Buried Bumper Syndrome Research Articles

Revision of Long‐term Gastrostomy

Insertion of gastrostomy has become a popular choice for children with feeding problems. With the passage of time, gastrostomies require revision for various reasons. The aims of the present study are to report our experience of the revision of long-term gastrostomies, to ascertain the reasons for revision, and to discuss any measures that may prevent the need for revision. We conducted a retrospective review of all of the patients requiring gastrostomy revision by the senior author between 2005 and June 2011. The patients had had their original operation in several different hospitals within the United Kingdom, between 1997 and 2008. We excluded those patients requiring the revision for an acute complication (within 1 month) or required revision for subsequent fundoplication. The patients' hospital notes were reviewed to identify the reasons for revision and a literature search was done to find ways to prevent these. There were 15 patients who required revision of gastrostomy. Epithelialisation of the gastrostomy track with gastric mucosa was the most common cause (9/15). Other reasons were buried bumper syndrome (BBS) (4/15) and migration of the gastrostomy exit site toward the rib cage (2/15). The mean interval before revision due to the epithelialisation of the tract was 101 months since the insertion of the gastrostomy. The mean for other complications was 26 months for BBS and 95 months for migration of the exit site. We believe that the incidence of gastrostomy revision could be reduced. Preventing epithelialisation is difficult and may be minimised by aggressive and generous use of topical silver nitrate. The gastrostomy exit site needs to be as far away from the rib edge as possible. Checking the bumper regularly or use of a gastrostomy balloon button instead of a tube eliminates BBS. Parents need to be aware of the possibility that a long-term gastrostomy may need surgical revision.

Percutaneous endoscopic gastrostomy for nutritional palliation of upper esophageal cancer unsuitable for esophageal stenting

Esophageal cancer is often diagnosed at an advanced stage and has a poor prognosis. Most patients with advanced esophageal cancer have significant dysphagia that contributes to weight loss and malnutrition. Esophageal stenting is a widespread palliation approach, but unsuitable for cancers near the upper esophageal sphincter, were stents are poorly tolerated. Generally, guidelines do not support endoscopic gastrostomy in this clinical setting, but it may be the best option for nutritional support. Retrospective evaluation of patients with dysphagia caused advanced esophageal cancer, no expectation of resuming oral intake and with percutaneous endoscopic gastrostomy for comfort palliative nutrition. We selected adult patients with unresecable esophageal cancer histological confirmed, in whom stenting was impossible due to proximal location, and chemotherapy or radiotherapy were palliative, using gastrostomy for enteral nutrition. Clinical and nutritional data were evaluated, including success of gastrostomy, procedure complications and survival after percutaneous endoscopic gastrostomy, and evolution of body mass index, albumin, transferrin and cholesterol. Seventeen males with stage III or IV squamous cell carcinoma fulfilled the inclusion criteria. Mean age was 60.9 years. Most of the patients had toxic habits. All underwent palliative chemotherapy or radiotherapy. Gastrostomy was successfully performed in all, but nine required prior dilatation. Most had the gastrostomy within 2 months after diagnosis. There was a buried bumper syndrome treated with tube replacement and four minor complications. There were no cases of implantation metastases or procedure related mortality. Two patients were lost and 12 died. Mean survival of deceased patients was 5.9 months. Three patients are alive 6, 14 and 17 months after the gastrostomy procedure, still increasing the mean survival. Mean body mass index and laboratory parameters were roughly stable 1 and 3 months after the gastrostomy procedure. In patients with advanced upper esophageal cancer where only palliative treatment is possible, nutritional support is easily achieved with percutaneous endoscopic gastrostomy, allowing patients to be at homes, surviving a significant period of time. Percutaneous endoscopic gastrostomy feeding should be considered as standard definitive nutritional palliation in patients with upper esophageal cancer, unsuitable for esophageal stenting.

PMO-084 The evolution of a virtual peg assessment team: activity and complications

IntroductionPatients referred for percutaneous Endoscopic Gastrostomy (PEG) insertion often have multiple co-morbidities which do not improve with PEG feeding and lead to significant post-procedure complications. Pre-assessment of patients for PEG...

