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Menni A, Tzikos G, Chatziantoniou G, Gionga P, Papavramidis TS, Shrewsbury A, Stavrou G, Kotzampassi K. Buried bumper syndrome: A critical analysis of endoscopic release techniques. World J Gastrointest Endosc 2023; 15:44-55. [PMID: 36925650 PMCID: PMC10011891 DOI: 10.4253/wjge.v15.i2.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/23/2022] [Accepted: 01/23/2023] [Indexed: 02/13/2023] Open
Abstract
Buried bumper syndrome (BBS) is the situation in which the internal bumper of the gastrostomy tube, due to prolonged compression of the tissues between the external and the internal bumper, migrates from the gastric lumen into the gastric wall or further, into the tract outside the gastric lumen, ending up anywhere between the stomach mucosa and the surface of the skin. This restricts liquid food from entering the stomach, since the internal opening is obstructed by gastric mucosal overgrowth. We performed a comprehensive search of the PubMed literature to retrieve all the case-reports and case-series referring to BBS and its management, after which we focused on the endoscopic techniques for releasing the internal bumper to re-establish the functionality of the tube. From the "push" and the "push and pull T" techniques to the most sophisticated-using high tech instruments, all 10 published techniques have been critically analysed and the pros and cons presented, in an effort to optimize the criteria of choice based on maximum efficacy and safety.
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Affiliation(s)
- Alexandra Menni
- Department of Surgery, Aristotle University of Thessaloniki, Thessaloniki 54636, Greece
| | - Georgios Tzikos
- Department of Surgery, Aristotle University of Thessaloniki, Thessaloniki 54636, Greece
| | - George Chatziantoniou
- Department of Surgery, Aristotle University of Thessaloniki, Thessaloniki 54636, Greece
| | - Persefoni Gionga
- Department of Surgery, Aristotle University of Thessaloniki, Thessaloniki 54636, Greece
| | | | - Anne Shrewsbury
- Department of Surgery, Aristotle University of Thessaloniki, Thessaloniki 54636, Greece
| | - George Stavrou
- Department of Surgery, Aristotle University of Thessaloniki, Thessaloniki 54636, Greece
| | - Katerina Kotzampassi
- Department of Surgery, Aristotle University of Thessaloniki, Thessaloniki 54636, Greece
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Bronswijk M, Maly M, Snauwaert C, Christiaens P. Endoscopic management of buried bumper syndrome: the balloon-dilation pull technique. Endoscopy 2022; 54:E741-E742. [PMID: 35299267 DOI: 10.1055/a-1775-7786] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Michiel Bronswijk
- Department of Gastroenterology, Imelda General Hospital, Bonheiden, Belgium.,Department of Gastroenterology and Hepatology, University Hospitals Leuven, Belgium.,Imelda Clinical GI Research Center, Bonheiden, Belgium
| | - Marlies Maly
- Department of Gastroenterology and Hepatology, Gent University Hospital, Belgium
| | - Christophe Snauwaert
- Department of Hepatology and Gastroenterology, St. Jan Hospital, Bruges, Belgium.,Clinique Universitaires Saint-Luc, Brussels, Belgium
| | - Paul Christiaens
- Department of Gastroenterology, Imelda General Hospital, Bonheiden, Belgium
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Abstract
AIM Buried Bumper (BB) is a complication of percutaneous endoscopic gastrostomy (PEG) that leads to tube dysfunction and major morbidity. Although many techniques have been described to manage BB, none are universally adopted, and laparotomy remains the mainstay. We introduce a novel endoscopic technique in paediatric surgery that avoids laparotomy. METHODS A retrospective review of medical records of patients who presented with BB to Cambridge University Hospital, UK, between January 2012 and June 2018 was done. Data collected included: demographics, tube size and type, interval between insertion and diagnosis of BB, hospital stay, technique used, and postoperative complications. The technique involved using an endoscopic snare passed from inside the stomach lumen through the PEG lumen to the outside, guided if required by a stiff nylon thread if no part of the PEG was visible, grasping the PEG tube externally after cutting it short, followed by a retrograde pull to remove the buried tube via the mouth. MAIN RESULTS Fifteen BBs were found in ten patients. Median patient age was 5.25 years (1.2-16.6). Median time between gastrostomy insertion and diagnosis of BB was 9 months (1-32). Twelve BBs were removed endoscopically with no postoperative complications. Patients had a replacement inserted through the original track and were discharged within 24 h. Two underwent laparotomies performed by surgeons unfamiliar with endoscopic technique, and one was converted to laparotomy owing to inability to transverse an encrusted and closed PEG tube lumen. CONCLUSION Endoscopic retrograde BB removal is a safe, easy, and quick technique with minimal complications. We strongly advocate widespread adoption of the technique before considering a laparotomy. LEVEL OF EVIDENCE Treatment study: Level IV.
