Buried Bumper Research Articles

A new method with commonly available devices for treating buried bumper syndrome.

A new method with commonly available devices for treating buried bumper syndrome.

Treatment of the Buried Bumper Syndrome​​​​​: A Retrospective Multicenter Study With Inclusion of 160 Cases.

The therapy of buried bumper syndrome (BBS) is difficult. The aim of this retrospective multicenter study was to analyze the treatment methods with focus on effectiveness and safety of endoscopic techniques. The analysis of all therapies and a comparison of the papillotome technique (PT) and needle knife-based nonpapillotome technique (NPT) were performed. Primary endpoint was technical success in one session, secondary endpoints overall technical success, number and duration of treatment sessions, SAE, and mortality. The primary treatment of 160 BBS cases, diagnosed between 2003 and 2021, was NPT in 60 (37.5%), PT in 43 (26.9%), push/pull technique (PPT) in 40 (25.0%), no removal in 9 (5.6%), laparotomy in 7 (4.4%) cases, and external incision in 1 (0.6%) case. For PT and NPT rates of technical success in one session were 95.5% and 45.0% (P<0.01), rates of overall technical success 100% and 88.3% (P=0.02), and mean number and duration of treatment sessions 1.05 (±0.21) versus 1.70 (±0.91) (P<0.01) and 32.17 (±21.73) versus 98,00 (±62.28) minutes (P<0.01), respectively. No significant differences between PT and NPT were found for SAE (15.9% vs. 25.0%) and mortality (2.3% vs. 1.7%). For PPT, laparotomy and external incision rates of technical success in one session and overall technical success were 100%, rates of SAE 2.5%, 50.0%, and 0% and mortality 0%, 10.0%, and 0%. Endoscopic therapy of BBS is treatment of choice in most cases with removal of incomplete BB by PPT. In case of complete BB PT appears more effective than NPT.

Intrajejunal levodopa in Parkinson's disease: Optimization of PEG application

The various forms of Percutaneous Endoscopic Gastrostomy (PEG) are highly relevant in neurology, as pump-administered intrajejunal levodopa application is one of the indispensable forms of therapy in advanced Parkinson's disease. Optimal PEG placement and follow-up are therefore significant for the success of the therapy. However, the standard intrajejunal administration of levodopa gel via a JET-PEG, i. e. a PEG with an internal catheter inserted into the jejunum, is not without problems for various reasons. In particular, the considerable cumulative complication rates demand a reconsideration of the situation. The very limited absorption area of the drug in the region of the flexura duodenojejunalis must also be taken into account. Causes of complications are predominantly a non-optimal application technique of PEG and internal catheter as well as the frequent lack of an adequate follow-up. In this paper, the details of a modified and optimized application technique compared to the conventional techniques are presented. These new methods have proved their usefulness in clinical applications for years, and additionally a new application form, the Hybrid-PEG, is presented. However, many of the details derived from anatomical/physiological, surgical and endoscopic aspects must be strictly observed during the application in order to reduce or avoid minor and major complications. In particular, problems are caused by local infections in the area of the insertion point of the PEG including peritonitis, leaks and buried bumper syndrome (BBS). The relatively frequent dislocations of the internal catheter also prove to be particularly troublesome. These can ultimately be avoided by clip fixation of the catheter tip down in the jejunum. In particular, the use of the newly developed Hybrid-PEG, a combination of endoscopically controlled gastropexy with three sutures and subsequent central thread-pull-through of the PEG tube, can significantly reduce the complication rate and thus achieve a decisive improvement for patients. The aspects discussed here are highly relevant for all those involved in the therapy of advanced Parkinson's disease. Trustful interdisciplinary collaboration between neurology and endoscopy/surgery/gastroenterology is a prerequisite for good clinical outcomes.