Pretherapeutic evaluation of buried bumper syndrome by endoscopic ultrasonography

Pretherapeutic evaluation of buried bumper syndrome by endoscopic ultrasonography

A Retrospective Correlation of Percutaneous Feeding Tube Stoma Length in Sitting and Supine Positions Compared With Body Mass Index

Accurate knowledge of stoma tract length is important to prevent gastric ulcer formation, buried bumper syndrome, and peristomal leakage/infection. Current guidelines suggest 0.5-1.0 cm of play between the skin and external bolster. The aim of this study was to determine if stoma tract length changes from supine and sitting position and if this change is related to BMI. Patients undergoing percutaneous feeding tube change from November 2006 to September 2009 were enrolled. Correlations were made between BMI and stoma tract length in both sitting and supine positions. Twenty-eight patients (24 percutaneous endoscopic gastrostomy [PEG], 4 direct percutaneous jejunal feeding tube) were included; 19 (68%) were female. The mean ± SD stoma length was 3.6 ± 0.9 cm in the supine position and 4.9 ± 1.4 cm in the sitting position. The mean ± SD stoma length change from supine to sitting position was 1.53 ± 0.9 cm. Mean ± SD BMI was 21.2 ± 4.5 (range, 14.9-33.8). Stoma length in the supine position (r = 0.65, P = .0002) and sitting position (r = 0.6, P = .0009) was strongly correlated with BMI. Change in stoma tract length was correlated with BMI (r = 0.43, P = .02). Stoma tract length is strongly correlated with BMI in both the sitting and supine positions. PEG stoma tract length changes significantly from the supine and sitting position. To prevent complications, most patients should have a longer distance set between internal and external bolsters than is recommended.

A novel laparoscopic approach for the surgical management of buried bumper syndrome

A novel laparoscopic approach for the surgical management of buried bumper syndrome

Wrośnięcie PEG ( buried bumper syndrome ) – rzadkie powikłanie przezskórnej gastrostomii endoskopowej

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Borkowska A, Jankowska A, Szlagatys-Sidorkiewicz A, Landowski P, Kamińska B. Buried bumper syndrome – a rare complication of percutaneous endoscopic gastrostomy tube feeding. Gastroenterology Review/Przegląd Gastroenterologiczny. 2012;7(2):111-113. doi:10.5114/pg.2012.28654. APA Borkowska, A., Jankowska, A., Szlagatys-Sidorkiewicz, A., Landowski, P., & Kamińska, B. (2012). Buried bumper syndrome – a rare complication of percutaneous endoscopic gastrostomy tube feeding. Gastroenterology Review/Przegląd Gastroenterologiczny, 7(2), 111-113. https://doi.org/10.5114/pg.2012.28654 Chicago Borkowska, Anna, Agnieszka Jankowska, Agnieszka Szlagatys-Sidorkiewicz, Piotr Landowski, and Barbara Kamińska. 2012. "Buried bumper syndrome – a rare complication of percutaneous endoscopic gastrostomy tube feeding". Gastroenterology Review/Przegląd Gastroenterologiczny 7 (2): 111-113. doi:10.5114/pg.2012.28654. Harvard Borkowska, A., Jankowska, A., Szlagatys-Sidorkiewicz, A., Landowski, P., and Kamińska, B. (2012). Buried bumper syndrome – a rare complication of percutaneous endoscopic gastrostomy tube feeding. Gastroenterology Review/Przegląd Gastroenterologiczny, 7(2), pp.111-113. https://doi.org/10.5114/pg.2012.28654 MLA Borkowska, Anna et al. "Buried bumper syndrome – a rare complication of percutaneous endoscopic gastrostomy tube feeding." Gastroenterology Review/Przegląd Gastroenterologiczny, vol. 7, no. 2, 2012, pp. 111-113. doi:10.5114/pg.2012.28654. Vancouver Borkowska A, Jankowska A, Szlagatys-Sidorkiewicz A, Landowski P, Kamińska B. Buried bumper syndrome – a rare complication of percutaneous endoscopic gastrostomy tube feeding. Gastroenterology Review/Przegląd Gastroenterologiczny. 2012;7(2):111-113. doi:10.5114/pg.2012.28654.

