What is Buried Bumper Syndrome?
Buried bumper syndrome (BBS) is a rare complication of percutaneous endoscopic gastrostomy (PEG) tubes where the internal fixation plate (bumper) becomes progressively embedded into the gastric wall and overgrown by gastric mucosa, occurring in 0.3-2.4% of patients. 1
Pathophysiology and Migration Pattern
- The internal bumper migrates through the gastric wall and can lodge anywhere along the gastrostomy tract, from partial to complete embedding within the tissue 1
- This occurs when excessive tension exists between the internal and external bolsters, causing pressure necrosis and progressive impaction of the bumper into the gastric mucosa 1, 2
Clinical Presentation
BBS typically presents with four cardinal features: 1, 3
- Peritubal leakage or infection at the gastrostomy site
- Immobile gastrostomy tube that cannot be rotated or advanced
- Abdominal pain at the tube site
- Resistance with formula infusion during feeding attempts
Additional presentations may include purulent discharge, erythema, tenderness at the PEG site, and in severe cases, signs of sepsis, peritonitis, or septic shock 4, 5
Timing: Early vs. Late Complication
While traditionally considered a late complication, BBS can occur both early and late after PEG insertion: 6
- Early BBS: Can develop within the first month post-insertion, occurring in up to 50% of BBS cases 6
- Late BBS: Median time to development is approximately 22 months (range 9-834 days) after PEG placement 2, 6
- The syndrome can manifest as early as 7 days post-insertion in severe cases 4
Risk Factors
Key risk factors that predispose to BBS include: 1
- Excessive tension between internal and external bolsters (most important modifiable factor)
- Malnutrition and poor wound healing
- Significant weight gain after successful enteral nutrition
- Inadequate aftercare and improper tube maintenance 1
Diagnostic Confirmation
Diagnosis requires imaging or endoscopic visualization: 1, 3
- Contrast study in prone position is critical—contrast may falsely appear to pass through the embedded bumper into the gastric lumen by gravity when the patient is supine 1, 3
- Endoscopic visualization directly confirms the diagnosis by showing the bumper covered by gastric mucosa 3, 2
- CT imaging can demonstrate malposition of the tube bumper within the gastric wall or subcutaneous tissue 4, 5
Treatment Approach
First-line treatment is external traction removal, which is successful in 88.9% of cases without complications: 3, 6
- Remove the buried tube by simple external traction and place a new gastrostomy tube through the existing or nearby tract 1, 3
- This minimizes trauma to the gastrostomy tract and avoids surgery in most cases 2, 6
For completely buried bumpers covered by gastric mucosa: 3, 2
- Use electrosurgical incisions (needle-knife sphincterotome) to create cruciform incisions starting at the center of the mucosal dome and reaching the bumper edges 1, 2
- This technique has a 100% success rate in experienced hands 3
- Insert a flexible guide wire through the internal orifice first to define anatomical settings before incision 2
Surgical intervention is reserved for: 2, 4, 6
- Peristomal abscess with deeply migrated bumper
- Complications such as perforation, peritonitis, or septic shock
- Failed endoscopic removal attempts
Prevention Strategies
BBS is avoidable with proper aftercare: 1
- Ensure the external fixation plate allows at least 5 mm of free movement and does not exert tension on the stoma 7
- Push the tube 2-3 cm ventrally and carefully pull back to the resistance of the internal fixation flange during each dressing change 7
- Rotate the tube regularly to prevent adhesion formation 8
- Provide proper education to patients' relatives and caregivers about tube maintenance 6
Complications and Mortality
Serious complications occur in approximately 22% of patients with BBS, including 6: