A multimodality endoscopic approach for the management of buried bumper syndrome

Buried bumper syndrome: A critical analysis of endoscopic release techniques

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.

Buried Bumper Syndrome: Early or Late?

Buried bumper syndrome (BBS) is a rare and serious complication of percutaneous endoscopic gastrostomy (PEG) tube placement. In the literature, BBS is considered to be a late complication of PEG procedure, but it may occur in the early period after PEG tube placement. Early diagnosis and proper treatment are important. Different treatment modalities may be used to treat BBS. The aim of this study was to evaluate patients with BBS. During a time frame between January 2015 and February 2020, a hospital medical database was screened for PEG placement and BBS. Buried bumper syndrome was found in 36 patients. Demographic and clinical characteristics of these patients were retrospectively investigated. Those who developed BBS in the first month were evaluated as early BBS. Those who developed BBS after more than a month were evaluated as late BBS. The median BBS development time was 135.9 ± 208.1 days (9-834 days). In 18 (50%) patients, BBS developed within the first month. Serious complications such as abscess and peritonitis were observed in 8 (22.2%) patients on admission. Thirty-two (88.9%) of 36 patients were treated with external traction and four patients were treated with surgery. No complications were observed in patients who were treated with traction. Five patients died, of whom three of them died because of BBS complications, whereas two of them died from other causes unrelated to BBS. Buried bumper syndrome is a complication that can be seen in the early period after gastrostomy. External traction is a reliable method for treating these patients. Proper education of patients' relatives and caregivers is very important to prevent BBS and related complications.

Multicenter cohort study of patients with buried bumper syndrome treated endoscopically with a novel, dedicated device

BACKGROUND AND AIMS

Buried bumper syndrome (BBS) is a rare adverse event of percutaneous endoscopic gastrostomy (PEG) placement in which the internal bumper migrates through the stomal tract to become embedded within the gastric wall. Excessive tension between the internal and external bumpers, causing ischemic necrosis of the gastric wall, is believed to be the main etiologic factor. Several techniques for endoscopic management of BBS have been described using off-label devices. The Flamingo set is a novel, sphincterotome-like device specifically designed for BBS management. We aimed to evaluate the effectiveness of the Flamingo device in a large, homogeneous cohort of patients with BBS.

METHODS

A guidewire was inserted through the external access of the PEG tube into the gastric lumen. The Flamingo device was then introduced into the stomach over the guidewire. This dedicated tool can be flexed by 180 degrees, exposing a sphincterotome-like cutting wire, which is used to incise the overgrown tissue until the PEG bumper is exposed. A retrospective, international, multicenter cohort study was conducted on 54 patients between December 2016 and February 2019.

RESULTS

The buried bumper was successfully removed in 53 of 55 procedures (96.4%). The median time for the endoscopic removal of the buried bumper was 22 minutes (range, 5-60). Periprocedural endoscopic adverse events occurred in 7 procedures (12.7%) and were successfully managed endoscopically. A median follow-up of 150 days (range, 33-593) was performed in 29 patients (52.7%), during which no significant adverse events occurred.

CONCLUSIONS

Through our experience, we found this dedicated novel device to be safe, quick, and effective for minimally invasive, endoscopic management of BBS.