A novel approach to treating buried bumper complicating PEG gastropexy

A novel approach to treating buried bumper complicating PEG gastropexy

A Rare Complication of Percutaneous Endoscopic Gastrostomy Tube Placement: Early Buried Bumper Syndrome (BBS)

Early Buried Bumper Syndrome (BBS) is a rare complication of Percutaneous Endoscopic Gastrostomy (PEG) tube placement where the internal bolster gets “buried” in the gastrocutaneous fistulous tract. BBS is usually a late complication. We present a case of early BBS, in Radiology Department of Dr Ziauddin Hospital, Karachi. Patient presented with fever and oozing from the side of PEG tube. CT scan abdomen findings revealed, the bumper of the percutaneous endoscopic gastrostomy tube retracted in subcutaneous fat just adjacent to the gastric wall and seen in the left sided rectus sheath outside the gastric lumen. Contrast was given through the peg during the procedure which show no extravasation of contrast in adjacent soft tissues. These findings consistent with early buried bumper syndrome.

Prospective randomized controlled trial comparing a novel and dedicated device with conventional endoscopic techniques for the treatment of buried bumper syndrome (with video)

Buried bumper syndrome (BBS) is a rare adverse event of PEG tubes. This study compared the newly developed Flamingo device (Fujifilm Medwork GmbH, Höchstadt, Germany) with conventional endoscopic techniques for BBS treatment. This prospective, randomized controlled trial compared the Flamingo set (study group) with other endoscopic techniques (control group) for BBS treatment in 6 German hospitals. The primary endpoint was procedure time. Further outcome parameters were technical success, adverse event rate, and number and cost of devices used in each group. Thirty-six patients (18 in each group; mean age, 73 years; 12 women) were included in this study between March 2018 and December 2022. Median time since placement of the feeding tube was 30 months. The bumper was located in the gastric corpus in 27 patients, and the internal bumper was completely overgrown in 31 patients. The duration of the removal procedure was 17 minutes (range, 3-72) in the study group compared with 38 minutes (range, 12-111) in the control group (P= .046). The primary technical success rate was 77.8% in the study group and 55.6% in the control group (P= .157), whereas the overall technical success rate was 100% compared with 83.3% (P= .070). Adverse events occurred in 4 patients (11.1%). Endoscopic removal of the buried bumper using the Flamingo device was significantly faster than that with other endoscopic techniques and showed a higher technical success rate. This device may become the endoscopic treatment of choice for BBS. (Clinical trial registration number: NCT03186066.).

T-piece Traction Removal for Buried Bumper Syndrome

Percutaneous endoscopic gastrostomy (PEG) has become the standard nutrition access with well-established procedural and long-term safety data. Yet, buried bumper syndrome (BBS) remains a major concern and complicates up to 5% of PEGs. Albeit poorly standardized, endoscopic management is possible in most internal disc migrations with variable traction- or dissection-based techniques available. Most advanced BBS stages > Cyrany stage 2 call for incision of hyperplastic tissue overgrowth due to insufficient traction forces for nondissection extraction.[1]

WEO Newsletter.

WEO Newsletter.

Endoscopic management of buried bumper syndrome using the Balloon Dilation Pull (BDP) technique: a multicenter analysis.

Buried bumper syndrome (BBS) may complicate percutaneous endoscopic gastrostomy placement. In these patients, endoscopic treatment ought to be considered. Various approaches have been published, ranging from dissectionbased techniques to novel dedicated devices, although the evidence supporting the use of the Balloon Dilation Pull (BDP) technique has been limited to single case reports. The aim of this paper is to assess the feasibility, efficacy and safety of the systematic use of the BDPtechnique for the endoscopic treatment of BBS. We performed a retrospective multicenter analysis of prospectively collected data from all patients treated with the BDP-technique between January 2011 and November 2021. In total, 26 patients were identified (median age 72 (SD ± 13) years, 74% male, 84.6% underlying neurological disease). Technical success was achieved in 92.3%, with a median procedure time of 17.5 minutes (range 5-27). Adverse events were identified in 3.8% of patients (N=1, aspiration, ASGE lexicon severity grade: moderate). Our experience suggests that the BDP-technique is highly efficacious and safe, using accessories readily available in every endoscopic unit. Given the limited procedure time and tools required, this procedure has the potential to further optimize patient care in the context of BBS.

