Complication Of Percutaneous Endoscopic Gastrostomy Research Articles

Recurrent Buried Bumper Syndrome: A Rare but Preventable Complication of Percutaneous Endoscopic Gastrostomy (PEG) Tube in an Obese Patient

PEG was initially developed in early 1980s and is now the preferred modality for long term enteral access for nutrition. Buried bumper syndrome was first described in 1988 and is a less frequent but a major complication of PEG tube placement. Incidence of buried bumper syndrome is around 0.3-2.4%. We report a 54-year-old female patient with a BMI of 40.37 who needed a long term nutritional access after undergoing tracheostomy. A 20 French PEG tube was placed without any complications. On a follow-up CT scan of the chest in one month, the G-tube internal diaphragm had migrated from the stomach into the abdominal wall musculature consistent with buried bumper syndrome. She was asymptomatic and afebrile. Physical exam was unremarkable without any evidence of erythema or purulence around the PEG tube site. Successful replacement with a 20 French PEG tube was performed endoscopically under direct visualization. A month later, the patient complained of abdominal pain around the tube site along with intermittent oozing of blood through the PEG tube. On examination, tenderness and discharge of secretions was noted around the PEG tube site. As the tract was mature and oral intake was adequate, it was decided to remove the tube. Repeat EGD was performed and PEG tube bumper was not visualized in the gastric cavity. The bumper was noted to have migrated within the tract. Using a guidewire, the PEG tube was safely removed. The defect in the gastric wall at the tract site was closed with placement of endoclips. Complete occlusion was ascertained by successful insufflation of the stomach. Buried bumper syndrome usually occurs due to excessive tightening of the external bumper of the gastrostomy tube against the abdominal wall which creats tension within the gastrostomy tube tract. The internal bumper will eventually erode and migrate through the gastric wall into the abdominal musculature resulting in buried bumper. Obesity is considered to one of the risk factors for buried bumper. In obese patients, alterations in the abdominal pannus during positional changes can create undue tension/friction in the gastrostomy tract thus resulting in migration of internal bumper leading to buried bumper syndrome. This can potentially be prevented by frequent inspection of the PEG tube, adjustment of the external bumper so that the tube is freely rotating, ensure 1 to 1.5 cm space between the bumper and the skin wall and avoid gauze pads between external bumper and the abdominal wall.FigureFigureFigure

Novel endoscopic management of buried bumper syndrome in percutaneous endoscopic gastrostomy: The Olympus HookKnife.

Buried bumper syndrome (BBS) is an uncommon but serious complication of percutaneous endoscopic ga-strostomy. It involves the internal fixation device, or “bumper”, migrating into the gastric wall and subsequent mucosal overgrowth. We described a case series of four patients with BBS treated with a novel endoscopic technique using a HookKnife between June 2016 and February 2017. The HookKnife is a rotating L-shaped cutting wire designed for hooking tissue and pulling it away from the gastric wall towards the lumen. The technique was successful in all four cases with no complications. Each patient was discharged on the day of treatment. The HookKnife is a manoeuvrable, safe and effective device for endoscopic removal of buried bumpers and could avoid surgery in a high risk group of patients. To our knowledge this technique has not been described previously. We suggest that this technique should be added to the treatment algorithms for managing BBS.

Gastrocolocutaneous Fistula: An Unusual Case of Gastrostomy Tube Malfunction with Diarrhea.

A gastrocolocutaneous fistula is a rare complication of percutaneous endoscopic gastrostomy (PEG). We report a case of a gastrocolocutaneous fistula presenting with intractable diarrhea and gastrostomy tube malfunction. A 62-year-old woman with a history of multiple system atrophy was referred to us because of PEG tube malfunction. Twenty days prior to presentation, the patient started developing sudden diarrhea within minutes after starting PEG feeding. Fluoroscopy revealed that the balloon of the PEG tube was located in the lumen of the transverse colon with the contrast material filling the colon. Subsequently, the PEG tube was removed and the opening of the gastric site was endoscopically closed using hemoclips. Clinicians should be aware of gastrocolocutaneous fistula as one of the complications of PEG insertion. Sudden onset of diarrhea, immediately after PEG feedings, might suggest this complication, which can be effectively treated with endoscopic closure.

Comparison of removal techniques in the management of buried bumper syndrome: a retrospective cohort study of 82 patients.

