Another approach to the buried bumper syndrome

Abstract

We read with interest the report by Ma et al.1Ma MM Semlacher EA Fedorak RN et al.The buried gastrostomy bumper syndrome: prevention and endoscopic approaches to removal.Gastrointest Endosc. 1995; 41: 505-508Abstract Full Text PDF PubMed Scopus (89) Google Scholar concerning the buried gastrostomy bumper syndrome. We observed this complication in a 24-year-old man suffering from mesencephalic syndrome type IV caused by head trauma. In order to feed the patient and to avoid aspiration, PEG was performed by the push method with a Sacks-Vine gastrostomy kit in December 1988. Seven years later, in April 1995, we evaluated the patient for a nonfunctioning gastrostomy tube. At inspection the skin surrounding the PEG tube was erythematous and indurated, and an attempt to inject water through the tube resulted in reflux around the tube site. At endoscopy a submucosal lesion positive for the “blind sign” was seen and the mucosa of the anterior wall of the gastric body appeared partly eroded. The inner bumper was not visible endoscopically. External traction on the tube produced a slight dimpling of the anterior gastric wall. A guide wire was passed through the gastrostomy tube and entered the stomach. The incision of the mucosa covering the dome with a needle knife did not allow the exposure of the inner bumper. Finally, a small cutaneous incision, performed under local anesthetic, was made on each side of the tube down to the bumper. The tube and bumper were removed, leaving the guide wire in place, without opening the peritoneum. Graduated dilators were inserted over the wire to enlarge the stoma to 22F. An 18F introducer gastrostomy tube was inserted over the wire, the balloon inflated, and the guide removed. The procedure was concluded with the standard technique. Feeding was resumed the next day and the patient was sent home. In this patient the needle-knife technique described by Ma et al.1Ma MM Semlacher EA Fedorak RN et al.The buried gastrostomy bumper syndrome: prevention and endoscopic approaches to removal.Gastrointest Endosc. 1995; 41: 505-508Abstract Full Text PDF PubMed Scopus (89) Google Scholar did not succeed in exposing the buried bumper. We think that the needle-knife technique is useful when the bumper has migrated partially or superficially. In cases of deep bumper migration into the gastric wall or impaction into the abdominal wall, the needle-knife method could cause bleeding or ulceration.1Ma MM Semlacher EA Fedorak RN et al.The buried gastrostomy bumper syndrome: prevention and endoscopic approaches to removal.Gastrointest Endosc. 1995; 41: 505-508Abstract Full Text PDF PubMed Scopus (89) Google Scholar The minimal surgical technique that we used allowed a change of gastrostomy tube without opening the peritoneum.