Buried bumper syndrome: A complication of percutaneous endoscopic gastrostomy

Abstract

Percutaneous endoscopic gastrostomy (PEG) is a widely used method of nutrition delivery for patients with long-term insufficiency of oral intake. The PEG complication rate varies from 0.4% to 22.5% of cases, with minor complications being three times more frequent. Buried bumper syndrome (BBS) is a severe complication of this method, in which the internal fixation device migrates alongside the tract of the stoma outside the stomach. Excessive compression of tissue between the external and internal fixation device of the gastrostomy tube is considered the main etiological factor leading to BBS. Incidence of BBS is estimated at around 1% (0.3%-2.4%). Inability to insert, loss of patency and leakage around the PEG tube are considered to be a typical symptomatic triad. Gastroscopy is indicated in all cases in which BBS is suspected. The depth of disc migration in relation to the lamina muscularis propria of the stomach is critical for further therapy and can be estimated by endoscopic or transabdominal ultrasound. BBS can be complicated by gastrointestinal bleeding, perforation, peritonitis, intra-abdominal and abdominal wall abscesses, or phlegmon, and these complications can lead to fatal outcomes. The most important preventive measure is adequate positioning of the external bolster. A conservative approach should be applied only in patients with high operative risk and dismal prognosis. Choice of the method of release is based on the type of the PEG set and depth of disc migration. A disc retained inside the stomach and completely covered by the overgrowing tissue can be released using some type of endoscopic dissection technique (needle knife, argon plasma coagulation, or papillotome through the cannula). Proper patient selection and dissection of the overgrowing tissue are the major determinants for successful endoscopic therapy. A disc localized out of the stomach (lamina muscularis propria) should be treated by a surgeon.

Keywords: Buried bumper syndrome; Complication; Endoscopy; Enteral nutrition; Percutaneous endoscopic gastrostomy.

Figure 1

Buried bumper syndrome. External view demonstrates tight position of the external fixator with peristomal granulations.

Figure 2

This chart demonstrates conflicting influence of the position of the external fixator (loose-tight) on the risk of complications (stomal infection, buried bumper syndrome and peritoneal leakage) as a function of time.

Figure 3

Buried bumper syndrome, gastroscopy. A: Pressure ulcer under the internal bolster repositioned to the gastric lumen; B: Hyperplastic tissue growing over the edge of the disk; C: Flat stomach wall with fistula orifice covering totally the internal bolster; D: Completely buried disc retracting the gastric mucosa; E: Internal bolster totally embedded in the stomach wall resembling a submucosal tumor. Flushing solution running from the internal orifice of the residual fistula.

Figure 4

Buried bumper syndrome, fluoroscopy (tubogram). Cavity around the buried bolster filled with contrast agent leaking through the fistula (arrow) to the stomach lumen.

Figure 5

Buried bumper syndrome, abdominal ultrasound. Internal retention disc (arrowheads) located out of the lamina muscularis propria of the stomach (arrow).

Figure 6

Buried bumper syndrome, computed tomography. Internal retention disc localized between the gastric and abdominal wall (courtesy of Pavel Ryska, MD, PhD, Department of radiology, University Hospital Hradec Kralove, Czech Republic).

Figure 7

Treatment methods of buried bumper syndrome. A: Extraction of the buried gastrostomy tube with simultaneous pull through of the new one (adapted from[36,63]); B: “Push-pull T technique”. Endoscopist pulls the buried gastrostomy tube by a polypectomy snare anchored using a “T-arm”, while the system is stabilized and pushed inside using a clamp (adapted from[27,72]); C: A polypectomy snare entraps the buried cannula as close to the skin as possible (thanks to splitting) (adapted from[75]); D: Papillotome introduced through a shortened cannula cuts the overgrowing tissue (adapted from[78-81]).