The buried bumper syndrome complicating percutaneous endoscopic gastrostomy in children

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.

Guided Transabdominal U-Stitches Gastropexy: A Simplified Technique for Secure Laparoscopic Gastrostomy Tube Insertion

Introduction: Insecure gastropexy, gastric mucosa overgrowth, granulation tissue formation, and a nonhealing gastrostomy are unwanted consequences encountered in the current minimally invasive gastrostomy tube (GT) placement techniques. Aiming to overcome these problems we have developed a simplified laparoscopic-assisted GT insertion (LAG) procedure using guided transabdominal U-stitches (GTU) gastropexy. Materials and Methods: We retrospectively reviewed all LAG cases performed in our institute using the GTU technique. In brief, a curved clamp is inserted intragastrically through the laparoscopic port and guides a needle across the abdominal and gastric walls to exit, then re-enter back, through the port in an out-in-out fashion creating multiple spaced transabdominal U-stitches that are tied over pledgets. Results: Between March 2008 and January 2015, 31 cases had LAG attempted using GTU. Two cases were converted to open procedures for non-LAG-related reasons. The median age of the remaining 29 cases was 37 (range, 0.3-154.9) months. Of those patients, 20 had fundoplication (LAG-Fundo), whereas the remaining 9 had LAG-only. The mean operative times for LAG-Fundo and LAG-only were 148 ± 57.5 minutes and 41 ± 12.4 minutes, respectively. During a median follow-up of 21 (range, 4-81) months we did not encounter any procedure-related mortality, intraabdominal leaks, or bowel injuries. One patient required redo gastropexy due to unplanned early U-stitch removal, and 7 cases had transient external GT leak, granuloma formation, and/or skin infection. Conclusions: GTU can achieve a simple and secure LAG, avoiding the catastrophic complications of intraabdominal leak without the need of special instruments or enlarging the port's wound. Using a smaller wound and intraabdominally placed mucosa helps in minimizing the risk of wound infection and external leak. Transient complications are expected during the earlier phase of the learning curve.

Are PEGJs a Risk Factor for the Buried Bumper Syndrome?

AIM

Percutaneous endoscopic gastrostomies (PEGs) with or without a jejunal extension (PEGJs) are a well-accepted method of enteral feeding. They are associated with a number of complications, including the buried bumper syndrome (BBS). We aimed to identify risk factors for BBS, our current management strategies, and optimal timing for surgical treatment.

METHODS

Hospital coding and a database compiled by our specialist nutrition nurse were used to identify all cases of buried bumpers from January 2012 to December 2014 as well as all PEG/PEGJ devices inserted during this time. A retrospective case note review was performed for each patient with BBS to identify risk factors, management strategies, and outcomes.

RESULTS

Two hundred twelve PEGs and 22 PEGJs were inserted. Nine patients were identified with BBS. Patients with PEGJ tubes were significantly more likely to develop BBS (7/22, 32%) than those with PEG tubes (2/212, 0.9%) P<0.01. There was one death in the study group because of abdominal sepsis associated with an intraperitoneal PEG bumper 33days after BBS was diagnosed and before removal was attempted. All other patients underwent laparotomy to remove the bumper. Mean hospital stay was 22days postoperatively.

CONCLUSIONS

Buried bumper syndrome is a serious condition which warrants urgent intervention. We have demonstrated a higher than expected rate of BBS associated with PEGJ tubes. We hypothesize that this may be related to the jejunal extensions leading to difficulty in the usual maintenance regimen that all carers are taught after PEG/PEGJ insertion.

