Buried Bumper Research Articles

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.

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.

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.

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.

Emergency surgery for complications related to percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy (PEG) is used to restore enteral nutrition in patients with inadequate oral intake. Because of its minimally invasive nature complications are thought to be rare. We analyzed data on all patients treated for PEG-related complications at the Department of General, Visceral, and Oncologic Surgery at the Klinikum Bremen-Mitte, Germany, between 2005 and 2008. A total of 38 patients with complications required surgical evaluation. Emergency laparotomy was performed for leakage in 16 patients, for a misplaced or dislodged PEG tube in nine patients, for buried bumper with accompanying signs of peritonitis in four patients and for gastrocutaneous fistula in one patient. Eight complications were managed conservatively. Early complications within 10 days (60 %) were related to leakage or mispositioning of the PEG, while PEG device migration and fistula formation represented late complications. Hospital mortality was 17 % with the underlying disease contributing significantly to the fatal outcome. Most PEG-associated major complications were related to technical errors and carried a high mortality.

A safe and simple method for removal and replacement of a percutaneous endoscopic gastrostomy tube after “buried bumper syndrome”

A safe and simple method for removal and replacement of a percutaneous endoscopic gastrostomy tube after “buried bumper syndrome”

Acute buried bumper syndrome: An endoscopic peg tube salvage approach

Acute buried bumper syndrome is an uncommon complication of percutaneous endoscopic gastrostomy (PEG) tube placement. If not recognized and treated appropriately, it can lead to serious complications including death. We report a case of an acute buried bumper syndrome, successfully managed with PEG tube repositioning through the original tract, without the need of replacement.

Management bei Buried-Bumper-Syndrom: neue endokopische minimalinvasive Push-Methode

The so-called buried bumper syndrome is characterised by a pathological alteration of the percutaneous endoscopic gastrostomy (PEG) in the form of a tissue overgrowth of the internal bumper of the tube. A lack of mobilisation of the tube and/or continuous traction on the PEG causes the bumper to be impacted by stomach mucosa. The consequence is a local chronic inflammatory process that may result in the occlusion of the feeding tube. As of now, different therapeutic methods exist: the surgical technique based on common laparotomy, the local invasive removal by cutting along the tube and inner flange from the outside and pulling it out (pull method) and the endoscopic recovery from inside the stomach. The authors have developed and evaluated a new endoscopic, minimally invasive technique (push method). In eight of nine patients the inner bumper could be freed by cutting with a papillotome which is brought into the stomach through the shortened PEG from the outside while maintaining endoscopic control. Afterwards the bumper is pushed to the inside with a dilatator and the patients are provided with a balloon system using the persisting stoma. The subsequent healing process proved to yield no further complications.

Gastric Outlet Obstruction and Pancreatitis Caused By Migrated Gastrostomy Tube: A Rare Scenario

Purpose: Percutaneous Endoscopic Gastrostomy (PEG) is a very common method of enteral nutritional support. The most common indication for PEG tube placement is oropharyngeal dysphagia secondary to cerebrovascular accident, advanced dementia, and benign and malignant oropharyngeal and esophageal obstruction. Use of PEG tube feeding has increased exponentially since its introduction in 1980. Major complications of PEG include aspiration, hemorrhage, peritonitis and rarely necrotizing fasciitis and tumor implantation. Minor complications include ileus, peri-stomal infection, stomal leakage, buried bumper, gastric ulcer, fistulous tracts and inadvertent removal. We report a case of gastric outlet obstruction and pancreatitis induced by migrated PEG tube. The migrated inner balloon of the PEG-tube blocked the duodenum causing gastric outlet obstruction and obstructed Ampulla of Vater leading to acute pancreatitis. The presenting symptoms rapidly resolved after prompt diagnosis and PEG tube repositioning. Case Report: An 83-year-old female nursing home resident with PEG tube feeding presented with two episodes of projectile vomiting. On physical examination at the time of admission, her vital signs were within normal limit and abdominal exam was benign. Admission labs showed Amylase - 460 U/L, Lipase - 291 IU/L, Total Bilirubin - 0.3 mg/dl, Direct Bilirubin - 0.1 mg/dl, ALP - 109 IU/L, AST - 102 U/L and ALT - 80 U/L. Abdominal sonogram excluded cholelithiasis or cholecystitis. However, CT abdomen revealed gastrostomy tube's balloon migrated in the duodenal bulb. The balloon was repositioned by deflating and then reinflating. Vomiting resolved and LFTs, amylase and lipase dramatically improved. Two days after admission, labs showed Amylase - 162, Lipase - 78, ALP - 80, AST - 25 and ALT - 42. Repositioning of the external bumper at mark 3-4 as needed will prevent PEG tube migration and related complications.

