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: prevention and management in the community

Percutaneous endoscopic gastrostomy (PEG) is a well-established form of artificial nutrition. Buried bumper syndrome (BBS) is a rare but severe complication related to this type of feeding tube. BBS is described as when the internal bumper migrates into the stoma tract and/or the mucosa, and the inner lining of the stomach starts to grow around and over the internal bumper. It can result in pain, infection and the loss of the feeding tube as a port of entry for delivery of nutrition, hydration and medication into the stomach. When suspected, BBS requires urgent referral into specialist hospital services. It is somewhat preventable with appropriate aftercare; however, incidents do occur. The evidence and guidance on care of PEGs differs, and more data and research are needed into the incidence of BBS and what influences it. Access to appropriate nutrition support teams is essential to support patients and their caregivers with all aspects of enteral feeding.

Advances in endoscopic therapy using grasping-type scissors forceps (with video)

Endoscopic submucosal dissection (ESD) is a globally accepted minimally invasive therapy for early-stage gastrointestinal tract tumors. Although numerous electrosurgical knives have been developed for ESD, technical difficulties and high complication rates (bleeding and perforation) have limited their use worldwide. The grasping-type scissors forceps [clutch cutter (CC)] is the first forceps-type resection device developed with reference to hemostatic forceps. The aim was to allow easy and safe ESD throughout the gastrointestinal tract, as a biopsy technique, using one device. The CC can grasp the target tissue accurately and pull it away from the underlying muscle layer prior to energizing the tissue, for safe and effective incision and hemostasis during ESD. Reported clinical studies showed that ESD using the CC (ESD-CC) is a safe (perforation rate: 0%-3.6%; delayed bleeding rate: 0%-4.2%), technically efficient (en-bloc resection rate: 88.9%-100%), and single-device method for dissecting early-stage gastrointestinal tract tumors. The ESD-CC technique is simple and easy to learn because it can be completed simply by repeating the grasp, pull, and coagulate and/or incise actions using an electrosurgical current. The reported self-completion rate by non-experts was significantly better with the CC than with conventional knives (61.7% vs 24.5%, respectively; P < 0.001). Furthermore, the CC is used for other endoscopic therapies, such as endoscopic polypectomy for large pedunculated polyps, endoscopic myotomy for Zenker’s diverticulum, endoscopic treatment of buried bumper syndrome, and endoscopic necrosectomy for wall-off pancreatic necrosis. The initial reports using CC for these therapies have shown favorable results. In this review, we describe the structural features of the CC, how to use the instrument, efficacies of ESD-CC, and other unique endoscopic therapies using the CC.

Buried Bumper Syndrome: A common complication of levodopa intestinal infusion for Parkinson disease

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is required for Levodopa/Carbidopa Intestinal Gel (LCIG) delivery in patients with advanced Parkinson's disease (PD) as well as for enteral feeding in a variety of neurological disorders. Buried Bumper Syndrome (BBS) is a serious complication of PEG. The frequency of BBS in patients receiving LCIG treatment has never been reported.

OBJECTIVES

To compare the frequency of BBS in patients on LCIG treatment or on enteral feeding over the past 12 years and identify possible risk factors.

METHODS

We reviewed prospectively recorded data from 2009 to 2020 on two case-series: LCIG-treated PD patients and non-PD patients on enteral nutrition. We identified all BBS incidences. Patients' characteristics, clinical manifestations, BBS management, possible risk factors and outcomes were analyzed.

RESULTS

During the 12 years, 35 PD patients underwent PEG insertion for LCIG infusion, and 123 non-PD patients for nutritional support. There were eight cases of BBS in six PD patients (17.1%). Six of them were effectively managed without treatment discontinuation. Of the enteral feeding patients, only one developed BBS (0.8%) (p < 0.001). We identified inappropriate PEG site aftercare, weight gain, early onset PD, longer survival, treatment duration, dementia and PEG system design as potential risk factors for BBS development.