A novel laparoscopic approach for the surgical management of buried bumper syndrome

This issue of the Annals contains letters about one recently published technical note and one tip, whose writers point out that they had published the same techniques some time ago. The Technical Section was established ten years ago to fill something of a void in ‘general’ surgical journals, by providing a forum for publication of new and/or useful points of surgical technique. From the outset I knew that many submissions would not be truly original. I ask specialist reviewers: ‘Is it novel, reasonable and/or sufficiently interesting to merit publication?’ If they advise that a technique is one they have seen but that it is useful and seems not to be widely known, then I request that the authors add a few words to point out that the technique is not original. If reviewers state that a technique has been reported in another journal, then it is not accepted: but the Annals does depend on its reviewers for that knowledge and they may well not be aware of ‘small’ publications among the plethora of journals that now exist. It certainly is disappointing to find that authors have not done a thorough literature search: there is little excuse for that nowadays. The Readers’ Pages allow rapid publication of letters if that needs to be pointed out. They also allow authors to respond if they believe that their technique has subtle differences and the Annals encourages such exchanges. I see one aspect of the Technical Section as being a place for trainees to gain their early experience of publishing. If they fail to do a proper literature search and are exposed publicly for that, then it is a deservedly painful step in their learning. Their senior co-authors must also be acutely aware of their own responsibilities for checking final manuscripts and the processes used in their preparation. My own unease in witnessing these exchanges is ameliorated just a little by the fact that it shows that surgeons are reading the Technical Section and noticing when notes and tips are not original. A novel laparoscopic approach for the surgical management of buried bumper syndrome

Mide Perforasyonu ve Peritonitle Birlikte Akut Gömülmüş Tampon Sendromu: Perkütan Endoskopik Gastrostominin Nadir Bir Komplikasyonu

Percutaneous endoscopic gastrostomy (PEG) is a broadly accepted procedure of enteral feeding for patients with inadequate oral intake. The side effects and complications of PEG are becoming more evident with its increasing use. Here, we report a case of buried bumper syndrome, gastric perforation and peritonitis after PEG. In our case, perforated area was closed endoscopically by using hemoclips. The patient was treated with intravenous broad spectrum antibiotics for 10 days and fed by parenteral nutrition. The patient responded well to medical treatment therefore there was not any need for a surgical exploration. Follow up endoscopy was performed 15 days later which showed closure of the perforation area. A new PEG tube was inserted 1 month later.

Sa1636 Buried Bumper Syndrome: Prevalence and Endoscopic Management

Buried bumper syndrome (BBS) is a rare long-term complication of percutaneous endoscopic gastrostomy (PEG) and consists of a progressive impaction of the inner bumper of the tube in the gastric wall, resulting from excessive traction and overtightening of the outer flange. The aim of our study was to report our own experience with patients with BBS, focusing on their endoscopic management.

Sa1668 Results of Two Different Techniques of Percutaneous Endoscopic Gastrostomy in Patients With Head and Neck Cancer - Experience of a Tertiary Referral Academic Center