Gastroenteric tube feeding: Techniques, problems and solutions

Gastroenteric tube feeding plays a major role in the management of patients with poor voluntary intake, chronic neurological or mechanical dysphagia or gut dysfunction, and patients who are critically ill. However, despite the benefits and widespread use of enteral tube feeding, some patients experience complications. This review aims to discuss and compare current knowledge regarding the clinical application of enteral tube feeding, together with associated complications and special aspects. We conducted an extensive literature search on PubMed, Embase and Medline using index terms relating to enteral access, enteral feeding/nutrition, tube feeding, percutaneous endoscopic gastrostomy/jejunostomy, endoscopic nasoenteric tube, nasogastric tube, and refeeding syndrome. The literature showed common routes of enteral access to include nasoenteral tube, gastrostomy and jejunostomy, while complications fall into four major categories: mechanical, e.g., tube blockage or removal; gastrointestinal, e.g., diarrhea; infectious e.g., aspiration pneumonia, tube site infection; and metabolic, e.g., refeeding syndrome, hyperglycemia. Although the type and frequency of complications arising from tube feeding vary considerably according to the chosen access route, gastrointestinal complications are without doubt the most common. Complications associated with enteral tube feeding can be reduced by careful observance of guidelines, including those related to food composition, administration rate, portion size, food temperature and patient supervision.

Gastrostomy insertion in children: percutaneous endoscopic or percutaneous image-guided?

BACKGROUND/PURPOSE

Gastrostomy insertion in children can be performed in many ways, but which is the best technique remains uncertain. This study evaluates the outcome of percutaneous endoscopic gastrostomy (PEG) and image-guided gastrostomy (IG).

METHODS

We reviewed children who had either PEG (n = 136) inserted by pediatric surgeons or IG (n = 195) inserted by interventional radiologists in our hospital between May 2004 and July 2008. Gastrostomy-related complications were given scores ranging from 20 for major complications (eg, peritonitis, gastrointestinal bleed, and visceral injury) to 1 for minor (eg, site infection and tube migration), and total score per month of follow-up was calculated per patient.

RESULTS

Conversion to laparoscopic or open gastrostomy was more frequent in PEG versus IG (P = .001). Fewer PEG patients (28%) had complications than did IG (47%) (P = .001). One PEG patient developed a gastrocolic fistula. In the IG group, 2 patients had transverse colon puncture, 1 had intraperitoneal tube detachment, and 1 had upper gastrointestinal bleeding. When scored and adjusted by length of follow-up, PEG had lower scores compared with IG, indicating a better outcome (P = .03). These findings were supported by zero-inflated Poisson regression analysis.

CONCLUSION

Major complications were rare and observed more frequently after IG. Minor complications were observed in both procedures but were significantly less common in PEG.

Nutritional factors associated with survival following enteral tube feeding in patients with motor neurone disease

BACKGROUND

Motor neurone disease (MND) is a progressive neurodegenerative disease leading to limb weakness, wasting and respiratory failure. Prolonged poor nutritional intake causes fatigue, weight loss and malnutrition. Consequently, disease progression requires decisions to be made regarding enteral tube feeding. The present study aimed to investigate the survival, nutritional status and complications in patients with MND treated with enteral tube feeding.

METHODS

A retrospective case note review was performed to identify patients diagnosed with MND who were treated with enteral tube feeding. A total of 159 consecutive cases were identified suitable for analysis. Patients were treated with percutaneous endoscopic gastrostomy (PEG), radiologically inserted gastrostomy (RIG) or nasogastric feeding tube (NGT). Nutritional status was assessed by body mass index (BMI) and % weight loss (% WL). Serious complications arising from tube insertion and prescribed daily energy intake were both recorded.

RESULTS

Median survival from disease onset was 842 days [interquartile range (IQR) 573-1263]. Median time from disease onset to feeding tube was PEG 521 days (IQR 443-1032), RIG 633 days (IQR 496-1039) and NGT 427 days (IQR 77-781) (P = 0.28). Median survival from tube placement was PEG 200 (IQR 106-546) days, RIG 216 (IQR 83-383) days and NGT 28 (IQR 14-107) days. Survival between gastrostomy and NGT treated patients was significant (P < or = 0.001). Analysis of serious complications by nutritional status was BMI (P = 0.347) and % WL (P = 0.489).

CONCLUSIONS

Nutritional factors associated with reduced survival were weight loss, malnutrition and severe dysphagia. Serious complications were not related to nutritional status but to method of tube insertion. There was no difference in survival between PEG and RIG treated patients.

