What is the treatment for buried bumper syndrome in patients with percutaneous endoscopic gastrostomy (PEG) tubes?

Treatment of Buried Bumper Syndrome

The buried bumper should be removed endoscopically using external traction in most cases, with a new gastrostomy tube placed through the existing or nearby tract. 1

Initial Management Approach

Remove the buried tube by external traction as the first-line treatment. This technique is successful in the majority of cases and minimizes trauma to the gastrostomy tract. 1 After removal, immediately replace with a new gastrostomy tube through the existing tract or at a nearby site. 1

The key principle is to use techniques that minimize trauma to the gastrostomy tract, as emphasized by the Society of Interventional Radiology and AGA guidelines. 1

Endoscopic Techniques Based on Bumper Depth

For Partially Buried Bumpers

• Attempt external traction first - this is safe and effective in 88.9% of cases without complications. 2, 3, 4
• The buried bumper can often be removed smoothly by external traction alone, even when partially embedded. 3, 4

For Completely Buried Bumpers

If the bumper is completely covered by gastric mucosa, use electrosurgical incisions to access and remove it endoscopically. 1

The most effective technique involves: 5, 6

• Insert a flexible guide wire through the internal orifice of the PEG to define anatomical position 5
• Make cruciform incisions of the gastric mucosa with a wire-guided papillotome (NOT a needle-knife) starting at the center of the mucosal dome covering the internal bumper 5, 6
• Extend incisions to reach the edges of the bumper 5
• Extract the inner bumper through the gastric tract 5

Critical caveat: Avoid using needle-knife papillotomes when possible - they cause bleeding in 31.8% of cases and serious adverse events in 45.5% of cases, including one death (4.5%). 6 Wire-guided papillotomes cause no bleeding and are significantly safer. 6

Tube Replacement Strategy

After successful removal: 3

• Replace immediately with a pull-type feeding tube using the pull method, OR
• Use a button or balloon replacement tube after dilating the old tract 3
• If the original tract is incompletely closed, insert the new PEG through the same route 4
• If the tract has completely closed, use an adjacent site for re-insertion 4

When Surgery Is Required

Reserve surgical intervention for: 5, 2

• Peristomal abscess formation 5
• Deeply migrated bumpers that cannot be accessed endoscopically 5
• Signs of peritonitis 2
• Failed endoscopic removal 2

Surgery was needed in only 11.1% of cases in one series and 4 of 36 patients (11.1%) in another, indicating endoscopic management succeeds in the vast majority. 5, 2

Diagnostic Confirmation

Before attempting removal, confirm the diagnosis: 1

• Perform contrast study with the patient in prone position - this is critical because contrast may falsely appear to pass through the embedded bumper into the gastric lumen by gravity when supine 1
• Endoscopic visualization confirms the diagnosis 1

Clinical Presentation to Recognize

Buried bumper syndrome typically presents with: 1

• Peritubal leakage or infection 1
• Immobile gastrostomy tube 1
• Abdominal pain 1
• Resistance with formula infusion 1

Important Timing Considerations

Buried bumper syndrome can occur early (within the first month in 50% of cases) or late (median 135.9 days, range 9-834 days). 2 This contradicts older literature suggesting it is exclusively a late complication. 2 The median time to diagnosis ranges from 18-22 months in other series. 5, 3

Expected Outcomes

• Success rate with external traction: 88.9% without complications 2
• Success rate with endoscopic techniques: 100% in experienced hands 5
• Median hospital stay: 4 days 5
• Mortality directly related to buried bumper syndrome complications: 8.3% (3 of 36 patients) when complications like abscess or peritonitis develop 2