Optimised endoscopic access for intrajejunal levodopa application in idiopathic Parkinson's syndrome

Pump-guided intrajejunal levodopa administration is one of the indispensable forms of therapy in advanced Parkinson's syndrome, along with deep brain stimulation and subcutaneous apomorphine injection. The standard application of levodopa gel via a JET-PEG, i.e. a percutaneous endoscopic gastrostomy (PEG) with an inserted internal catheter into the jejunum, has not been unproblematic due to the restricted absorption area of the drug in the region of the flexura duodenojejunalis and especially due to the sometimes considerable accumulated complication rates of a JET-PEG. Causes of complications are mainly a non-optimal application technique of PEG and internal catheter as well as the often missing adequate follow-up care. This article presents the details of a—compared to the conventional technique—modified and optimised application technique, which has been clinically proven successfully for years. However, many details derived from anatomical, physiological, surgical and endoscopic aspects must be strictly observed during the application to reduce or avoid minor and major complications. Local infections and buried bumper syndrome cause particular problems. The relatively frequent dislocations of the internal catheter (which can ultimately be avoided by clip-fixing the catheter tip) also prove to be particularly troublesome. Finally, using the Hybrid technique, a new combination of an endoscopically controlled gastropexy with 3 sutures and subsequent central thread pull-through (TPT) of the PEG tube, the complication rate can be dramatically reduced and thus a decisive improvement achieved for patients. The aspects discussed here are highly relevant for all those involved in the therapy of advanced Parkinson's syndrome.

Minimal incision endoscopic PEG pull through (MIEPT) technique for buried bumper: first pediatric report

Minimal incision endoscopic PEG pull through (MIEPT) technique for buried bumper: first pediatric report

Buried bumper syndrome, a rare and severe complication of percutaneous endoscopic gastrostomy: importance of early diagnosis in poststroke patients

Introduction: Percutaneous Endoscopic Gastrostomy (PEG) is considered a low-risk procedure; however, side effects may happen, the majority being of mild severity. Among the severe complications, few cases entitled “Buried bumper syndrome” (BBS) have been described. BBS corresponds to the migration of the internal fixation along the stoma tract, becoming lodged between the external wall of the stomach and the skin, which can be associated with local infection, peritonitis, and/or necrotizing fasciitis. Case description: On 06/03/2021 at 29 years old male patient, with no relevant medical history is admitted to the São João Hospital with an extensive midbrain and brainstem hemorrhagic lesion, shown on CT scan. The patient lost his oral route and ability to communicate. Due to severe dysphagia, a PEG was placed without immediate complications. 3 days later, the nursing team reported peri-stomal food losses and local inflammation, with the patient unable to verbalize any complaint. Although there was an adjustment of the PEG by the gastroenterologist, these reports recur for the next week, being detected by the medical team after a routine full body evaluation of the patient. After a new evaluation, a CT was performed, reporting “PEG, whose balloon is located between the median abdominal wall and the anterior surface of the left hepatic lobe”, compatible with the complication described as “buried bumper syndrome”. Discussion: The present case emphasizes the importance of correctly identifying the complications after undergoing PEG, as well as the risk factors and consequences associated with this syndrome, namely in patients with post-stroke status, whose communication is often compromised, and special attention must be given

Retrospective analysis of the methods and complications following the insertion of a PEG tube in children

IntroductionA long-term intragastric feeding is the indication for percutaneous endoscopic gastrostomy (PEG) placement in a patient. The procedure is performed in children with central nervous system (CNS) disorders, congenital heart defects and neoplastic or metabolic diseases. The PEG placement procedure is most commonly performed by a gastroscopy procedure.AimThe study aimed to retrospectively analyse the methods applied and complications following PEG tube insertion in patients of the Regional Specialist Children's Hospital in Olsztyn, Poland, in the years 2000–2019.Material and methodsA retrospective analysis was conducted of medical histories and records of children qualified for PEG placement procedure. PEG procedure was performed on 48 children: 24 boys and 24 girls. The mean age was 7 years. PEG was inserted in cerebral plasy in 30 patients, congenital defects in 11 and genetic disorders in 7.Results and discussionThe reasons for PEG insertion included dysphagia in 30 children, no weight gain in 7, aspiration of gastric contents to the bronchial tree in 6, and feeding difficulties in 10. Two methods for performing PEG insertion procedure were employed: a gastroscopy alone (31 cases) and a laparoscopic-assisted gastroscopy (17). The following complications were: local complications at the incision site (28), PEG dysfunction (13), vomiting (9), sepsis (2), buried bumper syndrome (1), oesophagitis (1), and gastrointestinal fistula (1).ConclusionsThe PEG placement procedure is burdened with a significant number of complications, however, they are mainly related to local inflammation or PEG dysfunction.