Results of Two Different Techniques of Percutaneous Endoscopic Gastrostomy in Patients With Head and Neck Cancer Experience of a Tertiary Referral Academic Center Felipe A. Retes, Fauze Maluf-Filho, Fabio S. Kawaguti, Carla Z. Neves, Bruno C. Martins, Fabio Y. Hondo, Marcelo S. Lima, Ulysses Ribeiro, Paulo Sakai Surgery of the Alimentary Tract, Cancer Institute of Sao Paulo, Sao Paulo, Brazil Introduction: Most of the patients with head and neck cancer (HNC) present with dysphagia caused by the malignant digestive stenosis usually aggravated by the treatment. In most of them, prolonged nutritional support will be needed. Percutaneous endoscopic gastrostomy (PEG) is considered the method of choice to provide nutritional support to these patients. On the other hand, severe complications related to PEG placement such as acute respiratory distress, metastasis to the gastrostomy site and increased rate of peristomal infection have been associated with HNC patients. Objective: describe the safety profile and the efficacy of two PEG techniquespull and introducer/gastropexy in HNC patients. Methods: retrospective review of prospectively collected data in an academic tertiary referral center. From December 2008 to May 2010, 77 HNC patients (84% male, median age 58,6 y, range 28 to 89 y) were referred to PEG placement. Patients with trismus or severe aerodigestive stenosis were submitted to the introducer technique with gastropexy (Frexapexat-Fresenius Germany) with the aid of a slim (4.9mm) scope (GIF-N180 Olympus Co, Japan). The remaining pts were submitted to standard PEG by the pull technique with a 24 or 20Fr feeding tube (PEGflow Cook, USA). The rates of technical success, complications, morbidity and mortality were determined. Results: PEG placement was possible in 76 patients (98.7%). The absence of transillumination and previous gastrectomy prevented PEG in one pt (1.3%). The pull technique was employed in 65 patients (85.5%) and the introducer technique with gastropexy with a 15 Fr tube, in 11 patients (14.5%). Major complications were observed in 6 (7.8%) and minor complications in 11 (14.4%) of the 76 patients. All the major complications were observed in the pull technique group (6/65pts-9.2%) and included acute respiratory distress in three pts (4,6%) with fatal outcome in one of them (1.5% mortality rate), one case of bleeding (1,5%), one case with buried bumper syndrome (1,5%) and inadvertent early withdrawn of the tube in one pt (1,5%). Minor complications were observed in 5 patients in the pull technique (7,6%) and included granuloma at the PEG site in two pts (3%), peristomal infection in two pts (3%) and local pain in one pt (1,5%). In the introducer/gastropexy technique group minor complications were observed in six pts (54,5%) and included tube dislodgment in four (36,3%), dermatitis in one (9%) and local pain in one pt (9%). Conclusions: PEG is a feasible, safe and effective procedure in HNC patients. Our preliminary data suggest that the pull technique is related to higher rates of severe complications and the introducer/gastropexy technique is associated with more frequent tube dysfunction. Randomized trials are needed to compare the push and introducer/gastropexy techniques in HNC pts.

A Feeding Tube Can Be Used for Palliative Decompression Too

Journal of Palliative MedicineVol. 14, No. 4 Letters to the EditorOpen AccessA Feeding Tube Can Be Used for Palliative Decompression TooAh San PangAh San PangSearch for more papers by this authorPublished Online:6 Apr 2011https://doi.org/10.1089/jpm.2010.0498AboutSectionsPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Dear Editor:Palliative medicine has gently and firmly established itself in my country, Singapore. “A Cup of Hot Chocolate” published in the June 2010 issue of the Journal of Palliative Medicine is evidence of how far it has come.1 When the article appeared, the community with which author Sean Lim was affiliated announced the event widely. I celebrated it too because palliative medicine has an important role to play. I do not work in this specialty; my perspective is necessarily that of an outsider and may not be applicable outside of Singapore.While much has been achieved, much more needs to be done. By way of example, I have used the reported case. It must be emphasized that I am not criticizing the institutions involved; sometimes it is simply just patient's choice.A nasogastric tube, or its variation, is not comfortable at all. Thus, 23% of physical restraints used in the nursing homes in Singapore are for the sole purpose of preventing the tube from being pulled out.2 In my opinion, it is ironic when an uncomfortable option is used for palliation.The percutaneous endoscopic gastrostomy is a better option. Although it is easily inserted using local anesthesia and sedation, tube dislodgement and difficult tube exchange can cause serious complications like buried bumper syndrome, hemorrhage, and peritonitis. Hence, it is understandable why some colleagues do not like it and advise their patients to stick with the low-risk but low-comfort nasoenteral option.With the availability of a new gastrostomy tube that is devoid of complications associated with tube dislodgement and tube exchange, it may be time for a re-think.3 In this way, more patients may be spared the discomfort and indignity during the last phase of their journey.References1 Lim RCSA cup of hot chocolateJ Palliat Med201013775.1. Lim RCS: A cup of hot chocolate. J Palliat Med 2010;13:775. Link, Google Scholar2 Mamun KLim JUse of physical restraints in nursing homes: Current practice in SingaporeAnn Acad Med Singapore200534158162.2. Mamun K, Lim J: Use of physical restraints in nursing homes: Current practice in Singapore. Ann Acad Med Singapore 2005;34:158–162. Medline, Google Scholar3 Pang ASA new feeding tube which is secure and easy to changeSingapore Med J200950740741.3. Pang AS: A new feeding tube which is secure and easy to change. Singapore Med J 2009;50:740–741. Medline, Google ScholarFiguresReferencesRelatedDetails Volume 14Issue 4Apr 2011 InformationCopyright 2011, Mary Ann Liebert, Inc.To cite this article:Ah San Pang.A Feeding Tube Can Be Used for Palliative Decompression Too.Journal of Palliative Medicine.Apr 2011.388-388.http://doi.org/10.1089/jpm.2010.0498creative commons licensePublished in Volume: 14 Issue 4: April 6, 2011PDF download