Background and study aims Buried bumper syndrome is an infrequent complication of percutaneous endoscopic gastrostomy (PEG) that can result in tube dysfunction, gastric perforation, bleeding, peritonitis or death. The aim of this study was to compare the efficacy of different PEG tube removal methods in the management of buried bumper syndrome in a large retrospective cohort. Patients and methods From 2002 to 2013, 82 cases of buried bumper syndrome were identified from the databases of two endoscopy referral centers. We evaluated the interval between gastrostomy tube placement and diagnosis of buried bumper syndrome, type of treatment, success rate and complications. Four methods were analyzed: bougie, grasp, needle-knife and minimally invasive push method using a papillotome, which were selected based on the depth of the buried bumper. Results The buried bumper was cut free with a wire-guided papillotome in 35 patients (42.7 %) and with a needle-knife in 22 patients (26.8 %). It could be pushed into the stomach with a dilator without cutting in 10 patients (12.2 %), and was pulled into the stomach with a grasper in 12 patients (14.6 %). No adverse events (AEs) were registered in 70 cases (85.4 %). Bleeding occurred in 7 patients (31.8 %) after cutting with a needle-knife papillotome and in 1 patient (8.3 %) after grasping. No bleeding was recorded after using a standard papillotome or a bougie ( P < 0.05). Ten of 22 patients (45.5 %) treated with the needle-knife had a serious AE and 1 patient died (4.5 %). Conclusions We recommend that incomplete buried bumpers be removed with a bougie. In cases of complete buried bumper syndrome, the bumper should be cut with a wire-guided papillotome and pushed into the stomach.

Postoperative complications following percutaneous endoscopic gastrostomy are common in children.

Inserting a feeding tube using percutaneous endoscopic gastrostomy may be necessary to ensure that children with eating problems receive sufficient enteral nutrition. The aim of this study was to investigate the perioperative and postoperative complications of percutaneous endoscopic gastrostomy when the pull-through method was the standard procedure. This was a retrospective review of 229 children (50.7% male) who underwent a gastrostomy procedure at Odense University Hospital, Denmark, from January 1, 2000 to December 31, 2012. The median age of the children was 1.6 years (range: 0-14.9), and the follow-up period was 36 months. Complications were graded according to the Clavien-Dindo classification. A total of 167 postoperative complications occurred in 118 of the 229 patients (51.5%). Of these, 89 were grade 1 complications, 49 were grade 2 complications, and 29 were grade 3b complications. No gastrostomy-related deaths were observed, and no single preoperative risk factor was identified. Perioperative complications were experienced by 2.6% of the patients. Gastrostomy feeding tube placement was associated with a high rate of postoperative complications of various grades when the pull-through method was the standard procedure. A consensus on how to report and grade complications arising from this procedure is warranted.

Abstract WP341: Outcomes After Percutaneous Endoscopic Gastrostomy in Stroke Patients With Dysphagia

Learning objectives: Inability to swallow without aspiration is a common complication of acute stroke. In patients with prolonged swallowing dysfunction, a percutaneous endoscopic gastrostomy (PEG) tube is placed. Although PEG placement is an increasingly common practice, there is a paucity of and sometimes conflicting information about utility and clinical outcomes after PEGs. PEG complications can range from minor to major and complication rates range from 16-75%. For a better understanding of PEG complications versus recovery of swallowing a retrospective study was performed on acute stroke patients who had a failed swallow evaluation and had a PEG placed. Methods: A retrospective review was performed of all patients with acute ischemic and hemorrhagic stroke admitted to a large academic medical center who had a PEG placed after failing a swallowing study between January 2016 and March 2016. Complications reviewed included acute bleeding within 24 hours, chronic GI bleeding related to PEG, inadvertent dislodging of PEG, PEG infections and unexpected return to the operating room. Additionally, information about recovery of swallowing function was collected. Results: 64 patients were included. Average age was 70 years (SD 13.5). A PEG was placed on average 9.1 (SD 5.3) days into hospitalization and LOS averaged 7.6 days (SD 7.7) after PEG placement. The total number of patients who experienced a complication after PEG placement was 14 (21.9%). The most common complications were PEG infections, 6 patients (9.4%) and GI bleeding within 30 days of PEG placement, 6 patients (9.4%). There were 2 inadvertently pulled PEGs (3.1%) and 2 unexpected returns to the OR (3.1%). Out of the complications 2 (3.1%) resulted in death, 2 (3.1%) required surgical intervention. At least 20 patients recovered swallowing within a median of 26 days. At least 5 (7.8%) patients achieved recovery of swallow function within 14 days of PEG placement. Five patients had PEGs placed for inability to swallow liquids. Conclusions: In the acute stroke population, placement of PEG tubes was associated with a 21.9% complication rate and a 3.1% risk of mortality.