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Abstract
BACKGROUND Buried bumper syndrome (BBS) is a severe complication of percutaneous endoscopic gastrostomy (PEG) based on the overgrowth of gastric mucosa over the inner bumper of a PEG and migration into the gastric or abdominal wall and with a highly variable incidence ranging between 0.9 and > 8 %. However, no classification has yet been described setting the extent of migration of the inner bumper in relation to therapy and the related risk, especially of perforation. OBJECTIVES In the past 12 years 38 patients presented with BBS. Initially, an attempt was made to treat all BBS patients endoscopically. A structured BBS classification into four types for estimation of the therapy risk was developed. METHOD BBS classification: IA: inner bumper partially extrakorporeal or subcutaneous with and without fistula; IB: inner bumper completely extrakorporeal, full thickness focal defect; II: partially visible inner bumper inside the stomach, good degree of mobility; IV: deep type., inner bumper not visible, mucosa without mobility. RESULTS Up to August 2014, examiners with different degrees of experience classified and treated 17 BBS patients according to the algorithm described above (type IA n = 2, type IB n = 2, type II n = 3, type III n = 4 and type IV n = 6). Problem-free endoscopic therapy was possible in all of the patients in whom good mucosa mobilization with or without partial identification of the inner PEG bumper could be previously induced. CONCLUSION The classification serves as an aid and takes both the therapist's experience and patient safety into consideration. In estimating the risk, it considers the following prevailing circumstances: More stringent obligation for patient information under the Patient Rights Act, with presentation of possibly necessary expansion of therapy; the obligation to cite relative alternative treatments; prior check of the resources available (specialist/surgery available yes/no).
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Cyrany J, Rejchrt S, Kopacova M, Bures J. Buried bumper syndrome: A complication of percutaneous endoscopic gastrostomy. World J Gastroenterol 2016; 22:618-627. [PMID: 26811611 PMCID: PMC4716063 DOI: 10.3748/wjg.v22.i2.618] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 06/25/2015] [Accepted: 10/26/2015] [Indexed: 02/06/2023] Open
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.
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Berry P, Langlands S, Campbell C, Direkze N, Ala A, Karat I, Keeling P, Taylor J. Removing PEG tubes with 'buried bumpers': Lessons learnt from four patients. Clin Nutr ESPEN 2015; 10:e49-e51. [PMID: 28531458 DOI: 10.1016/j.clnesp.2014.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 11/21/2014] [Accepted: 11/21/2014] [Indexed: 10/23/2022]
Abstract
We noted an increase in the number of presentations with dysfunctional PEG tubes due to the 'buried bumper syndrome' (BBS). There is no standard approach to this problem, although case reports exist of endoscopic needle knife excision and forceful pulling. We present a description of our experience in the management of this problem and the lessons learnt by complications or adverse outcomes. Two patients died within 2 weeks of endoscopic therapy. Successful and safe endoscopic removal appears dependent on the depth of the bumper, and this may be gauged by whether or not a wire can be inserted into the gastric lumen via the external portion of the tube. Further experience with radiological estimation of depth is required. The underlying frailty of this group of patients requires careful pre-intervention risk assessment and may favour a conservative approach.
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Affiliation(s)
- Philip Berry
- Department of Gastroenterology, Hepatology and Nutrition, Frimley Park Hospital NHS Foundation Trust, Portsmouth Road, Frimley, Camberley, GU16 7UJ, United Kingdom.
| | - Sarah Langlands
- Department of Gastroenterology, Hepatology and Nutrition, Frimley Park Hospital NHS Foundation Trust, Portsmouth Road, Frimley, Camberley, GU16 7UJ, United Kingdom
| | - Claire Campbell
- Department of Gastroenterology, Hepatology and Nutrition, Frimley Park Hospital NHS Foundation Trust, Portsmouth Road, Frimley, Camberley, GU16 7UJ, United Kingdom
| | - Natalie Direkze
- Department of Gastroenterology, Hepatology and Nutrition, Frimley Park Hospital NHS Foundation Trust, Portsmouth Road, Frimley, Camberley, GU16 7UJ, United Kingdom
| | - Aftab Ala
- Department of Gastroenterology, Hepatology and Nutrition, Frimley Park Hospital NHS Foundation Trust, Portsmouth Road, Frimley, Camberley, GU16 7UJ, United Kingdom
| | - Isabella Karat
- Department of Surgery, Frimley Park Hospital NHS Foundation Trust, Portsmouth Road, Frimley, Camberley, GU16 7UJ, United Kingdom
| | - Peter Keeling
- Department of Anaesthesia, Frimley Park Hospital NHS Foundation Trust, Portsmouth Road, Frimley, Camberley, GU16 7UJ, United Kingdom
| | - Jeremy Taylor
- Department of Radiology, Frimley Park Hospital NHS Foundation Trust, Portsmouth Road, Frimley, Camberley, GU16 7UJ, United Kingdom
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Curcio G, Granata A, Ligresti D, Tarantino I, Barresi L, Traina M. Buried bumper syndrome treated with HybridKnife endoscopic submucosal dissection. Gastrointest Endosc 2014; 80:916-7. [PMID: 25436407 DOI: 10.1016/j.gie.2014.07.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 07/03/2014] [Indexed: 02/08/2023]
Affiliation(s)
- Grabiele Curcio
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Antonino Granata
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Dario Ligresti
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Mario Traina
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
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Coumaros D, Tsesmeli NE. Esophageal stent occlusion from a gastrostomy tube: balloon dilator-assisted endoscopic management. Am J Gastroenterol 2008; 103:2404-5. [PMID: 18844631 DOI: 10.1111/j.1572-0241.2008.02010_6.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Lee TH, Lin JT. Clinical manifestations and management of buried bumper syndrome in patients with percutaneous endoscopic gastrostomy. Gastrointest Endosc 2008; 68:580-4. [PMID: 18620346 DOI: 10.1016/j.gie.2008.04.015] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2008] [Accepted: 04/14/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND Buried bumper syndrome has been regarded as an uncommon and late complication after percutaneous endoscopic gastrostomy (PEG) tube insertion. A variety of techniques have been reported to treat this problem, but only a few published cases exist. OBJECTIVE Our purpose was to present the clinical manifestations and our management of a series of 19 patients with buried bumper syndrome. DESIGN Case series study. SETTING Referral medical centers. PATIENTS Within 5 years, 31 episodes of buried bumper syndrome occurred in 10 men and 9 women. The estimated prevalence was 8.8% (19 in 216 PEG procedures during this period). INTERVENTION All the buried tubes were removed smoothly by external traction and replaced with a new pull-type feeding tube by the pull method or a button or balloon replacement tube after dilation of the old tract. MAIN OUTCOME MEASUREMENTS Success rate, complication rate. RESULTS The duration between occurrence of buried bumper syndrome and PEG placement ranged from 1 to 50 months, with a median of 18 months. All the episodes were treated successfully except for one, in which reinsertion failed and a new PEG tube was inserted 1 week later. No significant complications occurred. LIMITATION Small sample size. CONCLUSIONS Buried bumper syndrome is not that uncommon and can occur soon after insertion of a PEG tube. The buried tube can be safely removed by external traction and in most cases can then be replaced with a pull-type or balloon replacement tube.
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Affiliation(s)
- Tzong-Hsi Lee
- Division of Gastroenterology, Departments of Internal Medicine, Far Eastern Memorial Hospital, National Taiwan University Hospital, Taipei, Taiwan
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Radhakrishnan N, Sharma RK, Ellul P, George R. The "Quill" technique--another method for managing buried bumper syndrome. Gastrointest Endosc 2006; 64:668. [PMID: 16996373 DOI: 10.1016/j.gie.2006.06.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2006] [Accepted: 06/14/2006] [Indexed: 02/08/2023]
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