Incidence and Prognostic Factors for the Development of Symptomatic and Asymptomatic Marginal Ulcers After Roux-en-Y Gastric Bypass Procedures.

INTRODUCTION: Marginal ulcer (MU) is a serious complication after Roux-en-Y gastric bypass (RYGB) procedures. This study reports the incidence, risk factors, and treatment outcomes of symptomatic and incidentally, at routine endoscopy diagnosed, MU. METHODS: All patients undergoing RYGB procedures between 2013 and 2018 at a single center were included. Upper endoscopy was performed in case of symptoms and/or routinely 2 and 5 years postoperatively. RESULTS: In total, 568 patients (83.3% female) underwent RYGB procedure with a median age of 40 years and median initial body mass index of 41 kg/m2. The median time to follow-up was 2.99 years. Routine 2- and 5-year upper endoscopy was performed in 256 (55.3%) and 65 (38.0%) eligible patients, respectively. In 86 (15.1%) patients, MU was diagnosed at a median time of 14.2 months (4.58-26.2) postoperatively and 24.4% of patients with MU were asymptomatic. In total, 76.7% of MUs were located on the side of the Roux limb. 88.4% of MUs were treated conservatively; re-operation was necessary in 10 (11.6%) patients. Smoking and type 2 diabetes mellitus were the only independent risk factors for MU development in multivariate analysis with a hazard ratio of 2.65 and 1.18 (HbA1c per unit >6.0), respectively. CONCLUSION: MU is a common complication after gastric bypass surgery with 25% of patients being asymptomatic. Follow-up routine endoscopy is recommended for early MU detection and subsequent accurate therapy, especially in patients with the independent risk factors smoking and type 2 diabetes mellitus.

Long-term Results of the Open Latarjet Procedure for Recurrent Anterior Shoulder Instability in Patients Older Than 40 Years.

BACKGROUND: Subgroup analyses of the Latarjet procedure have suggested that age over 40 years is a risk factor for dislocation arthropathy. PURPOSE: To analyze long-term results of the open Latarjet procedure for recurrent anterior shoulder dislocation in patients at least 40 years of age. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 39 consecutive patients (40 shoulders) with a mean age of 48 years (range, 40-66 years) at surgery were evaluated at a mean follow-up of 11.0 years (range, 8-16 years). Of these, 15 patients (38%) had undergone previous soft tissue stabilization surgery. Long-term results were assessed clinically and radiographically, including computed tomography scanning at final follow-up. RESULTS: No recurrence of dislocation was noted. Subluxation had occurred in 3 patients (8%), and apprehension persisted in 5 patients (13%). The total Walch-Duplay score averaged 89 points at the final follow-up, and the mean Subjective Shoulder Value (60%-91%) had improved significantly (P < .001). In total, 36 patients rated their result as excellent, 3 as good. Further, 6 patients (15%) underwent joint-preserving reoperation, and 1 patient (3%) had reverse total shoulder arthroplasty for severe dislocation arthropathy. Dislocation arthropathy was severe in 14 patients (37%) and had progressed by at least 2 grades in 17 patients (45%). Patients with severe dislocation arthropathy had already shown degenerative changes preoperatively as opposed to those who ultimately had no or moderate dislocation arthropathy (n = 24) (P < .001). Progression of dislocation arthropathy was associated with lateral (>1 mm) graft positioning (P < .001) and older age at surgery (r = 0.58; P < .001). CONCLUSION: The open Latarjet procedure for recurrent anterior shoulder instability in patients older than 40 years reliably restores stability and leads to high patient satisfaction. This procedure is, however, associated with a substantial rate of advanced but clinically mild symptomatic dislocation arthropathy, which is associated with the degree of preoperative joint degeneration, older age at surgery, and lateral graft placement.