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NESS 2006 Annual Meeting
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Gastrointestinal Graft-Versus-Host Disease: An Emerging Surgical Dilemma in Contemporary Cancer Care
Jennifer L Irani1, Corey S Cutler1,2, Stanley W Ashley1, Michael J Zinner1, Edward E Whang1, Chandrajit P Raut1
1Brigham and Women's Hospital, Boston, MA;2Dana-Farber Cancer Institute, Boston, MA

Objective: To determine the natural history and guidelines for the surgical management of gastrointestinal (GI) graft-versus-host disease (GVHD) after allogeneic hematopoietic stem cell transplantation (HSCT).
Design: Case series from a prospective database.
Setting: Tertiary care referral center/National Cancer Institute-designated Comprehensive Cancer Center.
Patients: Sixty-three (3%) of 2065 patients undergoing HSCT for hematologic malignancies from February 1997 to March 2005 were diagnosed clinically with severe (Grade III-IV) GI GVHD.
Main Outcome Measures: Percutaneous or surgical intervention. Perforation, obstruction, ischemia, hemorrhage, and abscess were considered surgically correctable problems.
Results: Severe GI GVHD was diagnosed in 63 patients (median age 42.5 years) at a median of 19.5 days after HSCT. Clinical diagnosis was confirmed histologically in 86%. On CT/MRI, 64% had bowel wall thickening, 22% had normal-appearing bowel, and 14% had nonspecific findings; none had evidence of perforation, obstruction, or abscess. All were initially treated with immunosuppression. Only 3 patients (5%) required intervention; 1 underwent percutaneous drainage of an abscess, and 2 patients underwent non-therapeutic laparotomy (one for worsening abdominal pain and one for pneumatosis intestinalis with pneumoperitoneum). Seventy-nine percent of patients have died (median time-to-death from HSCT, 148 days; from GI GVHD diagnosis, 110 days). None who underwent an autopsy died from a surgically correctable cause.
Conclusions: This series represents a large single-center experience with GI GVHD reviewed from a surgical perspective. Operative intervention is rarely required. Therefore, mature surgical judgment is necessary to confirm the absence of surgically reversible problems, thus avoiding unnecessary operations in this challenging patient population.

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