S2528 Think "Inside the Loop:" A Novel Method for Repositioning a Migrated G-J Tube

Introduction: Gastrojejunostomy tube (G-J tube) migration is common in patients requiring long term percutaneous enteral feeding. These patients often present with forceful vomiting and decreased PO intake. This case discusses a method for repositioning a migrated G-J tube using an endoloop (detachable snare device) and Resolution Clips. Case Description/Methods: A 26-year-old female with a history of cystic fibrosis (CF), chronic malnutrition requiring enteral feeds, CF-related liver disease and variceal bleeding presented with 5 days of abdominal pain and coffee ground emesis. Initially, the patient was tachycardic and vomiting intermittently. Bright red blood was visible in the emesis bag. Physical exam was notable for epigastric tenderness without peritoneal signs. The skin around the G-J tube insertion site was non-tender with no signs of infection. CT of the abdomen revealed gastrosplenic varices and appropriate positioning of the enteral tube. There was no evidence of GI perforation or obstruction. An EGD demonstrated a patent gastrostomy tube in the gastric body. The jejunal tail was coiled up against the inflamed lumen of the stomach. The suture at the tip of the tail had degraded, dislodging the tube from its original position along the jejunal wall. There were blood clots in the body of the stomach but no evidence of active bleeding. Given the suspicion that the migrated feeding tube was the cause of the patient’s symptoms, a decision was made to reposition it. An endoloop was tied around the tip of the G-J tube to serve as a substitute for the suture. A cold snare was then used to secure the endoloop and drag the tail into the jejunum. The endoloop was secured to the intestinal wall using 2 Resolution Clips. The patient’s symptoms resolved after the EGD and she was discharged in stable condition (Figure). Discussion: Migration of a G-J tube is commonly associated with severe motility disorders, such as cystic fibrosis. Oftentimes, the tube will loop inside the stomach or continue toward the esophagus. The tube itself can cause gastric outlet obstruction, leading to gastric distention, nausea and vomiting. These patients are an aspiration risk and should be initially managed with IV hydration, antiemetics, and stopping of tube feeds. In addition, it is important to assess for complications such as sepsis, hemorrhage, buried bumper, or perforation of the GI tract. If the feeding tube is patent, it is reasonable to have it repositioned based on clinical judgment and provider expertise.Figure 1.: Upper Endoscopy: A. Intact gastrostomy with a patent G-J tube present in the gastric body. The jejunal tail is coiled up in the lumen of the stomach. B. The tip of the G-J tube with surrounding trauma to the body of the stomach, characterized by edema, erythema, and inflammation. The thread at the tip of the G-J tube had degraded (yellow arrow). C. An endoloop was tied at the neck of the tip of the G-J tube (black arrow) to serve as a substitute for the suture. D. A cold snare was used to secure the endoloop (black arrow) and drag the tip of the G-J tube into the jejunum. E. The endoloop (black arrow) attached to the tip of the G-J tube was secured to the wall of the jejunum using a Resolution Clip (pink arrow).

S3691 Where Is the Bumper? A Case of Percutaneous Endoscopic Gastrostomy (PEG) Tube Malfunction