Gastroenterologische Endoskopie

Endoscopy is often used in gastroenterology. It can prevent early recurrence of bleeding from esophageal varices. Computed virtual chromoendoscopy can diagnose pathological changes at the esophagogastric transitional zone in non-erosive reflux disease. In the buried bumper syndrome the internal bumper, which has migrate into the gastric wall, should be removed endoscopically. Double-balloon enteroscopy is one of the flexible enteroscopy techniques with an acceptable complication rate and remains the diagnostic and therapeutic gold standard for small bowel endoscopy. Hyperplastic polypoidal lesions of more than 1 cm in the colon should be removed, because it is not possible to distinguish definitively between hyperplastic polyps and serrated adenoma. Endoscopic ultrasound of the biliary tract makes it possible to remove biliary tract stones cost-effectively and without radiology. Endoscopic ultrasound-guided necrosectomy of the pancreas has become the standard method and has replaced percutaneous drainage and operative intervention.

Long-term percutaneous endoscopic gastrostomy: characteristic computed tomographic findings

Patients with a long-term PEG may suffer from complications and received physical and endoscopic examinations. However, these examinations do not provide information between skin and stomach. We present the findings of computed tomography (CT) for patients with long-term percutaneous endoscopic gastrostomy (PEG). After 1 year PEG (183 patients), 57 patients had received CT examinations. Skin indentation, soft-tissue thickening, peritoneal gap, internal bumper migration, and clinical abnormalities detected by CT examination were recorded. Thickness of subcutaneous fat, muscle, and abdominal wall along the tract were measured. The same parameters at 3 cm away from the tract were obtained for comparison. CT demonstrated that 28 (49.1%) patients present soft-tissue thickening, 19 (33.3%) patients present skin indentation, and 24 (42.1%) patients present a peritoneal gap. One patient with internal bumper migration, 3 patients had buried bumper syndrome, 2 patients had gastric herniation, and 1 patient had esophageal cancer metastasizes to the PEG site. Thickness of subcutaneous fat, muscle, and abdominal wall decreased significant. CT can provide detailed anatomy and orientation along the PEG tube. Familiarity of the CT appearance can minimize potential complications before PEG tube replacement.

A Case of Buried Bumper Syndrome Complicated by Abdominal Wall Abscess in an Elderly Patient

The percutaneous endoscopic gastrostomy is used for nutritional support in patients requiring prolonged tubal feeding. Unfortunately, numerous complications, such as infection, stomal leak, fever, local pain, ileus and tube occlusion, have been reported since its introduction. The buried bumper syndrome is a rare but well-recognized long-term complication. The tight anchorage between the internal and external bumpers leads to gastric mucosal erosion and embedding of the internal bumper into the gastric wall, obstructing feeding. Our case involves an elderly patient with a buried bumper syndrome complicated by an abdominal wall abscess. A similar case has not been reported in Korea before. This article reports our findings and management with a review of the literature.

Acute Buried Bumper Syndrome

Buried bumper syndrome (BBS) is an uncommon complication of percutaneous endoscopic gastrostomy (PEG) tube placement. This unusual phenomenon occurs when the internal bumper of a PEG tube erodes and migrates through the gastric wall and becomes lodged anywhere between the gastric wall and the skin. If not removed and treated appropriately, it can lead to life-threatening complications. It is considered to be a late complication, with most cases occurring from months to years later. We present an unusual case of a very rapid development of BBS, along with a brief review of contributing factors and treatment recommendations.

