What is the appropriate management of wound dehiscence of a percutaneous endoscopic gastrostomy (PEG) stoma caused by buried bumper syndrome?

Management of Wound Dehiscence in PEG Stoma from Buried Bumper Syndrome

Remove the buried bumper immediately by external traction, protect the surrounding skin with zinc oxide-based barriers, and replace the PEG tube through the existing tract if it remains patent or at an adjacent site if the original tract has closed. 1, 2, 3

Immediate Removal of the Buried Bumper

• Remove the buried bumper by external traction without requiring surgical intervention, endoscopic dissection, or radiological procedures. 2, 3
• The buried tube can be safely removed by simply pulling it out externally in the vast majority of cases, with success rates approaching 100% in published series. 2, 3
• If external traction fails (rare), endoscopic removal using a needle knife sphincterotome is the next approach, which is successful in nearly all cases. 1, 4
• For endoscopic removal when external traction is unsuccessful, pass a ureteric catheter through the shortened external PEG tube into the gastric cavity, trap it within an endoscopic snare, and apply traction to dislodge the bumper with minimal gastric wall disruption. 4
• Surgical removal via external incision or laparotomy should be reserved only for the rare cases where both external traction and endoscopic methods fail, as surgery carries higher risks of pain, wound infection, and gastrocutaneous fistula formation. 4, 5

Wound and Skin Protection During Active Dehiscence

• Apply zinc oxide-based skin protectants or barrier creams immediately to the dehisced wound area to prevent chemical irritation from gastric contents. 1
• Use a hydrocolloid wafer as a keyhole dressing around the tube site to protect skin from gastric contents and absorb exudate. 1, 6
• Apply a powdered absorbing agent if significant moisture or leakage is present at the dehiscence site. 1, 6
• Use foam dressings rather than gauze to reduce local skin irritation, as foam lifts drainage away from the skin while gauze contributes to maceration. 1

Adjunctive Medical Management

• Start proton pump inhibitors to decrease gastric acid secretion and minimize the corrosive effect of leaked gastric contents on the dehisced wound. 1
• Consider gastric decompression if leakage is severe or if there are signs of peritonitis. 1
• Temporarily delay or stop enteral nutrition in cases of obvious leakage with significant wound dehiscence until the tube is replaced and proper positioning confirmed. 1
• Optimize nutritional status with parenteral nutrition if enteral feeding must be suspended, particularly in patients with diabetes, immunosuppression, or pre-existing malnutrition that impairs wound healing. 1

PEG Tube Replacement Strategy

• Replace the PEG tube immediately after bumper removal through the existing tract if it remains patent (which occurs in most cases). 2, 3
• If the original tract has completely closed, insert a new PEG tube at an adjacent site rather than attempting to force placement through a closed tract. 3
• Use either a pull-type feeding tube via the pull method or a button/balloon replacement tube after dilation of the old tract. 2
• Confirm proper intragastric positioning by instilling water-soluble contrast through the tube and obtaining a KUB before initiating feeding. 7
• After confirmed placement, ensure the external fixation plate allows 5-10 mm (0.5-1 cm) of free tube movement to prevent recurrence of buried bumper syndrome. 1, 7

Post-Replacement Wound Care

• Clean the wound area daily with an antimicrobial cleanser and inspect for signs of infection (erythema >5 mm, purulent discharge, fever). 1, 6
• Apply sterile dressings under the tube using a Y-compress to avoid formation of a moist cavity under the external fixation plate. 1, 6, 7
• Perform daily sterile dressing changes until the wound shows signs of healing, then transition to dressing changes every 2-3 days. 1
• Take a swab for microbiological examination if persistent infection is suspected, and treat with antibiotics based on culture results. 1

Prevention of Recurrence

• Begin rotating the tube daily and moving it inward at least 2-3 cm (ideally 5-10 cm) once weekly after the gastrostomy tract has healed (approximately one week post-replacement). 1
• After mobilization, return the tube to its initial position with 0.5-1 cm of free distance between the skin and external bolster. 1
• Never overtighten the external fixation plate against the skin, as excessive compression between internal and external fixation devices is the primary risk factor for buried bumper syndrome recurrence. 1
• Flush the tube with 40 ml of water after each feed or medication administration to maintain patency. 8

Critical Pitfalls to Avoid

• Do not attempt surgical exploration as the first-line approach, as external traction is successful in the vast majority of cases and avoids surgical morbidity. 2, 3
• Recognize that buried bumper syndrome can occur as early as 1 month after PEG placement, not just as a late complication, so maintain vigilance even in recently placed tubes. 2
• Do not ignore alarming signals such as difficulty mobilizing the tube, leakage around the insertion site when flushing, frequent feeding pump alarms, abdominal pain, or chronic site infections, as these indicate developing buried bumper syndrome. 1
• Be aware that buried bumper syndrome can lead to life-threatening complications including peritonitis, necrotizing fasciitis, and extensive abdominal wall necrosis if not promptly addressed. 5