Severe acute gastrointestinal graft-vs-host disease: an emerging surgical dilemma in contemporary cancer care.
OBJECTIVE
To determine the natural history of and guidelines for the surgical management of severe acute gastrointestinal (GI) graft-vs-host disease (GVHD) after allogeneic hematopoietic stem cell transplantation (HSCT).


METHODS
Case series from a prospective database.


METHODS
Tertiary care referral center/National Cancer Institute-designated Comprehensive Cancer Center.


METHODS
A total of 63 of 2065 patients (3%) undergoing HSCT for hematologic malignancies from February 1997 to March 2005 diagnosed clinically with severe (stage 3 or 4) acute GI GVHD. Main Outcome Measure Percutaneous or surgical intervention. Perforation, obstruction, ischemia, hemorrhage, and abscess were considered surgically correctable problems.


RESULTS
Severe acute GI GVHD was diagnosed in 63 patients (median age at HSCT, 47.6 years) at a median of 23 days after HSCT. Clinical diagnosis was confirmed histologically in 84% of patients. On computed tomography and/or magnetic resonance images, 64% had bowel wall thickening, 20% had a normal-appearing bowel, and 16% had nonspecific findings; none had evidence of perforation, obstruction, or abscess. All were initially treated with immunosuppression. Only 1 patient (1.6%) required intervention, undergoing a nontherapeutic laparotomy for worsening abdominal pain. A total of 83% of patients have died (median time to death from HSCT, 119 days; from GI GVHD diagnosis, 85 days). None who underwent an autopsy died of a surgically correctable cause.


CONCLUSIONS
This series represents a large single-center experience with GI GVHD reviewed from a surgical perspective. Operative intervention was 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.
Irani
Jennifer L
JL
Department of Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
Cutler
Corey S
CS
Whang
Edward E
EE
Clancy
Thomas E
TE
Russell
Sara
S
Swanson
Richard S
RS
Ashley
Stanley W
SW
Zinner
Michael J
MJ
Raut
Chandrajit P
CP
D000208:Acute Disease; D000328:Adult; D000368:Aged; D016208:Databases, Factual; D005260:Female; D005500:Follow-Up Studies; D006086:Graft vs Host Disease / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery*; D019337:Hematologic Neoplasms / Q000473:pathology / Q000628:therapy*; D018380:Hematopoietic Stem Cell Transplantation / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016896:Treatment Outcome