Replacement of mushroom cage gastrostomy tube using a modified technique to allow percutaneous replacement with an endoscopic tube in patients with amyotrophic lateral sclerosis

Radiologic inserted gastrostomy (RIG) is the preferred method in our institution for enteral feeding in amyotrophic lateral sclerosis (ALS). Skin-level primary-placed mushroom cage gastrostomy tubes become tight with weight gain. We describe a minimally invasive radiologic technique for replacing mushroom gastrostomy tubes with endoscopic mushroom cage tubes in ALS. All patients with ALS who underwent replacement of a RIG tube were included. Patients were selected for a modified replacement when the tube length of the primary placed RIG tube was insufficient to allow like-for-like replacement. Replacement was performed under local anesthetic and fluoroscopic guidance according to a preset technique, with modification of an endoscopic mushroom cage gastrostomy tube to allow percutaneous placement. Assessment of the success, safety, and durability of the modified technique was undertaken. Over a 60-month period, 104 primary placement mushroom cage tubes in ALS were performed. A total of 20 (19.2%) of 104 patients had a replacement tube positioned, 10 (9.6%) of 104 with the modified technique (male n = 4, female n = 6, mean age 65.5 years, range 48-85 years). All tubes were successfully replaced using this modified technique, with two minor complications (superficial wound infection and minor hemorrhage). The mean length of time of tube durability was 158.5 days (range 6-471 days), with all but one patient dying with a functional tube in place. We have devised a modification to allow percutaneous replacement of mushroom cage gastrostomy feeding tubes with minimal compromise to ALS patients. This technique allows tube replacement under local anesthetic, without the need for sedation, an important consideration in ALS.

Comparison of two percutaneous radiological gastrostomy tubes in the nutritional management of ALS patients

Patient care and minimizing complications post gastrostomy have to date received little attention in ALS patients. We compare the complications associated with pigtail and mushroom type percutaneous radiological gastrostomy tubes in this patient group. Patients requiring PRG received either Wills-Oglesby or the skin level Entristar. Retrospective review of the clinical notes was performed capturing demographic data, peristomal infection, tube displacement, tube failure, nutritional status, site of disease onset, and survival. Thirty-five patients (Group 1) had the Wills-Oglesby tube of which 14 (40%) tubes required replacement. The Entristar tube was inserted in 29 patients (Group 2) where 8 (28%) required replacement (NS). The incidence of infection was significantly lower with the Entristar tube, (p<0.001). The mean time to tube removal in Group 2 was 223 days (SD 147; range 71-494 days) due to 'buried bumper syndrome'. We conclude that the Entristar skin level gastrostomy tube is associated with a reduction in peristomal infection, tube failure and blockage compared with the Wills-Oglesby tube.

The push-pull T technique: an easy and safe procedure in children with the buried bumper syndrome

Percutaneous endoscopic gastrostomy (PEG) tube placement is a well-established procedure in adults as well as in pediatric patients who cannot be orally fed. However, potential serious complications may occur. The buried bumper syndrome is a well-recognized long-term complication of PEG. Overgrowth of gastric mucosa over the inner bumper of the tube will cause mechanical failure of formula delivery, rendering the tube useless. However, published experience in children with buried bumper syndrome is very scarce. In the authors' clinic, 76 PEG tubes were placed from 2001 to 2008, and buried bumper syndrome occurred in 1 patient. The authors report on their experience with buried bumper syndrome, an adapted safe endoscopic removal technique, as well as recommendations for prevention of buried bumper syndrome.

Clinical manifestations and management of buried bumper syndrome in patients with percutaneous endoscopic gastrostomy

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.

Unnecessary delay of diagnosis of buried bumper syndrome resulting in surgery

Percutaneous endoscopic catheter gastrostomy (PEG) is a convenient way to supply enteral nutrition for patients with swallowing disorders. One rare complication of PEG is the buried bumper syndrome where gastric mucosa overgrows the internal bumper and prevents free flow of the feeding solution. As a consequence, the application of enteral feeding has to be stopped until a free outflow is re-established. We report a case of buried bumper where symptoms were misinterpreted for several months as PEG stoma infection by the homecare service. This led to a vastly delayed diagnosis and treatment. As endoscopic intervention was unsuccessful, surgical PEG removal was required. In consequence, we recommend early endoscopic exploration in cases with prolonged inflammatory signs at the PEG stoma site in order to avoid misdiagnosis of buried bumper syndrome and to allow timely endoscopic intervention.