PTH-057 Endoscopic management of buried bumper syndrome

Abstract

Introduction Buried Bumper Syndrome (BBS) is an uncommon, yet potentially serious complication of percutaneous gastrostomy tube (PEG) placement with a quoted incidence of 1%. Usually identified during routine nursing assessment, release of a buried bumper can be achieved via external manipulation, endoscopically or via surgery. Aim Review the frequency and success of endoscopic treatment of BBS. Methods At Basildon University Hospital a 4-level stepwise approach was adopted for management of Buried Bumper Syndrome, with each level representing an escalation of therapy. 29. Level 1– Release achieved by external manipulations by a nurse or radiologist. 30. Level 2– Endoscopic if the internal bumper can be seen through a relatively wide tract it may be pulled through by graspers or snare. 31. Level 3–Sometime the tract is narrow and may require quadrantic incisions (3a) or subsequent balloon dilations (3b) before release. 32. Level 4– Cannot be endoscopically released and require surgery. Retrospective review of endoscopy records held on Unisoft from August 2009 to Jan 2018 by a bespoke Access query. Endoscopy and clinical records were reviewed of the identified patients. By definition no Level 1 cases would be identified. Results 27 incidences of BBS requiring 30 endoscopic procedures in 18 patients were identified. 4 (22%) patients had repeated distinct episodes of BBS (2–5). 18 episodes of BBS were successful resolved endoscopically (67%). Interventions were 4x Level 2, 9x level 3a, 5x Level 3b. Endoscopic treatment of 9 episodes of BBS were unsuccessful (Level 4). 4/9 patients had a surgical removal, though one precipitated a 2 month admission complicated by an ITU stay. The other 5 patients were deemed unfit, though one patient continued to suffer from septic episodes related to the bumper. The PEG insertion date was unknown many patients (e.g out of area, pre-2009) but for 12 patients the time from insertion to attempted release of BBS was known. 2 episodes Conclusion This is a relatively infrequent endoscopic dilemma with only 27 instances over a 8.5 year study period. However with rare scenarios the referral pathway can be unclear. Only one endoscopist managed Level 3 releases and by default they became the routine destination for Nutrition team referrals. This allowed a 66% success rate but disappointingly 22% of the patients had recurrent episodes. Recommendations 1) Education of the institutions caring for these patients. 2) Single endoscopists to develop expertise in each centre 3) If successful, attempt to site a new PEG in a second area despite the difficulty.