title: Diaphragmatic crural augmentation utilising cross-linked porcine dermal collagen biologic mesh (Permacol) in the repair of large and complex para-oesophageal herniation: a retrospective cohort study.
abstract: OBJECTIVE
  To evaluate the safety, efficacy and durability of selective integration of porcine dermal collagen (Permacol) biologic mesh for crural re-construction in large or complex para-oesophageal hernia surgery.
  
  
  BACKGROUND
  Surgical repair of para-oesophageal herniation has been associated with high rates of failure. The utilisation of prosthetic mesh is controversial with complications including erosion and fistulation. Long-term outcomes for biologic mesh crural augmentation are unclear.
  
  
  METHODS
  A retrospective analysis of patients who underwent a biologic mesh (Permacol) augmented cruroplasty in the repair of large and/or complex para-oesophageal hernia was performed utilising the prospectively maintained oesophago-gastric database at the Royal Devon and Exeter Hospital between October 2004 and January 2013. This technique was selectively used for patients where the lateral extent of the diaphragmatic-crural defect prevented the fashioning of a sound, tension-free repair with sutures alone, or previous surgery had failed. Successful outcome was defined by resolution of symptoms and structural integrity of the repair.
  
  
  RESULTS
  Fifty one procedures were performed on 49 patients (15 male), median age 75 (range 25-91). Post-operative morbidity included 2 (3.9%) oesophageal injuries managed conservatively, and 2 (3.9%) patients who suffered early repair breakdown requiring immediate surgical re-intervention. Four patients (8%) required endoscopic dilatation due to dysphagia, one (2%) in the early post-operative phase. The median follow-up was 36 months (range 6-105). All patients reported initial symptomatic resolution. Two patients (4%) were demonstrated to have breakdown of their repair during the follow-up period, both of whom underwent revision mesh-augmented surgery and are re-incorporated in this series. Late-onset dysphagia in two (4%) patients may be mesh-related, but no other complications were observed and a Kaplan-Meier analysis of this series predicts a symptom-free rate of approximately 94% at 5 years.
  
  
  CONCLUSIONS
  The selective integration of biologic mesh to augment the crural repair in para-oesophageal hernia with extensive diaphragmatic defects appears to be safe, effective and infers the potential of long-term satisfactory outcomes.
authors.affiliation: Department of Upper Gastro-Intestinal Surgery, Royal Devon and Exeter Hospital, Barrack Road, Exeter, EX2 5DW, UK.
authors.forename: H C
authors.initials: HC
authors.lastname: Travers
authors.affiliation: Department of Upper Gastro-Intestinal Surgery, Royal Devon and Exeter Hospital, Barrack Road, Exeter, EX2 5DW, UK.|University of Exeter Medical School, Exeter, UK.
authors.forename: J O
authors.initials: JO
authors.lastname: Brewer
authors.affiliation: Department of Upper Gastro-Intestinal Surgery, Royal Devon and Exeter Hospital, Barrack Road, Exeter, EX2 5DW, UK.|University of Exeter Medical School, Exeter, UK.
authors.forename: N J
authors.initials: NJ
authors.lastname: Smart
authors.affiliation: Department of Upper Gastro-Intestinal Surgery, Royal Devon and Exeter Hospital, Barrack Road, Exeter, EX2 5DW, UK. saj.wajed@nhs.net.|University of Exeter Medical School, Exeter, UK. saj.wajed@nhs.net.
authors.forename: S A
authors.initials: SA
authors.lastname: Wajed
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000818:Animals; D001672:Biocompatible Materials; D003094:Collagen; D003964:Diaphragm / Q000601:surgery*; D005260:Female; D006551:Hernia, Hiatal / Q000601:surgery*; D059685:Herniorrhaphy / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013526:Surgical Mesh; D013552:Swine
chemical_list: D001672:Biocompatible Materials; C422414:Permacol; D003094:Collagen
keywords: Biologic; Hernia; Mesh; Para-oesophageal