% transmission risk to healthcare workers via needlestick) but this does NOT contraindicate surgery 5
• High viral load (>10^7 IU/mL) increases transmission risk but NOT surgical complications 2, 1
• Action: Proceed with surgery using enhanced precautions 1

Hepatitis C (HCV RNA-positive):

• Transmission risk to healthcare workers is 1.8% per needlestick exposure 6, 5
• Viral load does NOT predict surgical outcomes 7
• Action: Proceed with surgery; consider DAA therapy post-operatively 2

HIV (detectable viral load):

• Transmission risk to healthcare workers is only 0.3% per needlestick (10-fold lower than HCV, 100-fold lower than HBV) 2, 5, 8
• CD4 count <200 cells/μL increases infection risk post-operatively, not a contraindication 2
• Action: Proceed with surgery; ensure antiretroviral therapy continues perioperatively 2

Hepatitis D (HDV RNA-positive):

• Only occurs with concurrent HBV infection 2
• Increases risk of cirrhosis and HCC compared to HBV alone 2
• Action: Manage as high-risk HBV patient 2

Hepatitis A/E:

• Acute self-limiting infections; surgery should be deferred during acute phase unless emergent 3, 4
• Once resolved (IgG-positive, IgM-negative), no special precautions needed 3

Perioperative Antiviral Management

When to Initiate Antiviral Prophylaxis

HBV patients requiring antiviral therapy:

• Decompensated cirrhosis: Treat if HBV DNA ≥2,000 IU/mL 2
• Compensated cirrhosis: Treat if any detectable HBV DNA 2
• Chronic hepatitis: Treat if ALT ≥2× ULN and HBV DNA ≥20,000 IU/mL (HBeAg-positive) or ≥2,000 IU/mL (HBeAg-negative) 2
• Immunosuppression planned (transplant, chemotherapy, biologics): Start entecavir, tenofovir DF, or tenofovir AF prophylaxis regardless of viral load to prevent reactivation 2, 1

HCV patients:

• No perioperative antiviral prophylaxis needed 2
• DAA therapy can be initiated post-operatively once recovered 2

HIV patients:

• Continue existing antiretroviral therapy throughout perioperative period 2
• Adjust dosing for drug-drug interactions with anesthetics/antibiotics 2

HBV/HCV co-infection:

• If HCV RNA detectable: Treat HCV with DAAs first 2
• If HBV DNA detectable and meets treatment criteria: Add nucleos(t)ide analog (entecavir or tenofovir) 2
• Monitor for HBV reactivation during HCV treatment 2

HBV/HIV co-infection:

• Use tenofovir-based regimen that treats both viruses 2

Intraoperative Precautions (Universal for ALL Viral Hepatitis/HIV Patients)

Enhanced barrier protection:

• Double gloving mandatory for all surgical staff 1
• Change outer glove if contaminated or every 90 minutes in prolonged procedures 2

Hands-free technique:

• Use neutral zone/basin for passing sharp instruments 1
• Announce verbally when passing sharps 2
• Never hand-to-hand transfer of needles or scalpels 1

High-risk procedures (orthopedic, cardiothoracic, trauma surgery with blind palpation):

• Consider blunt-tip suture needles where feasible 2
• Minimize digital palpation in body cavities 2

Staff protection:

• All surgical team members must be vaccinated against HBV with documented protective antibody levels (anti-HBs >10 mIU/mL) 1, 5

Postoperative Management

No special isolation required beyond standard precautions 1

Monitor liver function:

• Check ALT, AST, bilirubin, INR on postoperative days 1,3, and 7 1
• Avoid hepatotoxic medications (acetaminophen >2g/day, NSAIDs in cirrhosis) 1

Refer to hepatology/infectious disease:

• All HBV patients meeting treatment criteria should be referred for antiviral therapy after surgical recovery 1
• HCV patients should be referred for DAA therapy 4-6 weeks post-operatively 2
• HIV patients should have infectious disease follow-up to optimize antiretroviral therapy 2

Special Situations

Emergency surgery:

• Proceed immediately with strict universal precautions even without complete viral workup 1
• Obtain baseline serologies intraoperatively 1

Cirrhotic patients (Child-Pugh B or C):

• Elective surgery has prohibitive mortality risk; defer unless life-threatening indication 2
• Emergency surgery: Correct coagulopathy with FFP/platelets, consider ICU-level monitoring 2

Immunosuppression planned post-operatively:

• Start HBV prophylaxis (entecavir or tenofovir) before initiating immunosuppression in all HBsAg-positive or anti-HBc-positive patients 2, 1
• Continue for ≥6-12 months after stopping immunosuppression 2

Critical Pitfalls to Avoid

Do NOT delay necessary surgery based solely on positive viral serology or high viral load 1

Do NOT assume HBeAg-negative HBV patients are non-infectious—they can still transmit virus 1

Do NOT stop antiretroviral therapy perioperatively in HIV patients—this risks viral rebound and resistance 2

Do NOT forget HBV reactivation prophylaxis in patients receiving immunosuppression—this can cause fulminant hepatic failure 2, 1

Do NOT rely on gloves alone—32% of needlestick injuries result in patient blood re-contacting the surgical field, creating bidirectional transmission risk 2