Acute Buried Bumper Syndrome

Purpose: Introduction: Acute Buried Bumper Syndrome (BBS) is an unusual complication of percutaneous endoscopic gastrostomy (PEG) tube placement that can be lethal if not recognized early on. We present a case of BBS occurring in just six days. Case Report: An 85-year-old male underwent an uneventful Boston Scientific PEG tube placement for feeding purposes after he was diagnosed with stage 2A esophageal Adeno CA. Six days later he presented with worsening abdominal pain and inability to infuse feedings through the tube. Examination revealed erythema and induration at the PEG tube site with the tube in place at about 2 cm mark. Rest of the physical exam and routine laboratory testing was unremarkable. Abdominal CT-scan revealed that the button of gastrostomy tube had migrated up in the abdominal wall within the peritoneal cavity ventral to the stomach. A diagnosis of acute BBS was made, and the patient was treated with PEG tube removal and broad spectrum antibiotics. The PEG site improved and on day seven of admission, a replacement G-tube using a guide wire and the original tract, was placed by Interventional Radiology. The patient recovered uneventfully. Discussion: Buried bumper syndrome is an unusual complication of PEG tube that occurs when the internal bumper migrates and becomes lodged anywhere between the gastric wall and the skin along the PEG-tube track. Endoscopy is considered the most definite test. Although not always needed, ultrasound, computerized abdominal tomography, and magnetic resonance imaging can be helpful in the diagnosis. Excessive tension between the internal and external bumpers causing gastric ulceration at the bumper site is thought to be the initiating factor in BBS. It is usually considered to be a late complication, but cases occurring within one to two months have been reported. Treatment recommendations include removal of the buried bumper, even in the asymptomatic patients, to avoid further complications. In cases where a patient presents with an abdominal wall abscess, it may not be possible to place the replacement tube through the same tract.Figure: CT scan showing internal bumper in the abdominal wall within the peritoneal cavity.

Two Case Reports of Gastric Ulcer From Pressure Necrosis Related to a Rigid and Taut Percutaneous Endoscopic Gastrostomy Bumper

Two complications are reported from excessively taut application of percutaneous endoscopic gastrostomy (PEG) external bumpers against the abdominal wall skin. First, a 55-year-old woman status post PEG developed a gastric ulcer, complicated by acute gastric bleeding, directly underneath the internal gastric PEG bumper. This complication was associated with replacement by an unknown healthcare worker of the standard flexible external (cutaneous) PEG bumper with an unauthorized rigid external clamp (bumper) and with excessively taut application of this clamp against the abdominal wall skin. No other causes or risk factors for gastric ulcers were present. The pathophysiology of this ulcer, similar to that of a decubitus ulcer, appears to be mucosal ischemia and pressure necrosis. Second, a 37-year-old man status post PEG developed a buried internal gastric bumper that caused PEG malfunction and abdominal pain from excessively taut application of the external PEG bumper. These case reports should alert healthcare workers that replacing a flexible external bumper with a rigid one and that tightening the external bumper excessively may cause pressure necrosis manifesting either as gastric or cutaneous ulcers or as a buried internal bumper. This alert is particularly important for nurses as they are likely to be the first healthcare workers to notice or be told of PEG failure because of their close involvement in the day-to-day care of the patient and their typically close rapport with the patient's family.

Buried bumper syndrome causing rectus abdominis necrosis in a man with tetraplegia

Case report. To enhance the early recognition of buried bumper syndrome in patients with tetraplegia requiring percutaneous endoscopic gastrostomy (PEG). Inpatient unit, Massachusetts, USA. A 44 year-old man with C2 American Spinal Injury Association grade A tetraplegia with a relatively recent PEG insertion secondary to poor nutritional intake. Several months after PEG placement, patient became febrile, hypotensive and complained of abdominal pain. Plain films showed a dilated bowel suggestive of ileus. Abdominal and pelvic computed tomography with and without contrast revealed PEG tube dislodgement, and a 21 cm x 2.8 cm left anterior abdominal wall collection consisting of air and contrast. Upon surgical intervention, the left rectus abdominis sheath and muscle were found to be necrotic. Buried bumper syndrome is a serious complication related to PEG tubes. For many people with tetraplegia, PEG is a life-saving procedure with minimal risks. However, emergencies do occur, making prompt recognition imperative to prevent a fatal sequela.

