The T-piece pull technique: A simple and effective method for treating buried bumper syndrome

Aims Percutaneous endoscopic gastrostomy (PEG) is an established route for enteral nutrition. Although rare, buried bumper syndrome (BBS) remains an important and challenging complication to manage. Gastric mucosal overgrowth over the internal bumper results in obstruction of the internal stoma and impedes delivery of nutritional feeds via the PEG tube. Many different techniques for treating BBS have been described, but these have largely been limited to case reports or small case series. This study aimed to determine the efficacy and safety of the T-piece pull technique

Methods A prospectively collected database for consecutive patient treated for BBS with the T-piece pull technique at a tertiary referral centre from September 2016 to September 2023 was analysed. In each patient, the buried bumper was first assessed endoscopically and the morphology was described using the Paris classification. The PEG tube was cut close to the abdominal wall and a biopsy forceps was passed through the PEG tube into the stomach under endoscopic visualisation. A 10mm snare was inserted through the working channel of the gastroscope, opened and then grabbed by the biopsy forceps before being pulled out of the PEG tube. The snare was closed around a 2cm cut piece of PEG tubing to create a T-piece. The snare was pulled back firmly through the PEG tube until the buried bumper was removed. The primary outcome was the rate of technical success. Secondary outcomes included buried bumper morphology, procedure time and the rate of adverse events

Results A total of 41 cases (25 female) of BBS were treated with the T-piece pull technique, with a mean age of 45 (range 19-78). The buried bumper morphology was Paris Is in 15, IIa in 20, IIa+IIc in 3, and IIb in 3 cases. The median procedure time was 18 minutes (range 13-45). Technical success was achieved in 93% of cases. In all the three failed procedures, the buried bumper showed a IIb morphology. Of these three, two underwent surgery while the other was left in-situ. Two complications were recorded, one case of non-specific abdominal pain and one episode of sepsis

Conclusions This is the largest study evaluating the T-piece pull technique for BBS to date, in which we demonstrate that this is a simple, effective, minimally invasive, cheap and safe procedure, utilising equipment that is available in an endoscopy unit. The Paris morphology is a simple and useful predictor of procedural success, and alternative techniques may be required for buried bumpers with IIb morphology

Publication History

Article published online:
15 April 2024