Evolution of surgical indication strategies and their impact on treatment outcomes in acute superior mesenteric venous thrombosis: a single-center retrospective cohort study

To compare how different surgical indication strategies affect treatment patterns and outcomes in patients with acute superior mesenteric vein thrombosis (SMVT), and to identify independent risk factors for intestinal wall full-thickness necrosis and in-hospital mortality. We retrospectively analyzed 125 patients with acute intestinal ischemia secondary to SMVT from October 2014 to October 2025. Patients were divided into two chronological cohorts according to the change in surgical indication strategy implemented at our institution: the liberal surgical indication period (October 2014 – October 2023, n = 102) and the strict surgical indication period (November 2023 – October 2025, n = 23). Baseline characteristics, treatment pathways, and in-hospital outcomes were compared between the two periods. Multivariate logistic regression was used to identify independent risk factors for in-hospital mortality and for full-thickness necrosis in patients undergoing surgery. The two periods were comparable with respect to baseline characteristics ( P > 0.05). Compared with the liberal period, the strict period had significantly lower rates of early surgery (4.3% vs. 63.7%, P < 0.001) and overall surgery (26.1% vs. 80.4%, P < 0.001). Full-thickness necrosis was identified in a significantly higher proportion of surgical specimens in the strict period than in the liberal period (83.3% vs. 18.3%, P = 0.002). Patients in the strict period had a longer median hospital stay (19 days vs. 12 days, P = 0.011), a trend toward lower ICU admission (30.4% vs. 50.0%, P = 0.089), and no significant difference in mortality (13.0% vs. 7.8%, P = 0.423). Multivariate analysis showed that lactate ≥ 4 mmol/L (aOR = 7.545, 95%CI: 1.827–31.149, P = 0.005) and elevated D-dimer (aOR = 1.047, 95%CI: 1.012–1.084, P = 0.008) were independently associated with in-hospital mortality. Given the limited number of death events ( n = 11), the above multivariate analysis results should be considered exploratory findings that require validation in larger prospective cohorts. In surgical patients, CT evidence of impaired bowel wall perfusion independently predicted pathologically confirmed full-thickness necrosis (aOR = 6.236, 95%CI: 1.663–23.388, P = 0.007). A strict surgical indication strategy with an anticoagulation-first approach was associated with a lower rate of surgery in SMVT patients and directs surgical intervention more precisely to those with established full-thickness necrosis. CT evidence of impaired bowel wall perfusion is a key warning sign for full-thickness necrosis and warrants urgent surgical evaluation. Hyperlactatemia and elevated D-dimer independently predict in-hospital mortality and should serve as core elements for early risk assessment and dynamic monitoring.