PTH-080 A multimodality endoscopic approach for management of buried bumper syndrome

Abstract

Introduction Buried bumper syndrome (BBS) is a rare, long-term complication of percutaneous endoscopic gastrostomy (PEG) placement, occurring in 2%–6% of the cases. BBS is thought to occur due to prolonged compression of the tissue between the external and internal fixators, leading to ‘burying’ of the PEG bumper into the gastric wall. Consequences of BBS include tube obstruction and more rarely bleeding, abscess formation, and perforation. Several endoscopic techniques are described for the management of BBS and these may be complimentary when used in combination. Methods A 32-year-old woman with diabetes, chronic kidney disease, a history of hypoglycaemic brain injury and gastroparesis, requiring a venting PEG, presented with abdominal pain. PEG tube obstruction led to the suspicion of BBS and abdominal computerised tomography confirmed this. Results At upper gastrointestinal endoscopy under general anaesthesia, the internal bumper was found to be completely buried by granulation and fibrotic tissue. A 2.5 mm FlushKnife (Fujifilm, Saitama, Japan) was initially used to partially dissect the overgrown gastric tissue in order to achieve insertion of a biopsy forceps down the external aspect of the PEG tube and through the dissected orifice. This manoeuvre opened a track in the overgrown tissue for insertion of a sphincterotome mounted on a JagWire (Boston Sci., MA, USA) through the external PEG tube. The sphincterotome was then flexed completely and several radial incisions on the overgrown tissue were performed using external traction on the sphincterotome. Finally, a 6 mm endoscopic balloon dilator was passed through the scope and pulled into the PEG tube by the biopsy forceps inserted through the external end of the tube. The balloon was then fully inflated within the PEG tube and traction was applied to the balloon and endoscope for release of the buried bumper and PEG tube remnant from the dissected overgrown tissue into the stomach. The dissected orifice was then closed using endoscopic clips. The procedure was performed under antibiotic prophylaxis. Conclusion To the best of our knowledge, this is the first use of a complimentary, multimodality endoscopic approach for the effective, minimally invasive, safe management of BBS.