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Inter-hospital Transfers May Not Impact Morbidity or Mortality in Acute Mesenteric Ischemia
Justin King, MD, Benjamin Jacobs, MD, James Hammond, BS, Jonathan Eliason, MD, Peter Henke, MD, Dawn Coleman, MD.
University of Michigan, Ann Arbor, MI, USA.

OBJECTIVES: Acute mesenteric ischemia (AMI) is a surgical emergency. Delays in treatment are associated with worse outcomes; delays resulting from inter-hospital transfer have not previously been reported to the best of our knowledge. We hypothesize that inter-hospital transfers are associated with worse outcomes in patients with AMI.
METHODS: We conducted a single-institution, retrospective review of patients with AMI (2009-2016). Patients were identified using appropriate CPT codes, excluding cases of aortic dissection, non-occlusive ischemia, and ischemic colitis. Routine patient information was extracted with an emphasis on patient care flow including times of transfer, diagnosis, and intervention. Outcomes were analyzed with Studentís T-test, Fisherís Exact Test, and simple linear regression.
RESULTS: We identified 58 patients with AMI. 34 underwent inter-hospital transfer. Etiologies included 47 with arterial ischemia and 11 with superior mesenteric vein thrombosis. Overall mortality was 25.9%. Mean interval between diagnosis and operation was 10.5 hours (SD 4.99). Patients who were transferred were more likely to be transported immediately to the OR without an initial period of observation (p=0.031); however, there was no difference in patients ultimately requiring operation (p=0.386). Patients were equally likely to undergo exploratory laparotomy (p=0.520), open or endovascular revascularization (p=1.000), and bowel resection (p=0.284). Length of bowel resection (p=0.096) did not differ between groups. There was no difference in mortality (p=0.761). Interval between diagnosis and operation was not associated with increased mortality (p=0.241), length of bowel resection (p=0.878), or severity of complication as scored by Clavien-Dindo classification (p=0.679).
Patients with AMI who were transferred demonstrated equivalent morbidity and mortality in comparison to those presenting directly to the treating hospital. Mortality was not affected by delays caused by transfer suggesting that transfer to a tertiary care facility is appropriate when local surgical support is inadequate and may not dramatically impact outcomes. Considering delays in diagnosis are common regardless of presenting location, ongoing efforts to optimize timely care is of urgent need.

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