title: Crura ultrastructural alterations in patients with hiatal hernia: a pilot study.
abstract: BACKGROUND
  Laparoscopic fundoplication for gastroesophageal reflux disease (GERD) and hiatal hernia has been validated worldwide in the past decade. However, hiatal hernia recurrence still represents the most frequent long-term complication after primary repair. Different techniques for hiatal closure have been recommended, but the problem remains unsolved. The authors theorized that ultrastructural alterations may be implicated in hiatal hernia. Thus, this study was undertaken to investigate the presence of these alterations in patients with or without hiatal hernia.
  
  
  METHODS
  Samples from Laimer-Bertelli connective membrane and muscular crura at the esophageal hiatus were collected from 19 patients with GERD and hiatal hernia (HH group), and from 7 patients without hiatal hernia enrolled as the control group (NHH group). Specimens were processed and analyzed by transmission electron microscopy.
  
  
  RESULTS
  Muscle and connective samples from the NHH group did not present any ultrastructural alteration that could be detected by transmission electron microscopy. Similarly, connective samples from the HH group showed no ultrastructural alterations. In contrast, all muscle samples from the HH group exhibited sarcolemmal alterations, subsarcolemmal vacuolar degeneration, extended disruption of sarcotubular complexes, increased intermyofibrillar spaces, and sarcomere splitting.
  
  
  CONCLUSIONS
  The evidence of ultrastructural alterations in all the patients in the HH group raises the suspicion that the long-term outcomes of antireflux surgery depend not only on the surgical technique, but also on the underlying muscular diaphragmatic illness.
authors.affiliation: Unit of Surgical Digestive Physiopathology, Second University of Naples, Naples, Italy. landino.fei@tin.it
authors.forename: L
authors.initials: L
authors.lastname: Fei
authors.forename: G
authors.initials: G
authors.lastname: del Genio
authors.forename: L
authors.initials: L
authors.lastname: Brusciano
authors.forename: V
authors.initials: V
authors.lastname: Esposito
authors.forename: D
authors.initials: D
authors.lastname: Cuttitta
authors.forename: F
authors.initials: F
authors.lastname: Pizza
authors.forename: G
authors.initials: G
authors.lastname: Rossetti
authors.forename: V
authors.initials: V
authors.lastname: Trapani
authors.forename: G
authors.initials: G
authors.lastname: Filippone
authors.forename: M
authors.initials: M
authors.lastname: Francesco
authors.forename: A
authors.initials: A
authors.lastname: del Genio
mesh_terms: D000328:Adult; D003964:Diaphragm / Q000648:ultrastructure*; D004943:Esophagogastric Junction / Q000648:ultrastructure; D005260:Female; D005764:Gastroesophageal Reflux / Q000473:pathology; D006551:Hernia, Hiatal / Q000473:pathology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D012016:Reference Values