Risk of Immediate and Delayed Complications with Percutaneous Gastrostomy and Jejunostomy Tubes in Patients Receiving Bevacizumab

Background: Bevacizumab is a humanized monoclonal antibody targeting the vascular endothelial growth factor. Although, it is generally well tolerated, gastrointestinal (GI) complications include perforation and bleeding. There is no data on the safety of performing a percutaneous endoscopic gastrostomy (PEG) or jejunostomy (PEJ) in patients receiving Bevacizumab. Objective: To determine the risk of immediate and delayed GI perforation and bleeding following PEG and PEJ tube placement in patients who received Bevacizumab within 60 days of the procedure. Methods: A retrospective chart review of all patients who underwent a successful PEG or PEJ between January 2003 and August 2008, and also received Bevacizumab within 60 days of the procedure was done. Data included demographics, type of cancer, prior treatment, indication for PEG/PEJ, timing of Bevacizumab and post-procedural complications. Results: 83 patients were identified. Underlying cancers included: head & neck (35), colorectal (19), ovarian (11), other GI (13) and others (5). Forty six (55%) were men and 37 (45%) were women. The mean age was 55 years (range, 21-80). Forty three (52%) underwent a major abdominal surgery prior to the procedure and the primary tumor was resected in 46 (55%) of them. There were 77 (92%) gastrostomies and 6 (8%) jejunostomies. The indication was enteral feeding in 46 (55%) and GI decompression in 37 (45%). Thirty nine had their procedure 13.6 +/- 12 days before starting Bevacizumab, 41 had their PEG/PEJ placed 31 +/- 30 days after stopping Bevacizumab and 4 while receiving Bevacizumab. There were 6 complications, 3 major and 3 minor: GI bleeding requiring transfusion (2), pneumatosis intestinalis and sepsis (1), abdominal pain (2), and a buried bumper (1). The bleeding was 105 and 30 days post procedure and Bevacizumab discontinuation respectively in the first patient and 15 and 60 days in the second patient. Neither was a procedure related complication nor was the PEG site a source of bleeding. One was bleeding from tumor and the other from hemobilia. One patient developed pneumatosis of the GI tract, along with air in the portal venous system, 2 and 17 days after PEJ placement and stopping Bevacizumab respectively. This was the only major procedure related complication and the patient improved with antibiotics and observation. Of the 3 minor, 2 had persistent abdominal pain that resolved spontaneously and 1 was a buried bumper that required PEG revision. Conclusion: Placement of PEG or PEJ tubes in patients receiving Bevacizumab within 60 days of the procedure is safe. Also, use of Bevacizumab is safe in patients who underwent a recent gastrostomy or jejunostomy.

Outcomes After Percutaneous Endoscopic Gastrostomy Insertion in Children

Percutaneous endoscopic gastrostomy (PEG) insertion is indicated for provision of enteral nutrition when oral feeding is not possible or inadequate. The aim of this study was to review the early and late morbidity of percutaneous gastrostomy insertion in children including major and minor complications. Methods: A retrospective chart review of children who underwent percutaneous endoscopic gastrostomy by the Dept of Gastroenterology, RCH in the last 4 years was undertaken. Patient demographics, indications for gastrostomy, and the incidence of major and minor complications were recorded. Early complications were defined as those occurring within one week of insertion and late complications as those occurring after the first week. Results: 60 patient charts have been reviewed to date. The median age of insertion was 5 years (range 2months-15.5years). Indications for PEG insertion included inadequate intake (39/60, 65%), unsafe swallow or aspiration risk (19/60, 32%), and complicated metabolic requirements (2/60, 3%) in two patient's with glycogen storage disorders. Four patients (6.6%) developed major complications after insertion. Two patients developed early complications with presumed peritonitis after the procedure requiring intravenous antibiotics and gut rest. Late complications included one patient with buried bumper syndrome at the time of conversion to a skin level device 3 months after initial PEG placement. The other patient developed pneumoperitoneum on conversion to gastrostomy button. Minor complications however were common and occurred in 80% (48) of patients. Most occurred late and included granulation tissue formation (56%, 34), site infection (8%, 5), inadvertent device avulsion (8%, 5), gastric ulcer related to the gastrostomy device (1.5%,1) and skin stomal pressure ulcer (5%, 3). All patients with major complications (6.6%) were managed successfully without any surgical intervention. Patients with inadvertent tube avulsion were able to be converted easily to a skin level device and did not require any further intervention. Other minor complications were managed conservatively. All patients were still alive at 12 months follow up. Conclusions: Major complications after PEG insertion are rare and do not impact significantly on long-term patient morbidity. Minor complications however are common and usually occur late, of which granulation tissue formation is the most frequent. PEG insertion is a safe procedure in children for the provision of enteral nutrition.