Low Abdominal Wall Thickness May Predict Percutaneous Endoscopic Gastrostomy Complications

Although percutaneous endoscopic gastrostomy (PEG) tube placement is a common and safe procedure to provide enteral feeding, some patients develop complications. The aim of this study was to identify risk factors for the development of post-PEG complications. We hypothesized that patients with low albumin, diabetes, higher body mass index (BMI), thicker abdominal walls, or psychomotor agitation would have more complications. A 2-year retrospective review was performed on patients who received a PEG tube at a single institution. Variables collected included age, preoperative albumin, BMI, abdominal wall thickness (AWT), psychomotor agitation, preoperative diabetes mellitus, and mortality. A total of 91 patients (70.3% male) were identified (mean age 58.7 years, SD 18.6). Seventeen patients (18.7%) had post-PEG complications and the 30-day mortality rate was 14.3 per cent. Mortality was not attributable to tube placement. Patients with complications weighed less (P = 0.005) and had a lower BMI (P = 0.010) than patients without complications. Additionally, patients with complications had significantly lower AWT (P = 0.02), mean AWT was 21.6 mm (SD 7.6) versus 27.6 mm (SD 8.1) in the noncomplication patients. AWT was the only factor independently associated with post-PEG complications (P = 0.047). There was no significant association between complications and mortality. Continued investigation on how to limit post-PEG complications remains imperative. In our population, lower AWT was independently associated with complications. Preoperative measurement of AWT by preprocedural imaging can potentially be used to predict the risk of post-PEG complications.

Comparison of operative outcomes between surgical gastrostomy and percutaneous endoscopic gastrostomy in infants

PurposeSafety profile of different gastrostomy procedures in small children has not been well studied. This study was conducted to investigate whether complication and mortality rates differ between surgical gastrostomy (G-tube) and percutaneous endoscopic gastrostomy (PEG) in infants and neonates. MethodsIn this retrospective study utilizing the Kids' Inpatient Database, all infants who underwent either G-tube or PEG as a sole procedure were identified. Variables included age, gender, race, presence of neurological impairment, prematurity, complex chronic condition, and severity of illness/risk of mortality subclasses. Postoperative complication, reoperation, and mortality rates were compared between G-tube and PEG. A subgroup of neonates was also analyzed. ResultsA total of 1456 infants were identified (G-tube n=874, PEG n=582). In univariate analysis, the rates of adverse outcomes were not significantly different (G-tube vs PEG complication rate was 7.3% and 6.7%, p=0.65; mortality rate 1.3% and 0.7%, p=0.29, respectively). Adjusted odds ratios (ORs) for complication were 1.07 (G-tube vs PEG, 95% confidence interval [CI] 0.700–1.620) for overall infants and 1.19 (95% CI 0.601–2.350) for the neonatal subgroup. Similarly, adjusted ORs for mortality did not differ significantly both in infants (OR 1.749, 95% CI 0.532–5.755) and in the neonatal subgroup (OR 2.153, 95% CI 0.566–8.165). ConclusionsWhen G-tube and PEG were performed as the only procedure throughout a hospitalization in infants and neonates, the two techniques had comparable risks of postoperative complications and mortalities. Level of evidenceRetrospective comparative study, Level III.

Tube Migration Leading to Gastric Outlet Obstruction: An Unusual Complication of Percutaneous Endoscopic Gastrostomy

Percutaneous endoscopic gastrostomy (PEG) placement is a well-established technique for administering long-term enteral nutrition. Gastric outlet obstruction is a rare complication of gastrostomy tube placement caused by migration of the tube into pyloric channel or duodenal bulb. A 72-year-old female presented with complaints of nausea and abdominal pain after recent PEG placement. The diagnosis of tube migration leading to gastric outlet obstruction was made after the inflated Mickey balloon was visualized obstructing the pyloric channel. The Mickey tube was carefully extracted with an endosnare. Early recognition of the tube migration leading to obstructive symptoms in a clinically appropriate scenario prevents further complications such as ulceration, necrosis and avoids surgical intervention. J Med Cases. 2017;8(12):407-408 doi: https://doi.org/10.14740/jmc2948w