Introduction: Percutaneous endoscopic gastrostomy (PEG) tubes are used for enteral access in patients requiring nutritional support. PEG tube placement and removal generally are regarded as safe procedures. However, complications can be experienced in 16-70%, ranging from benign pneumoperitoneum to gastric outlet obstruction, buried bumper syndrome, and bowel perforation. Our case describes a retained internal bumper during PEG tube removal that undergoes spontaneous passage. Case Description/Methods: Our patient is a 71-year-old male with a past medical history of tongue cancer treated with chemoradiation and subsequent dysphagia due to esophageal strictures necessitating PEG tube placement. He presented to the hospital with nausea, recurrent emesis, and an inability to tolerate tube feeds. His PEG tube was placed to gravity with one liter of output and relief of symptoms. A plan was made to proceed with gastrojejunostomy (G-J) tube to mitigate his symptoms. During bedside removal of his PEG tube, the internal bumper was noted to no longer be attached to the tube (Figure 1A). A Foley catheter was placed in the tract to maintain its patency. As the bumper was presumed to be retained in the stomach, esophagogastroduodenoscopy was performed but there was no evidence of foreign body throughout the exam. A computed tomography scan of his abdomen was obtained urgently and showed passage of the bumper into the jejunum (Figure 1B). Serial abdominal radiographs were obtained over the following day showing migration of the bumper into the rectum and was subsequently passed in his stool. Thereafter, the patient has successfully G-J tube placement by interventional radiology. His tube feeds were advanced to goal rate and the patient was no longer having any nausea or vomiting. Discussion: Retained PEG tube internal bumper is a rare complication of PEG tube removal. Prior case reports have described bumper migration into the small bowel where it became lodged and resulted in small bowel obstruction. At least one prior case resulted in small bowel perforation. In cases of bowel obstruction, surgical intervention is warranted. However, in most cases this complication simply warrants clinical monitoring for evidence of obstruction or passage of the PEG bumper; in most reported cases, endoscopic retrieval was not attempted or feasible, and resolved via spontaneous bumper passage through the gastrointestinal tract.Figure 1.: (A) PEG tube with internal bumper no longer attached. (B) CT scan of abdomen showing PEG tube bumper in the jejunum (orange arrow).

S1887 A Case of PEG-Induced Pancreatitis

Introduction: PEG (percutaneous endoscopic gastrostomy) tube placement is a commonly performed procedure for patients in need of long-term enteral nutrition. It is a relatively safe procedure, with some complications including bleeding, infection, buried bumper syndrome, and dislodgement. Even rarer is the tube migration into the duodenum, obstructing the ampulla, causing biliary obstruction and pancreatitis. We present a case of pancreatitis secondary to migrated PEG tube bumper [1, 2]. Case Description/Methods: An 83-year-old male with a history of stroke and dysphagia, who one year prior had a PEG tube placed presenting with vomiting and epigastric pain and tenderness. Initial lipase was 1761 (reference 8-69 U/L), alkaline phosphatase was 145 (reference 36-112 IU/L), transaminases, bilirubin, and triglycerides were normal. Abdominal CT scan showed a migrated PEG tube balloon in second part of the duodenum at level of the ampulla (Figure). As it turned out patient was tolerating oral diet thus PEG was no longer needed. GI team deflated the balloon and removed the PEG without any further complications. With aggressive fluid resuscitation, patient's symptoms resolved after two days. Discussion: Pancreatitis due to migrated PEG tube obstructing the ampulla is a rare entity, with only a few case reports published. Patient's can present with nonspecific symptoms with significantly elevated hepatic and pancreatic enzymes. CT findings can show pancreatic inflammation and biliary/pancreatic duct dilation with PEG bumper at level of ampulla [1, 2]. Physical exam findings would show very little external tubing indicating distal internal migration of PEG bumper. Interestingly this can also cause intermittent gastric outlet obstruction. Treatment is PEG tube removal/replacement, and IV fluids. Marking the tube at the insertion site can help in diagnosis of migration, if it happens. Patients and care givers should be educated about tube care, regular follow-ups to ensure positioning and to ascertain the timing of removal.Figure 1.: Migration of percutaneous gastrostomy tube balloon to second portion of duodenum at level of ampulla.

