Choice of first emergency room affects the fate of patients with acute mesenteric ischaemia: the importance of referral patterns and triage
Open accessAbstract
Objectives Despite modern advances in diagnosis and treatment, acute arterial mesenteric ischaemia (AMI) remains a high mortality disease. One of the key modifiable factors in AMI is the first door to operation time, but the factors attributing to this parameter are largely unknown. The aim of this study was to evaluate the factors affecting delay, with special focus on the pathways to treatment.Methods This was a single academic centre retrospective study. Patients undergoing intervention for AMI caused by thrombosis or embolism of the superior mesenteric artery between 2006 and 2015 were identified from electronic patient records. Patients not eligible for intervention or with chronic, subacute onset, colonic only, venous, or non-occlusive mesenteric ischaemia were excluded. Patients were divided into two groups according to the first speciality examining the patient (surgical emergency room [SER], surgeon examining the patient first or non-surgical emergency room [non-SER], internist examining the patient first). The primary endpoint was first door to operation time and secondary endpoints were length of stay and 90 day mortality.Results Eighty-one patients with AMI were included. Fifty patients (62%) died during the first 30 days and 53 (65%) within 90 days. Presenting first in non-SER (vs. SER) was independently associated with a first door to operation time of over 12 h (OR 3.7 [95% CI 1.3-10.2], median time 15.2 h [IQR 10.9-21.2] vs. 10.1 h [IQR 6.9-18.5], respectively, p = .025). The length of stay was shorter (median 6.5 days [4.0-10.3] vs. 10.8 days [7.0-22.3], p = .045) and 90 day mortality was lower in the SER group (50.0% vs. 74.5%, p = .025).Conclusions The first specialty that the patient encounters seems to be crucial for both delayed management and early survival of AMI. Developing fast/direct pathways to a unit with both gastrointestinal and vascular surgeons offers the possibility of improving the outcome of AMI.
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In patients with AMI, initial referral to the surgical emergency room (vs non-surgical) was associated with fewer bowel resections.
“Time to CT, diagnosis, and operation were all shorter in patients with AMI initially referred to the surgical emergency room as opposed to non-surgical, which also led to shorter hospital stay, fewer bowel resections, and a lower 90 day mortality rate (50% vs. 75%). 120”
From Editor's Choice - European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Diseases of the Mesenteric and Renal Arteries and Veins. (2025) · cites this paper as [120]
The Primary operative treatment section reports no significant difference in the choice of operative treatment between patients first seen in surgical and non-surgical emergency rooms. It does not support an association between surgical emergency room referral and fewer bowel resections. (LLM, conf=0.82)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredDiagnostic delay resulting from admission under the wrong specialty is detrimental to outcomes for AMI, as time to intervention is crucial.
“As known for other emergency surgical conditions, diagnostic delay resulting from admission under the wrong specialty is also detrimental to outcomes for AMI, as time to intervention is crucial8,9.”
From Acute mesenteric ischaemia (2023) · cites this paper as [9]
The Abstract (page unavailable) reports longer times to operation and higher 90-day mortality when an internist rather than a surgeon examined the patient first. The Results also report shorter times to diagnosis in the surgical-ER group. However, the Discussion says this study did not detect a correlation between time to operation and mortality, so it does not establish that the delay itself caused the worse outcomes. (LLM, conf=0.88)
Experimental — accuracy not yet measuredIn patients with AMI, initial referral to the surgical emergency room (vs non-surgical) was associated with shorter hospital stay.
“Time to CT, diagnosis, and operation were all shorter in patients with AMI initially referred to the surgical emergency room as opposed to non-surgical, which also led to shorter hospital stay, fewer bowel resections, and a lower 90 day mortality rate (50% vs. 75%). 120”
In patients with AMI, initial referral to the surgical emergency room (vs non-surgical) was associated with lower 90-day mortality (50% vs 75%).
“Time to CT, diagnosis, and operation were all shorter in patients with AMI initially referred to the surgical emergency room as opposed to non-surgical, which also led to shorter hospital stay, fewer bowel resections, and a lower 90 day mortality rate (50% vs. 75%). 120”
In patients with AMI, initial referral to the surgical emergency room (vs non-surgical) was associated with shorter time to CT, diagnosis, and operation.
“Time to CT, diagnosis, and operation were all shorter in patients with AMI initially referred to the surgical emergency room as opposed to non-surgical, which also led to shorter hospital stay, fewer bowel resections, and a lower 90 day mortality rate (50% vs. 75%). 120”
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- Authors
- Lemma, A. N., Tolonen, M., Vikatmaa, P., Mentula, P., Vikatmaa, L., Kantonen, I., Leppäniemi, A., & Sallinen, V.
- Affiliations
- University of Helsinki (FI)
- Corresponding author
- Sallinen, Ville
- ORCID
- Venue
- European Journal of Vascular and Endovascular Surgery
- Publisher
- Elsevier BV
- Published
- 2019-06
- Volume
- 57
- Issue
- 6
- Pages
- 842-849
- ISSN
- 1078-5884 (ISSN-L)
- OpenAlex
- W2945742878
- Cited by
- 31
- References
- 32
- Citations by year
- 2025: 3 · 2024: 2 · 2023: 6 · 2022: 7 · 2021: 10 · 2020: 2 · 2019: 1
- FWCI
- 4.82
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- European Journal of Vascular and Endovascular Surgery (publishedVersion)
- PubMed (publishedVersion)
- Työväentutkimus Vuosikirja (submittedVersion, other-oa)
- Funders
- Vatsatautien tutkimussäätiö Foundation
- Mary And Georg Ehrnrooth's Foundation
- Biomedicum Helsinki Foundation
- Topics
- Health Sciences › Medicine › Surgery › Abdominal vascular conditions and treatments
- Health Sciences › Medicine › Epidemiology › Acute Ischemic Stroke Management
- Health Sciences › Medicine › Emergency Medicine › Appendicitis Diagnosis and Management
- Keywords
- superior mesenteric artery thrombosis, superior mesenteric artery embolism, referral patterns, triage, length of hospital stay, 90-day mortality
- MeSH terms
- Academic Medical Centers, Acute Disease, Aged, Aged, 80 and over, Choice Behavior, Emergency Service, Hospital, Female, Humans, Length of Stay, Male, Mesenteric Vascular Occlusion, Referral and Consultation, Retrospective Studies, Risk Factors, Specialization, Time Factors, Triage, Treatment Outcome, Mesenteric Artery, Superior, Critical Pathways, Electronic Health Records, Time-to-Treatment, Mesenteric Ischemia
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