Infant gastrostomy outcomes: The cost of complications

PurposeComparative outcomes of enhanced percutaneous endoscopic gastrostomy (PEG) and laparoscopic gastrostomy (LG) have not been elucidated in infants. We describe the outcomes and procedural episodic expenditures of PEG versus LG in this high-risk population. MethodsOne hundred eighty-three gastrostomies in children under 1year were reviewed from our institution spanning 1/2011–6/2015. Pertinent demographics and 3-month complications (mortality, gastrocolic fistula, reoperation, cellulitis, granulation, pneumonia, and tube dislodgement <6weeks) were collected. Facility and professional administrative data was used to conduct a charge and cost analysis of PEG and LG procedures as well as their statistically significant complications. ResultsSeventy-eight PEG and 105 LG infants were compared. LG infants were significantly younger, had higher ASA class, and increased frequency of cardiopulmonary disease. Significant major complications included a 3.8% incidence of gastrocolic fistula among PEGs (3.8% vs 0%, p=0.04) and 7.6% early tube dislodgements among LG infants (0 vs. 7.6%, p=0.01), resulting in $86,896 of additional charges with PEG complication. Incorporating complication frequency, average charges and variable cost per case were $8964 and $253 greater using PEG. ConclusionsDespite a healthier cohort, infants undergoing enhanced PEG have more morbid and costly complications. LG may be the less burdensome approach to gastrostomy in infants.Level of evidence: Case–Control Study/Retrospective Comparative Study – Level III.

Buried Bumper Syndrome: A Case Report of a Rare Complication of Percutaneous Endoscopic Gastrostomy

Percutaneous endoscopic gastrostomy (PEG) is thought to be a, relatively, safe procedure with a low rate of complications. Buried bumper syndrome (BBS) is the migration of the internal fixation device of PEG (bumper) out of the stomach and consists of a major and, usually, late complication with potentially lethal results. We present a case of such complication resulting in an extended anterior abdominal wall necrosis. An 87-year-old woman with a PEG placement 6 months before, due to Alzheimer’s disease and inability of oral feeding, presented in a severe septic condition and with necrotic inflammation of the abdominal wall. Computerized tomography confirmed the migration of internal bumper subcutaneously. Excision of the gastrostomy and surgical debridement was performed, but, due to the patient’s deteriorated condition, she died after 24 hours. PEG is ideal for patients with swallowing deficiencies, but severe complications may occur. Prevention and initiate diagnosis of the BBS are important for an early treatment, in order to avoid such severe complications. J Med Cases. 2016;7(8):331-333 doi: http://dx.doi.org/10.14740/jmc2569w

Complications of Percutaneous Endoscopic Gastrostomy in Dogs and Cats Receiving Corticosteroid Treatment

BackgroundCorticosteroid treatment is commonly required in veterinary patients for treatment of inflammatory, immune‐mediated, neurologic, and neoplastic diseases, which also may require assisted enteral nutrition via percutaneous endoscopic gastrostomy (PEG).ObjectiveTo evaluate complications associated with PEG use in dogs and cats receiving corticosteroid treatment.AnimalsForty‐two animals were included in the study: 12 dogs and 2 cats in the steroid group and 26 dogs and 2 cats in the control group.MethodsMedical records, between January 2006 and March 2015, were reviewed. Patients were included if the PEG tube was in use for at least 24 hours and if complete medical records were available. Patients were assigned to the control group if they were not treated with corticosteroids during PEG use or to the steroid group if they had received corticosteroids during PEG tube use. Complications were classified as minor, moderate, and major in severity. Maximum severity complication rate was compared between groups.ResultsThe general prevalence of complications was found to be similar between groups (P = .306), but in the steroid group, 43% of the cases developed a major severity complication compared with 18% of the control group (P = .054).Conclusion and Clinical ImportanceOwners of dogs and cats receiving corticosteroids, in which PEG is planned, should be counseled about possible complications beyond those associated with PEG tube usage alone.

Buried Bumper Syndrome: A Case Report of a Rare Complication of Percutaneous Endoscopic Gastrostomy

Buried Bumper Syndrome: A Case Report of a Rare Complication of Percutaneous Endoscopic Gastrostomy

Two cases of gastrocolonocutaneous fistula as a complication of percutaneous endoscopic gastrostomy

Two cases of gastrocolonocutaneous fistula as a complication of percutaneous endoscopic gastrostomy

Buried bumper syndrome: A complication of percutaneous endoscopic gastrostomy.

