Acute buried bumper syndrome: An endoscopic peg tube salvage approach

Abstract

Acute buried bumper syndrome is an uncommon complication of percutaneous endoscopic gastrostomy (PEG) tube placement. If not recognized and treated appropriately, it can lead to serious complications including death. We report a case of an acute buried bumper syndrome, successfully managed with PEG tube repositioning through the original tract, without the need of replacement.

The Challenging Buried Bumper Syndrome after Percutaneous Endoscopic Gastrostomy

“…BBS is an unusual complication with an estimated incidence ranging from 0.3 to 2.4% [ 14 , 15 , 16 ]. It can be manifested with minor complications such as feeding intolerance, peristomal leak, pain, swelling at the site of tube insertion, stoma infection and tube obstruction, whereas major complications including peritonitis, perforation, gastrointestinal bleeding, abdominal wall abscesses or sepsis can rarely happen [ 8 , 9 ]. In our case, the tube stoma site showed ischemic marks and pressure necrosis 1 week after PEG insertion, and the patient developed signs of sepsis which rapidly progressed to septic shock.…”

“…The time of presentation of BBS varies in the literature; it is commonly expected to occur after 3 weeks to 3 months. Bhat et al [ 9 ] reported a case of early BBS which was managed with tube repositioning endoscopically as no other complications were present, and the authors explained it with severe retching and inadvertent pull during retching. Geer and Jeanmonod et al [ 14 ] observed a case with BBS 3 weeks after PEG tube insertion which was treated with endoscopic replacement.…”

“…The primary treatment of BBS is the replacement of the buried tube if the PEG insertion site is salvageable [ 9 ]. It has been recommended to remove buried bumper even in asymptomatic patients to prevent major complications like subcutaneous tissue infection, abdominal wall perforation and peritonitis [ 5 ].…”

“…It has been proposed that excessive pressure between the internal and external bolsters of the gastrostomy tube can cause mucosal ischemia, necrosis and infection resulting in BBS [ 7 , 8 ]. BBS could be suspected in patients based on history, physical examination and failure to insert and rotate the PEG tube before repositioning the external bumper [ 9 ]. The most definitive technique to diagnose BBS is gastrointestinal endoscopy, whereas imaging techniques such as ultrasonography and abdominal computerized tomography (CT) are also useful for diagnosis [ 6 ].…”

Buried bumper syndrome: a rare complication of percutaneous endoscopic gastrostomy.

“…However, there are described cases of BBS as soon as 10 days after PEG placement [ 13 ]. In that situation the PEG tube can be salvaged and repositioned to the stomach without the need of replacement [ 14 ]. Although in our case BBS was recognized early, the orifice in the gastric wall was covered by fibrin and gastric mucosa; moreover, the internal bumper had migrated outside the gastric wall, so pulling the PEG tube back to the stomach using forceps or snare was impossible.…”