Title: Treatment of acute mesenteric ischemia between 2010 and 2020 – a German nation-wide
study
Version: 3 Date: 28 Jul 2023
Reviewer:  Martin Altreuther
Reviewer's report:
Thank you for the opportunity to review the revised manuscript.
I am happy with most of the responses and changes in the manuscript, but in my opinion, the
issue regarding the large group of patients who are discharged alive is still not discussed good
enough.
40.7 % of the patients in your study are discharged alive after conservative treatment, and the
diagnosis AMI is therefor unlikely. If you remove this group from your analysis, your figures
will be different, and closer to previously reported figures.
As you see from the example calculation below (figures after removel of the patients where
the diagnosis AMI is unlikely), 55.9 % of the patients where AMI is likely, die in hospital –
which is slightly better than the 60 % you report from your reference, but quite close.  30 % of
the patients where AMI is likely, receive no surgical treatment and die in hospital, while 70 %
receive some form of surgical treatment, of which 65 % visceral surgery and about 9 % some
kind of revascularization.
This indicates that treatment still is for late for most of the patients, and some kind of damage
control (bowel resection) usually is necessary. Whether this is due to patients presenting too late
or due to lack of a revascularization service is impossible to conclude from your data, but in my
opinion, your figures prove that there is a large potential for improvement for this patient group,
which is not expressed clearly enough in your discussion.
All patients 251997 100 %
Discharged alive 168544 66,9 %
Death in hospital 83453 33,1 %
Endovascular 4922  2,0 %
Vascular surgery 8544  3,4 %
Visceral surgery 97042  38,5 %
Conservative treatment 147926 58,7 %
Discharged alive 102634 40,7 % For this group, the diagnosis AMI is unlikely
After removal of the patients where the diagnosis AMI is unlikely.
All patients 149363 100,0 %
Discharged alive 65910 44,1 %
Death in hospital 83453 55,9 %
Endovascular 4922 3,3 %
Vascular surgery 8544 5,7 %
Visceral surgery 97042 65,0 %
Conservative treatment and death in hospital 45292 30,3 %
Specific comments:
Side 10 Line 12-14 You state that revascularization is not possible any more in case of bowel
ischemia, perforation or peritonitis, which is incorrect. It is correct that a necrotic bowel segment
cannot be saved by revascularization, however other segments which are ischemic without
established necrosis may be salvaged by revascularization, even after resection of the necrotic
segments.
Side 10 line 20   “for which any further treatment is unnecessary”. I suggest you consider a
different wording, like …where palliation is the only remaining option, where the patient is
considered inoperable for revascularization or bowel surgery.
Title: Treatment of acute mesenteric ischemia between 2010 and 2020 – a German nation-wide
study
Version: 3 Date: 28 Jul 2023
Reviewer:  Martin Altreuther
Reviewer's report:
Thank you for the opportunity to review the revised manuscript.
I am happy with most of the responses and changes in the manuscript, but in my opinion, the
issue regarding the large group of patients who are discharged alive is still not discussed good
enough.
40.7 % of the patients in your study are discharged alive after conservative treatment, and the
diagnosis AMI is therefor unlikely. If you remove this group from your analysis, your figures
will be different, and closer to previously reported figures.
As you see from the example calculation below (figures after removel of the patients where
the diagnosis AMI is unlikely), 55.9 % of the patients where AMI is likely, die in hospital –
which is slightly better than the 60 % you report from your reference, but quite close.  30 % of
the patients where AMI is likely, receive no surgical treatment and die in hospital, while 70 %
receive some form of surgical treatment, of which 65 % visceral surgery and about 9 % some
kind of revascularization.
This indicates that treatment still is for late for most of the patients, and some kind of damage
control (bowel resection) usually is necessary. Whether this is due to patients presenting too late
or due to lack of a revascularization service is impossible to conclude from your data, but in my
opinion, your figures prove that there is a large potential for improvement for this patient group,
which is not expressed clearly enough in your discussion.
