T-piece Traction Removal for Buried Bumper Syndrome

Abstract

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, endoscopicmanagement is possible in most internal disc migrations with variable tractionor 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 A 54-year-old institutionalized male patient suffering from cerebral palsy dependent on enteral nutrition presented with suspicion of BBS due to insufficient PEG forward mobility, with tube patency maintained. BBS was confirmed using computed tomography, in addition and compatible with laboratory signs of systemic inflammation, suggesting a small intramural abscess. After institution of broad-spectrum antibiotics, the patient underwent upper endoscopy the following day with the internal disc not visible. Instead, an elevated lesion reminiscent of a submucosal tumor with central putrid discharge emerged (►Fig. 1A). However, given adequate internal drainage, no specific treatment was needed beyond antibiotic treatment. After adequate washing, the abscess cavity could be entered with the scope tip with gentle pressure and the disc was visualized (►Fig. 1B). Next, the external tube length was reduced, and a standard biopsy forceps advanced through the tube (►Fig. 1C). A polypectomy snare was advanced through the endoscope, opened and grasped by the forceps (►Fig. 1D). An estimated 3-cm piece, the fashioned T-piece, was cut from the tube and externally grasped by the snare (compare ►Fig. 1E). Beforehand, a nylon thread from a commercially available PEG tube set was tied to the tube and pulled into the stomach along with the tube system withdrawn into the stomach. Alternatively, the nylon thread might have been placed through the indwelling PEG tube beforehand. After repeat endoscopy of the intramural cavity, a new PEG was inserted in the pull technique (►Fig. 1F; ►Video 1). Concerning chances of migration of the newly placed PEG tube as it has been placed in the same area, in fact, there are no specific data available for this critical issue. However, in the author’s opinion, migration and/or BBS are rather a question of proper PEG care by well-trained nurses rather than a question of endoscopy technique and/or tactics.