• Sheraz R Markar, Hugh Mackenzie, Jeremy R Huddy, Sara Jamel, Alan Askari, Omar Faiz, George B Hanna, and Giovanni Zaninotto.
• *Department of Surgery & Cancer, Imperial College London, London†St Mark's Hospital and Academic Institute, Harrow, UK.
• Ann. Surg. 2016 Nov 1; 264 (5): 854-861.

Objective(i) To establish at a national level clinical outcomes from patients presenting with acute para-esophageal hernia (PEH); and (ii) to determine if a hospital volume-outcome relationship exists for the management of acute PEH.BackgroundCurrently, no clear guidelines exist regarding the management of acute PEH, and practice patterns are based upon relatively small case series.MethodsPatients admitted as an emergency for the treatment of acute PEH between 1997 and 2012 were included from the Hospital Episode Statistics database. The influence of hospital volume upon clinical outcomes was analyzed in unmatched and matched comparisons to control for patient age, medical comorbidities, and incidence of PEH hernia gangrene.ResultsOver the 16-year study period, 12,441 patients were admitted as an emergency with a PEH causing obstruction or gangrene. Of these, 90.8% patients were admitted with PEH with obstruction in the absence of gangrene and 9.2% with PEH with gangrene. The incidences of 30 and 90-day mortality were 7% and 11.5%, respectively, which did not decrease during the study period. Unmatched and matched comparisons showed, in high-volume centers, there were significant reductions in utilization of emergency surgery (8.8% vs 14.9%; P < 0.0001), 30-day (5.3% vs 7.8%; P < 0.0001), and 90-day mortality (9.3% vs 12.7%; P < 0.0001). Multivariate analysis also confirmed high hospital volume was independently associated with reduced 30 and 90-day mortality from acute PEH.ConclusionsAcute PEH represents a highly morbid condition, and treatment in high-volume centers provides the appropriate multidisciplinary infrastructure to manage these complex patients reducing associated mortality.

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