All patients 251997 100 %
Discharged alive 168544 66,9 %
Death in hospital 83453 33,1 %
Endovascular 4922  2,0 %
Vascular surgery 8544  3,4 %
Visceral surgery 97042  38,5 %
Conservative treatment 147926 58,7 %
Discharged alive 102634 40,7 % For this group, the diagnosis AMI is unlikely
After removal of the patients where the diagnosis AMI is unlikely.
All patients 149363 100,0 %
Discharged alive 65910 44,1 %
Death in hospital 83453 55,9 %
Endovascular 4922 3,3 %
Vascular surgery 8544 5,7 %
Visceral surgery 97042 65,0 %
Conservative treatment and death in hospital 45292 30,3 %
Specific comments:
Side 10 Line 12-14 You state that revascularization is not possible any more in case of bowel
ischemia, perforation or peritonitis, which is incorrect. It is correct that a necrotic bowel segment
cannot be saved by revascularization, however other segments which are ischemic without
established necrosis may be salvaged by revascularization, even after resection of the necrotic
segments.
Side 10 line 20   “for which any further treatment is unnecessary”. I suggest you consider a
different wording, like …where palliation is the only remaining option, where the patient is
considered inoperable for revascularization or bowel surgery.
Please review this paper.
user
Title: Treatment of acute mesenteric ischemia between 2010 and 2020 – a German nation-wide
study
Version: 3 Date: 28 Jul 2023
Reviewer:  Martin Altreuther
Reviewer's report:
Thank you for the opportunity to review the revised manuscript.
I am happy with most of the responses and changes in the manuscript, but in my opinion, the
issue regarding the large group of patients who are discharged alive is still not discussed good
enough.
40.7 % of the patients in your study are discharged alive after conservative treatment, and the
diagnosis AMI is therefor unlikely. If you remove this group from your analysis, your figures
will be different, and closer to previously reported figures.
As you see from the example calculation below (figures after removel of the patients where
the diagnosis AMI is unlikely), 55.9 % of the patients where AMI is likely, die in hospital –
which is slightly better than the 60 % you report from your reference, but quite close.  30 % of
the patients where AMI is likely, receive no surgical treatment and die in hospital, while 70 %
receive some form of surgical treatment, of which 65 % visceral surgery and about 9 % some
kind of revascularization.
This indicates that treatment still is for late for most of the patients, and some kind of damage
control (bowel resection) usually is necessary. Whether this is due to patients presenting too late
or due to lack of a revascularization service is impossible to conclude from your data, but in my
opinion, your figures prove that there is a large potential for improvement for this patient group,
which is not expressed clearly enough in your discussion.
All patients 251997 100 %
Discharged alive 168544 66,9 %
Death in hospital 83453 33,1 %
Endovascular 4922  2,0 %
Vascular surgery 8544  3,4 %
Visceral surgery 97042  38,5 %
Conservative treatment 147926 58,7 %
Discharged alive 102634 40,7 % For this group, the diagnosis AMI is unlikely
After removal of the patients where the diagnosis AMI is unlikely.
All patients 149363 100,0 %
Discharged alive 65910 44,1 %
Death in hospital 83453 55,9 %
Endovascular 4922 3,3 %
Vascular surgery 8544 5,7 %
Visceral surgery 97042 65,0 %
Conservative treatment and death in hospital 45292 30,3 %
Specific comments:
Side 10 Line 12-14 You state that revascularization is not possible any more in case of bowel
ischemia, perforation or peritonitis, which is incorrect. It is correct that a necrotic bowel segment
cannot be saved by revascularization, however other segments which are ischemic without
established necrosis may be salvaged by revascularization, even after resection of the necrotic
segments.
Side 10 line 20   “for which any further treatment is unnecessary”. I suggest you consider a
different wording, like …where palliation is the only remaining option, where the patient is
considered inoperable for revascularization or bowel surgery.
assistant