Small Bowel Obstruction Secondary to Migrated PEG Tube Alleviated by Double Balloon Enteroscopy (DBE): Non Surgical Management of a Rare Complication

Purpose: PEG is the preferred method for feeding patients requiring long term enteral nutrition because of its ease of placement and procedure-related mortality rate of less than 1-3%. Numerous rare complications have been described in the literature including infection, perforation, bleeding and buried bumper syndrome. However small bowel obstruction secondary to a migrated feeding tube is one of the rarest complications reported in the literature. Methods: We report a case of a migrated feeding tube that led to small bowel obstruction (SBO) and was successfully retrieved through DBE. This noninvasive technique saved the patient from laparotomy, likely bowel resection, decreased hospital length of stay, and undue complications associated with surgery. A 66 year old female with a past medical history of CAD, stroke, and severe dementia presents with vomiting and loss of her PEG tube. Physical exam reveals a mildly tender abdomen but overt signs of pain could not be appreciated given the patient's neurological status. Computerized tomography of the abdomen revealed the peg tube and balloon to be migrated within the ileum leading to obstruction and dilatation of the proximal small bowel. No overt free air or bowel wall thickening had developed and thus a non-surgical approach, double balloon enteroscopy via the anal approach, was considered. Results: Using sequential inflation and deflation of the overtube and endoscope balloons with pleating of the bowel, the colon and ileum were traversed. Upon entering the mid-to-distal ileum the migrated feeding tube was appreciated and a small ulceration was seen at the distal margin of the feeding tube. A 0.035in Jagwire was advanced through the lumen of the feeding tube, followed by a CRE dilating balloon (10-12 mm). The balloon was inflated to maximum size of 12 mm to provide proper traction. The endoscope was then gradually withdrawn under direct visualization, with removal of the feeding tube via the anus. Conclusion: The patient's symptoms subsequently resolved, and she was discharged to her nursing facility. The etiology of how the PEG tube became dislodged is still unknown, however it is speculated that iatrogenic mishandling of the tube may have caused it to fracture and migrate forward. The following is the first such case from our review of the literature to alleviate SBO with DBE due to a migrated feeding tube.

Buried Bumper Syndrome

Buried Bumper Syndrome

Acute Pancreatitis Secondary to Ampullary Obstruction Due to a Migrated Gastrostomy Tube

Purpose: Case Report: A 38-year-old white female with past medical history of mental retardation, seizure disorder, hypothyroidism, and osteoporosis was admitted with complaints of apparent painful abdominal distention, fever and vomiting. Patient was on PEG tube feedings for several years. There was no history of alcohol use and medication list included levothyroxine, phenytoin, docusate sodium and calcium carbonate. The patient was febrile (T-103 F), hypotensive (87/49) and tachycardic (P-122). On examination, patient's abdomen was distented, mildly firm with decreased bowel sounds but no guarding or rigidity. Laboratory work-up showed H/H of 17.3/50.4, WBC count 27500, amylase and lipase of 1602 and 1903 respectively. The liver function test, serum triglyceride level, serum calcium level and IgG subclass 4 were normal. Ultrasound of the abdomen did not reveal any gallstone, sludge or biliary dilatation. A subsequent CT scan of the abdomen with oral and intra-venous contrast showed peri-pancreatic fat stranding suggestive of pancreatitis; the stomach was filled with fluid and the gastrostomy tube balloon was noted to be impacted in the second part of the duodenum. The PEG tube was pulled back then externally secured to allow drainage of fluid and air. Patient was managed with aggressive hydration, ventilatory support and antibiotics. Her clinical condition improved with amylase and lipase returning to normal. Discussion: PEG tube feeding is considered a safe, efficient and convenient method of long term enteral nutrition. It is generally associated with minor complications like abdominal pain, infection, leakage, buried bumper syndrome, gastrointestinal bleeding and ulceration. Acute pancreatitis is an extremely rare complication of gastrostomy tube insertion mainly due to migration and direct mechanical ampullary obstruction at the level of the second duodenum. To our knowledge, this is the third case of PEG-induced pancreatitis reported throughout the medical literature. It is important to recognize this life threatening complication in patients with PEG tube presenting with abdominal pain and vomiting.Figure 1: Computed tomography showing PEG tube and acute pancreatitis.

Buried bumper syndrome arising from a percutaneous endoscopic cecostomy tube

Buried bumper syndrome (BBS) is a well-recognized complication of PEG placement caused by excessive outward traction on the tube. It can develop 1 to 50 months after tube insertion and is manifested by difficulty in feeding; peristomal leakage, bulging, and pain; and skin breakdown.1,2 Treatment involves manual or endoscopic removal of the tube with replacement, if needed.1,3 To our knowledge, this is the first case of BBS arising in a patient with a percutaneous endoscopic cecostomy (PEC) tube.