CONCLUSIONS

BBS occurs more frequently in LCIG patients than in patients receiving enteral feeding. If detected early, it can be successfully managed, and serious sequalae or treatment discontinuation can be avoided. Regular endoscopic follow-up visits of LCIG-treated patients and increased awareness in patients and clinicians are recommended.

May chronic cough in chronic obstructive pulmonary disease be a contraindication of Percutaneous Endoscopic Gastrostomy placement: a case report

Background

Percutaneous Endoscopic Gastrostomy (PEG) can involve some complications, despite the good safety of its track record. The Buried Bumper Syndrome (BBS) is a rare, late and dangerous complication that consists in the erosion of the internal bumper through the gastric wall.

Case presentation

We report the development of BBS in a man with chronic obstructive pulmonary disease (COPD) who had a persistent chronic cough which was prevalently but not solely in the morning and required placement of a PEG tube for continuous infusion of Levodopa/carbidopa intestinal gel for advanced Parkinson's disease.

Conclusion

We believe that COPD with chronic cough while not representing an absolute contraindication to PEG placement, may potentially cause BBS and therefore an appropriate regimen of tube care by expert personnel is mandatory in this setting.

The Challenging Acute Buried Bumper Syndrome: A Case Report

Percutaneous endoscopic gastrostomy (PEG) is the preferred route of feeding and nutritional support in patients requiring long-term enteral nutrition. Major complications related to the procedure are rare. Buried bumper syndrome is a late major complication, occurring in 0.3-2.4% of patients. Although considered a late complication, it can rarely occur in an acute setting early after the procedure. We present the case of an early buried bumper syndrome, presenting 1 week after PEG tube placement, with local stoma infection associated with an infected cavity within the abdominal wall with feeding content, successfully managed with antibiotic therapy and PEG tube repositioning through the original track.

Novel endoscopic management of buried bumper syndrome in percutaneous endoscopic gastrostomy: The Olympus HookKnife

Buried bumper syndrome (BBS) is an uncommon but serious complication of percutaneous endoscopic ga-strostomy. It involves the internal fixation device, or “bumper”, migrating into the gastric wall and subsequent mucosal overgrowth. We described a case series of four patients with BBS treated with a novel endoscopic technique using a HookKnife between June 2016 and February 2017. The HookKnife is a rotating L-shaped cutting wire designed for hooking tissue and pulling it away from the gastric wall towards the lumen. The technique was successful in all four cases with no complications. Each patient was discharged on the day of treatment. The HookKnife is a manoeuvrable, safe and effective device for endoscopic removal of buried bumpers and could avoid surgery in a high risk group of patients. To our knowledge this technique has not been described previously. We suggest that this technique should be added to the treatment algorithms for managing BBS.

[Buried bumper syndrome: A new classification and therapy algorithm]

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).

The Challenging Buried Bumper Syndrome after Percutaneous Endoscopic Gastrostomy

Buried bumper syndrome (BBS) is a rare complication developed after percutaneous endoscopic gastrostomy (PEG). We report a case of a 38-year-old male patient who sustained severe traumatic brain injury that was complicated with early BBS after PEG tube insertion. On admission, bedside PEG was performed, and 7 days later the patient developed signs of sepsis with rapid progression to septic shock and acute kidney injury. Abdominal CT scan revealed no collection or leakage of the contrast, but showed malpositioning of the tube bumper at the edge of the stomach and not inside of it. Diagnostic endoscopy revealed that the bumper was hidden in the posterolateral part of the stomach wall forming a tract inside of it, which confirmed the diagnosis of BBS. The patient underwent laparotomy with a repair of the stomach wall perforation, and the early postoperative course was uneventful. Acute BBS is a rare complication of PEG tube insertion which could be manifested with severe complications such as pressure necrosis, peritonitis and septic shock. Early identification is the mainstay to prevent such complications. Treatment selection is primarily guided by the presenting complications, ranging from simple endoscopic replacement to surgical laparotomy.

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.

Buried bumper syndrome: A complication of percutaneous endoscopic gastrostomy

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.

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.