Percutaneous endoscopic gastrostomy tube removal and replacement after “buried bumper syndrome”: the simple way

Percutaneous endoscopic gastrostomy (PEG) feeding tubes are required for an increasing number of patients with long-term nutritional requirements. "Buried bumper syndrome" (BBS) occurs in 2-6% of PEG placements. In the past, this has been a difficult problem to resolve. The authors aimed to design a safe and simple method of dealing with BBS that can be performed by any endoscopist on a routine endoscopic list with the patient under sedation. For 6 years, the authors have used a minimally invasive way to deal with BBS. They have successfully treated 20 BBS patients on a routine endoscopy list with the patient under sedation. The existing PEG is divided 5 cm from the skin. A pair of stent-grasping forceps is inserted via the tube. A snare then is passed via the gastroscope, caught in the stent-grasping forceps, and brought out via the PEG tube. Next, the tube is split as deeply as possible into the PEG exit site, and the snare is closed around the tube. Gentle traction is applied along the endoscope, allowing the internal bumper to concertina and pop through the mucosa. Another PEG can now be placed at a separate site, although the authors have successfully used the same tract. All the patients were followed up, with no further problems related to BBS. The authors' method is a simple way of addressing the difficult BBS problem. It can be used to remove and replace a PEG with a buried bumper on a routine endoscopy list with the patient under sedation.

The Push‐Pull T Technique: An Easy and Safe Procedure in Children With the Buried Bumper Syndrome

Percutaneous endoscopic gastrostomy (PEG) tube placement is a well-established procedure in adults as well as in pediatric patients who cannot be orally fed. However, potential serious complications may occur. The buried bumper syndrome is a well-recognized long-term complication of PEG. Overgrowth of gastric mucosa over the inner bumper of the tube will cause mechanical failure of formula delivery, rendering the tube useless. However, published experience in children with buried bumper syndrome is very scarce. In the authors' clinic, 76 PEG tubes were placed from 2001 to 2008, and buried bumper syndrome occurred in 1 patient. The authors report on their experience with buried bumper syndrome, an adapted safe endoscopic removal technique, as well as recommendations for prevention of buried bumper syndrome.

Metastatic hypopharyngeal and esophageal cancer to a percutaneous endoscopic gastrostomy site

The patient was a 63-year-old man who underwent percutaneous endoscopic gastrostomy (PEG) for nutritional management while undergoing radiochemotherapy for hypopharyngeal and esophageal cancer. At about 6 months after PEG, redness and swelling were seen around the gastrostomy site, and pathological testing confirmed the same poorly differentiated squamous cell carcinoma as the hypopharyngeal and esophageal cancer. The tumor caused symptoms associated with buried bumper syndrome to increase significantly.