An Incidental Discovery of a Serious Complication

An Incidental Discovery of a Serious Complication

EP-642 Case Report: Using the Novel Flamingo Device for Endoscopic Treatment of Buried Bumper Syndrome in high risk patients

Abstract Aim Buried Bumper Syndrome is a rare, major late complication of percutaneous endoscopic gastrostomy (PEG) occurring in 1% of cases. It occurs when the internal bumper of the PEG tube erodes into the gastric wall. This lead to a loss of patency, leakage and inability to change the tube endoscopically. Until recently, the treatment was surgical removal under general anaesthesia. However, patients with BBS are likely to have significant co-morbidities thus deeming the procedure high risk. Method We present a case report demonstrating successful treatment of BBS completed endoscopically using the Flamingo device with a good patient outcome. The Flamingo device is a new endoscopic tool that acts like a sphincterotome. Appropriate consent was taken from the patient. This was performed on a 56 year old patient suffering from multiple sclerosis causing dysphagia for which a PEG tube was inserted in 2018 for nutrition. Over time, his care home noticed significant leakage from the site. At gastroscopy, he was diagnosed with BBS. Due to his risk for surgical intervention, the Flamingo device was trialled to remove the buried bumper and allow insertion of a new PEG. Results As demonstrated in the photos, the mucosa was successfully cut allowing the buried bumper PEG to be retrieved. A new PEG was inserted without complication. The patient was discharged the following day and no complications have arisen 3 months later. Conclusion The Flamingo device has proven to be a safe and minimally-invasive method to treat BBS endoscopically in this patient.

Unusual application of an endoscopic-laparoscopic rendezvous technique to restore the percutaneous gastrostomy in buried bumper syndrome.

A 66-year-old man with cerebrovascular disease underwent placement of a percutaneous endoscopic gastrostomy (PEG) using a 20-Fr dome-bolstered tube. After 1-month, the patient was admitted to our institute for investigation of infusion resistance and leakage around the tube. On physical examination, the internal bumper was not rotatable or moveable, and was subcutaneously palpable. A computed tomography scan confirmed dislocation of the peritoneal bumper ([Fig. 1 a]). Endoscopically, just a small dimple was visible in the mucosa of the anterior wall of the stomach ([Fig. 1 b]), confirming the diagnosis of complete buried bumper syndrome. The PEG was removed with gentle external traction.

PEG placements during the COVID-19 pandemic An audit of the procedures performed by a single consultant operator at a tertiary teaching hospital

PEG feeding provides a valuable nutritional access for patients with a functional gastrointestinal tract. The aim of this project was to audit all the PEG procedures performed by a single consultant operator during the Covid-19 pandemic including the indications, outcomes and complications. All the procedure reports were accessed to identify the patients, indications and immediate outcomes. For every patient, all the letters from all specialties were accessed for the dates following the procedure through the clinical records platforms to identify any later complications. A total of 92 procedures were performed between 15/3/2020 and 31/4/2021 in a total of 84 patients. Lists were operating at less than half capacity compared to pre Covid-19. 65 were planned PEG insertions, 17 were planned removals, and 10 were planned replacements. 5 of the procedures were for PEG-J insertion or replacement. The main indication was Head and Neck Ca in 59/92 procedures followed by CVA 9/92, chronic nausea/vomiting/gastroparesis in 6/92, dysphagia with or without aspiration risk in 4/92, MND in 4/92, CNS tumour post-op (pineal gland) in 2/92, cerebral palsy in 1/92, multiple sclerosis in 1/92, neurodegenerative disorder in 1/92, neuromuscular disorder in 1/92, chronic pancreatitis in 1/92, cystic fibrosis in 1/92, depression with poor oral intake in 1/92 and learning difficulties in 1/92. 83/92 procedures were completed successfully. 2 procedures had a failed intubation, 1 because of a subglottal stricture. The rest of the abandoned procedures were due to patient distress (2/92), high oesophageal stricture (1/92), failed cannulation (1/92), body habitus (1/92), stomach not translluminated and patient desaturation (1/92). One of the planned replacements failed because of a buried bumper. In two patients there was a small leak around the PEG site, 1 identified in the endoscopy room, 1 a few weeks later but both were managed conservatively and the PEG was kept in place. No other complications identified. From October 2020 the consistent use of Corflo PEGs reduced the service demands as these can be easily removed in the community. Lists during the COVID-19 pandemic were significantly impacted, especially UGI procedures, as these are aerosol generating procedures. The vast majority of the procedures are completed successfully and there are no significant complications. Most failed procedures are due to patient related factors such as tolerance and anatomical factors. The use of PEGs that can be removed in the community avoiding further endoscopic procedures is a valuable tool especially in this pandemic and early post-pandemic setting.