Percutaneous endoscopic gastrostomy (PEG) is a widely used method of nutrition delivery for patients with long-term insufficiency of oral intake. The PEG complication rate varies from 0.4% to 22.5% of cases, with minor complications being three times more frequent. Buried bumper syndrome (BBS) is a severe complication of this method, in which the internal fixation device migrates alongside the tract of the stoma outside the stomach. Excessive compression of tissue between the external and internal fixation device of the gastrostomy tube is considered the main etiological factor leading to BBS. Incidence of BBS is estimated at around 1% (0.3%-2.4%). Inability to insert, loss of patency and leakage around the PEG tube are considered to be a typical symptomatic triad. Gastroscopy is indicated in all cases in which BBS is suspected. The depth of disc migration in relation to the lamina muscularis propria of the stomach is critical for further therapy and can be estimated by endoscopic or transabdominal ultrasound. BBS can be complicated by gastrointestinal bleeding, perforation, peritonitis, intra-abdominal and abdominal wall abscesses, or phlegmon, and these complications can lead to fatal outcomes. The most important preventive measure is adequate positioning of the external bolster. A conservative approach should be applied only in patients with high operative risk and dismal prognosis. Choice of the method of release is based on the type of the PEG set and depth of disc migration. A disc retained inside the stomach and completely covered by the overgrowing tissue can be released using some type of endoscopic dissection technique (needle knife, argon plasma coagulation, or papillotome through the cannula). Proper patient selection and dissection of the overgrowing tissue are the major determinants for successful endoscopic therapy. A disc localized out of the stomach (lamina muscularis propria) should be treated by a surgeon.

A case of hepatic portal venous gas as a complication of percutaneous endoscopic gastrostomy.

A case of hepatic portal venous gas as a complication of percutaneous endoscopic gastrostomy.

Percutaneous Endoscopic Gastrostomy and Buried Bumper Syndrome

Percutaneous Endoscopic Gastrostomy (PEG) is a method of placing percutaneously a tube into the stomach by endoscopy. This technique is a relatively safe and effective method indicated in the treatment of neurologic diseases with irreversible swallowing problem or proximal esophageal pathology. Complications can occur including pain at the site, leakage of stomach contents and malfunction of the tube. Possible complications include infections of the PEG site, aspiration, bleeding and perforation. In this article we would like to bring to attention a rare complication of PEG, the Buried Bumper Syndrome (BBS) that presented in an 86-year-old female with gradual migration of the internal bumper alongside the stoma tract outside the stomach.

Two Cases of Early Onset Acute Buried Bumper Syndrome after Percutaneous Endoscopic Gastrostomy

Buried bumper syndrome (BBS) is an unusual complication of percutaneous endoscopic gastrostomy (PEG) tube placement, typically occurring 3-6 months thereafter. Few documented cases exist of BBS occurring within 14 days of PEG tube insertion (termed early onset BBS). Information regarding the clinical features and appropriate management of early onset BBS is limited. Herein we report our experience of two cases of early onset BBS successfully treated endoscopically, together with the literature review.

Complications of PEG are not related to age – The result of 10-year multicenter survey

PurposeThe aim of this study was to analyze whether the insertion of Percutaneous Endoscopic Gastrostomy (PEG) during infancy is related to higher morbidity. Moreover, we analyzed the structure of indications to PEG placement in various age groups of pediatric patients. Material/methodsThe study involved medical data of children after PEG insertion from six Polish endoscopic centers: infants (<12 months of age), toddlers (12–36 months), and preadolescents (>36 months). ResultsThe overall prevalence of early complications associated with PEG insertion was 5.14%; while they were noted in infants and preadolescents, none were recorded in toddlers. The analyzed age groups did not differ significantly in terms of the prevalence of late complications. Cerebral palsy (34.86%) and other chronic neurological conditions (34.29%) were the most frequent indications to PEG insertion in the whole group. Patients with congenital heart defects and multiple defect syndrome were inserted PEG at the youngest age; in contrast, the age at insertion was the highest in cystic fibrosis patients. ConclusionsThe early qualification to nutritional intervention via endoscopically formed gastrostomy can have important clinical implications with regards to improved therapeutic outcomes and reduced morbidity rates.

Non-necrotizing abdominal wall fasciitis: A rare complication of percutaneous endoscopic gastrostomy and its successful management

Non-necrotizing abdominal wall fasciitis: A rare complication of percutaneous endoscopic gastrostomy and its successful management