Percutaneous Endoscopic Gastrostomy in Diabetic Patients

Purpose: Percutaneous Endoscopic Gastrostomy (PEG) is a procedure of choice for enteral nutrition in patients with functional gastrointestinal tract. PEG has been performed in patients with multiple co morbidities with a low morbidity and mortality including patients with Diabetes. Review of literature shows that there are very few published studies analyzing the complications of PEG placement in diabetic patients. The aim of our study was to compare complications of PEG placement in diabetic patients with non diabetic patients to find any possible difference in mortality or morbidity between the two groups. Methods: All patients who underwent percutaneous endoscopic gastrostomy in IMC as inpatients from January 2005 to March 2007 were included in the study. All patients who had PEG placement on ambulatory basis were excluded from this study. There were total 104 patients out of whom 91 were women and 13 men. Group 1 (DM group) consist of 36 patients, Male 5, Female 31. Group 2 (non DM group) consists of 68 patients, (Male 8, Female 60). Indications for PEG placement in DM group included various neurologic impairment like Alzheimer's dementia 8 (22.2%), Cerebrovascular accident 21 (58.3%) and chronic ventilator dependent 7 (19.4%). Indications for PEG in non DM patients were neurological impairment like Alzheimer's Dementia 33 (48.5%), Cerebrovascular accident 26 (38.2%) and chronic vent dependent 10 (14.7%). Patients received preoperative antibiotics as short-term prophylaxis. Results: All PEG complications were compared between DM (group1) and non DM (group2) patients. Wound infection (group1) 2, (group2) 5 (P 0.54), peristomal leakage (group1) 1, (group2) 2 (P 0.3), inadvertent PEG removal (group1) 10, (group2) 16 (P 0.402). Mortality unrelated to PEG placement in (group1) 12, (group2) 8 (P 0.432). There were no significant differences in mortality or morbidity between diabetic and non diabetic patients. In addition there was no statistically significant difference in complications among diabetic patients whether on insulin or oral hypoglycemic agents. Other complications of PEG like bleeding, necrotizing fasciitis, esophageal/gastric perforation, colocutaneous fistula, buried bumper syndrome, peritonitis, pneumoperitoneum, paralytic ileus, gastric outlet obstruction and death secondary to PEG placement were not reported in either group. Conclusion: Although diabetes mellitus is considered to be associated with more post operative wound complications, our study did not show any statistically significant increase in morbidity or mortality of PEG in diabetic patients when compared to non diabetics. It is suggested that PEG is a safe procedure in diabetic patients.

Acute Pancreatitis Induced by Gastrostomy Tube (GT) Migration

Purpose: Approximately 120,000 percutanaeus endoscopic gastrostomy (PEG) procedures are performed in U.S. annually. Although PEG placement is generally safe, 16 to 70% complication rate is reported. Minor complications include wound infection, tube dysfunction, gastric outlet obstruction, peristomal leakage, bleeding, cutaneous or gastric ulceration, pneumoperitoneum and temporary ileus. Major complications include necrotizing fasciitis, esophageal or gastric perforation, buried bumper syndrome, and inadvertent PEG removal. Here we present another complication of GT migration into the duodenum. This complication has been under-recognized and rarely reported. Methods: This is a case series study. Five nursing home patients with PEG who were admitted with obstructive symptoms, elevated serum amylase and lipase and normal liver enzymes were reviewed. In all cases the physical and radiological examination (Fig. 1), revealed migration of the GT into the duodenum. Symptoms were resolved after GT replacement or retraction. Serum amylase and lipase were also normalized within 2 to 3 days. No other causes for acute pancreatitis were identified. In one case the patient was re-admitted several times with migrated GT and similar findings. Pancreatic enzymes were normalized after GT replacement in every occasion.Figure 1: Arrow shows migrated GT balloon into the duodenumResults: In all cases, there was evidence of migrated GT balloon compressing periampullary area with increased amylase and lipase, which normalized when the balloon was deflated and moved away from the ampullary region. This condition was associated with balloon-type internal bolster, replaceable GT. Conclusion: In elderly patients with PEG, abdominal pain, vomiting and hyperamylasemia, a migrated GT to the periampullary region should be looked for and the GT should be repositioned.

Clinical manifestations and management of buried bumper syndrome in patients with percutaneous endoscopic gastrostomy

Buried bumper syndrome has been regarded as an uncommon and late complication after percutaneous endoscopic gastrostomy (PEG) tube insertion. A variety of techniques have been reported to treat this problem, but only a few published cases exist. Our purpose was to present the clinical manifestations and our management of a series of 19 patients with buried bumper syndrome. Case series study. Referral medical centers. Within 5 years, 31 episodes of buried bumper syndrome occurred in 10 men and 9 women. The estimated prevalence was 8.8% (19 in 216 PEG procedures during this period). All the buried tubes were removed smoothly by external traction and replaced with a new pull-type feeding tube by the pull method or a button or balloon replacement tube after dilation of the old tract. Success rate, complication rate. The duration between occurrence of buried bumper syndrome and PEG placement ranged from 1 to 50 months, with a median of 18 months. All the episodes were treated successfully except for one, in which reinsertion failed and a new PEG tube was inserted 1 week later. No significant complications occurred. Small sample size. Buried bumper syndrome is not that uncommon and can occur soon after insertion of a PEG tube. The buried tube can be safely removed by external traction and in most cases can then be replaced with a pull-type or balloon replacement tube.