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

Introduction

Feeding via the digestive tract is the most physiological form of nutrition. If the patient is not able to eat, nutrition may be achieved through different tubes. These include naso-gastric, naso-jejunal, gastrostomy and jejunostomy tubes. For patients who require long tube feeding, the most convenient and the safest way is food administration through a tube directly to the stomach [1].

There are three methods of inserting a gastric tube: classic surgical, laparoscopic and endoscopic. Presently, percutaneous endoscopic gastrostomy (PEG) is the most prevalent one. Since first described in 1980 by Gauderer, it has become very popular [2]. In children PEG is performed in general anaesthesia. The procedure takes place either in the endoscopic or operating room, sometimes in the Intensive Care Unit. The most common indications include sucking, chewing and swallowing disturbances in children with neurological disorders such as cerebral palsy, hypoxic-ischaemic encephalopathy, and spinal muscular atrophy [3].

The insertion of a PEG tube may involve some complications – early and late ones. The former include oesophageal or stomach perforation, pneumoperitoneum and peritonitis. The latter, occurring more often, are skin infections, granulation or leakage near the insertion point. Another, very rare complication is embedding of the internal bolster in the gastric mucosa [4].

Case report

A 3-year-old boy, with deletion of chromosome 13, was admitted to the clinic because of gastrostomy dysfunction. The PEG tube (Ch 14, Flocare®, Nutricia) was inserted a year before because of swallowing disorder and progressing malnutrition. Until this hospitalization the boy’s state had not been monitored and his parents had not complained of any troubles with the tube. After admission to our clinic the endoscopic examination revealed complete overgrowth of the internal bumper by gastric mucosa. Because of an anaesthetic complication, i.e. respiratory insufficiency, PEG removal was postponed. When the child’s condition was stable, after pneumonia treatment, the boy was discharged from hospital and scheduled for PEG replacement in 2 weeks time. Despite the recommendation, the parents did not bring the boy to the follow-up visit, but he was admitted to the clinic after 5 months with another tube dysfunction. Physical examination revealed puce leakage around the external site. Once again endoscopic examination revealed the internal bumper completely overgrown. Only a weak stream of physiological saline – externally administered – was draining through (Figure 1). The rail was used to expose the internal bolster of the tube. To remove the tube, a star-like incision was made (Figure 2). It facilitated cutting off the end of the tube and its removal. Next, another tube with a balloon at the end was inserted (Figure 3) and complete healing of the stomach mucus membrane was achieved.

Discussion

Buried bumper syndrome is an extremely rare complication of PEG. Prevalence varies in different clinics in the range 2–6.1% of patients fed via PEG, with some reporting less than 2% [5, 6]. The case described above was diagnosed one year after insertion. However, English researchers report this complication as soon as 10 days after the procedure, but also a few years later [5, 6].

The considered reasons for burying of the internal bumper or even part of the tube are round shape of the bolster, malnutrition, thickening of the abdominal wall (due to body mass gain) and excessive tension on the tube [6]. These factors lead to mucus membrane ischaemia, necrosis and then abnormal regeneration with overgrowth of the plate [6].

Faulty function of the tube, in the boy mentioned above, manifested with resistance during formula administration and purulent drainage around the stoma site. These are similar to those described by other authors, who also observed leaking gastric juices, redness and skin edema, abdominal pain, and tube immobilization [5-7]. Other symptoms are melaena and abdominal distension [8].

There is no recommended course of action for buried bumper syndrome. There are a few techniques described for tube removal: surgical, endoscopic and laparoscopic ones [6, 7, 9, 10]. In patients with high risk during general anaesthesia, the pulling method is recommended [6]. In our patient endoscopic removal of the gastrostomy tube was done.

Considering the risk for tube overgrowth in the gastric wall, it is of utmost importance to prevent this complication. It may be achieved firstly by leaving an approximately 5 mm space between the skin and the external bolster. This prevents excessive tension of the internal bolster to the gastric wall and so prevents gastric ischaemia [1, 9]. It is also recommended to rotate the tube daily, unblock it and reinsert it into the stomach by pulling back [1]. Gençosmanog˘lu et al. suggest that the best way to prevent the internal bolster from ingrowing is to replace the PEG tube with a balloon ending [9].

There is only one published paper describing mortal consequences of buried bumper syndrome, because of peritonitis [8].

Percutaneous endoscopic gastrostomy is currently a widely accepted method of feeding tube insertion. Although quite safe and applied in children, this procedure might be seriously complicated. Having that in mind, it is highly important to attend to the feeding stoma carefully and educate both patients and their parents in this subject

References

 1. Löser C, Aschl G, Hébuterne X, et al. ESPEN guidelines on artificial enteral nutrition-percutaneous endoscopic gastrostomy (PEG). Clin Nutr 2005; 24: 848-61.

 2. Gauderer WL, Ponsky JL, Izant RJ. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg 1980; 15: 872-75.

 3. Avitsland TL, Kristensen C, Emblem R, et al. Percutaneous endoscopic gastrostomy in children: a safe technique with major symptom relief and high parental satisfaction. J Pediatr Gastroenterol Nutr 2006; 43: 624-8.

 4. Schrag SP, Sharma R, Jaik NP, et al. Complications related to percutaneous endoscopic gastrostomy (PEG) tubes. A comprehensive clinical review. J Gastrointest Liver Dis 2007; 16: 407-18.

 5. Vu C. Buried bumper syndrome: old problem, new tricks.

J Gastroenterol Hepatol 2002; 17: 1125-8.

 6. Kejarival D, Aravinthan A, Bromley D. Buried bumper syndrome: cut and leave it alone! Nutr Clin Pract 2008; 23: 322-4.

 7. Hodges EG, Morano JU, Nowicki MJ. The buried bumper syndrome complicating percutaneus endoscopic gastrostomy in children. J P Gastroenterol Nutr 2001; 33: 326-8.

 8. Anagnostopoulos GK, Kostopoulos P, Arvanitidis DM. Buried bumper syndrome with a fatal outcome, presenting early as gastrointestinal bleeding after percutaneous endoscopic gastrostomy placement. J Postgrad Med 2003; 49: 325-7.

 9. Gençosmanog˘lu R, Koç D, Tözün N. The buried bumper syndrome: migration of internal bumper of percutaneous endoscopic gastrostomy tube into the abdominal wall. J Gastroenterol 2003; 38: 1077-80.

10. Boreham B, Ammori B. Laparoscopic percutaneous endoscopic gastrostomy remowal in a patient with buried bumper syndrome: a new approach. Surg Laparosc Endosc 2002; 12: 356-8.