Easler, Jeffrey

Fogel, Evan

Hajj, Ihab I. El

Lehman, Glen A.

Sherman, Stuart

Watkins, James

VideoGIE

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VIDEOFigusurroanchT-fasabdomatio18F sWrittwwwDifferent endoscopic management of 2 cases of acute buriedbumper syndromere 1. A, CT scan of the abdomen showing the internal mushroom bumper of a gastrostomy tube buried within the anterior abdominal wall withunding inﬂammation (Pre), and CT image after placement of 2 T-fasteners (Post). B, Cope gastrointestinal suture anchor set: 2 spring coil sutureors (or T-fasteners), an introducer, and a loader (reproduced from the Cook Endoscopy Image Library). C, Endoscopic image showing 2 newly placedteners on either side of the gastrostomy site, the buried internal mushroom bumper (not shown), and the jejunostomy tube. D, CT scan of themen showing the internal mushroom bumper of a gastrostomy tube (G-tube) buried within the anterior abdominal wall, with surrounding inﬂam-n. E, Representative image of a manually enforced internal mushroom bumper of a new 24F G-tube by 2 added and sutured bars (2 segments of anilicone jejunostomy tube). F, Endoscopic image showing 2 newly placed bars sutured to the internal mushroom bumper.Acute buried bumper syndrome (BBS) is an uncommonadverse event of PEG-tube placement and represents apotential surgical emergency. We describe 2 cases of acuteBBS within 5 and 9 days after placement of a gastrostomy-jejunostomy tube (G-J tube), respectively, rescuedendoscopically by the use of 2 different techniques(Video 1, available online at www.VideoGIE.org).CASE 1A 56-year-old woman with chronic pancreatitis (CP)underwent uncomplicated placement of a 24F EndoVive/en transcript of the video audio is available online at www.VideoGIE.org..VideoGIE.orgSafety gastrostomy tube (G-tube) (Boston Scientiﬁc;Natick, Mass) and a 12F jejunostomy tube (J-tube) (CookMedical; Bloomington, Ind). The patient came to theemergency department 5 days later, after an accidentalpartial pull of the G-tube.The results of her physical examination were as follows:stable vital signs, and erythema, induration, and tendernessof the gastrostomy site. Her abdominal CT showed nopneumoperitoneum, G-tube internal mushroom bumperwithin the anterior abdominal wall (Fig. 1A), and J-tubein an adequate position.Gastropexy was performed under endoscopy/ﬂuoros-copy guidance and by use of a Cope gastrointestinalVolume 2, No. 11 : 2017 VIDEOGIE 297Videosuture anchor set (Cook Medical) (Fig. 1B). TwoT-fasteners (1 on either side of the existing G-tubesite) were placed within the gastric lumen (Fig. 1C)and sutured to the skin. A wire was advanced throughthe existing J-tube, and the J-tube and buried G-tubewere manually removed.A 28F MIC balloon PEG-J (Kimberly-Clark; Neenah,Wisc) was placed over the guidewire. The internal balloonwas overinﬂated, then snugged to the gastric wall by astandard external disk. The patient recovered well. Abdom-inal CT 2 weeks later showed decreased inﬂammation, withthe MIC G-J tube in place (Fig. 1A). The externalgastropexy sutures were then removed.CASE 2A 44-year-old woman with CP had a similar presentationof acute BBS 9 days after placement of a 24/12F G-J tube(Fig. 1D). The J-tube was manually removed. The internalburied mushroom bumper was pushed inward. A wirewas advanced through the existing gastrostomy, graspedwith a snare, and pulled out of the mouth.Two bars were manually created by cutting 2 seg-ments of an 18F silicone J-tube. The bars were manuallyadded and sutured to the internal mushroom bumper ofa new 24F G-tube, allowing its surface area to beincreased (Fig. 1E). This was lubricated and passedover the guidewire through the mouth and into thestomach (Fig. 1F), pushing out and replacing theburied G-tube.298 VIDEOGIE Volume 2, No. 11 : 2017A J-tube was then passed through the G-tube andadvanced over a wire placed endoscopically to thejejunum. Future removal of the internal mushroombumper with sutured bars is typically accomplished byuse of the following steps: with the patient intubated forairway protection, we cut the external segment of the G-tube and push inward the internal mushroom bumperwith sutured bars. This latter is grasped by use of the Trap-ezoid RX retrieval basket (Boston Scientiﬁc), thensquashed by use of the Alliance II inﬂation handle (BostonScientiﬁc). Everything is then removed through themouth.DISCLOSUREAll authors disclosed no ﬁnancial relationshipsrelevant to this publication.Ihab I. El Hajj, MD, MPH, James Watkins, MD, JeffreyEasler, MD, Evan Fogel, MD, Stuart Sherman, MD,Glen A. Lehman, MD, Department of Internal Medicine,Division of Gastroenterology and Hepatology, Section ofInterventional Endoscopy, Indiana University School ofMedicine, Indianapolis, Indiana, USACopyright ª 2017 American Society for Gastrointestinal Endoscopy.Published by Elsevier Inc. This is an open access article under the CCBY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).http://dx.doi.org/10.1016/j.vgie.2017.07.015www.VideoGIE.org

Different endoscopic management of 2 cases of acute buried bumper syndrome

Ihab I. El Hajj

James Watkins

Jeffrey Easler

Evan Fogel

Stuart Sherman

Glen A. Lehman

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Different endoscopic management of 2 cases of acute buried bumper syndrome

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