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

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 (PermacolTM) 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