Double Trouble: A Case of Double Bumper in a Gastrostomy Patient

Abstract

Percutaneous endoscopic gastrostomy (PEG) was developed by Gauderer in 1980. Placement could be accomplished by the pull (Ponsky), push (Sachs-Vine), introducer (Russell) and T-fastener (Versa) methods. Indications include inability to consume sufficient nutrition for longer then one month (despite functional GI tract), hydration, medications administration and gastric decompression. Complications associated with PEG tube placement can be divided into three categories, occurring at: any time, early or late. Complications occurring at any time include tube dysfunction, peristomal wound infection, necrotizing fasciitis, intra-abdominal bleeding, peritonitis, peristomal ulceration and gastric outlet obstruction. Early complications include pneumoperitoneum, ileus and perforation. Late complications include tube deterioration/migration, tract tumor seeding and fistula formation. A rare complication is buried bumper syndrome (BBS) which is a slow erosion of internal bolster into the gastric wall caused by tight apposition of the external bolster against the abdominal wall, and ultimately leads to pain and the inability to infuse feedings. We present a case of a 74 year old female with past medical history of end-stage Alzheimer's dementia who presented with PEG tube blockage. Original PEG tube was placed 1 year prior to admission in El-Salvador. Attempted removal of the PEG tube using traction technique caused breakage of the tube at the internal bolster. EGD was performed and showed extrinsic compression at insertion site, however, bolster was not identified. Abdominal CT scan was performed and showed bolster buried in-between the abdominal wall and peritoneum. As patient's family refused any surgical intervention, a decision was made to insert a new PEG tube through existing stoma and buried internal bumper. Repeat CT scan confirmed position of the PEG tube with retained internal bumper anchored between new internal bumper and abdominal wall (“Double Bumper”). Tube feeds were started and patient was discharged home. On 3 months follow-up, stoma site appeared healthy and PEG tube appeared functional. This case demonstrates a new non-surgical management of BBS. Anchoring the retained bumper prevents migration which could potentially result in small bowel obstruction (has been reported in literature). We propose that the “Double Bumper” method should be the new standard in managing the BBS in high risk surgical patient who need continued enteral feeding.Figure 1Figure 2Figure 3