AJR 2001; 176:766-768
© American Roentgen Ray Society
Radiologic Removal of Buried Gastrostomy Bumpers in Pediatric Patients
John J. Crowley1,
Daya Vora,
Cristie J. Becker and
Lindsey S. Harris
1
All authors: Department of Pediatric Imaging, Children's Hospital of Michigan,
3901 Beaubien Blvd., Detroit, MI 48201.
Received February 4, 2000;
accepted after revision September 13, 2000.
Address correspondence to J. J. Crowley.
Introduction
Patients who are unable to tolerate oral feeding require placement of a
safely anchored gastrostomy tube. Such tubes may be placed by either the
antegrade or the retrograde technique. In the antegrade technique, one slides
the feeding tube down the patient's esophagus and out through the anterior
abdominal wall over a guidewire. A disk on the trailing back portion of the
tube keeps the tube within the stomach
[1]. A "buried
bumper" is a condition in which the gastric mucosa grows over this
internal disk or bumper, burying it in the anterior abdominal wall
[2,3,4].
It has been proposed that the condition is caused by an internal bumper that
has been pulled too tightly against the anterior abdominal wall, causing
ischemic necrosis and an inflammatory response
[3]. Although the buried bumper
is well described in the gastroenterology literature, there are few references
to the buried bumper in radiology articles (Cahill A et al., presented at the
Society for Pediatric Radiology meeting, May 1999). Potentially serious
complications may follow tube placement including perforation, peritonitis,
and even death [3,
5]. Traditionally, this
complication has required endoscopy or open surgery
[2,3,4].
We describe a technique by which six bumpers have been successfully removed in
the radiology department without recourse to endoscopy, surgery, or operating
room time.
Materials and Methods
Over a 3-year period (November 1995-November 1998), we identified six
patients with a gastrostomy tube in which the internal bumper could not be
pushed easily into the gastric lumen (Fig.
1A). Every patient had a Sacks-Vine gastrostomy tube (Ross
Products, Abbott Laboratories, Columbus, OH). The average age of the patients
was 5.8 years at time of tube removal, and the gastrostomy tubes had been in
place for an average of 14 months. The nature of the proposed procedure was
explained to the patients' parents along with alternatives and possible
complications, with an emphasis on the possibility of gastric perforation. All
procedures were carried out with the patient under general anesthesia as
follows.
Part A
A directional catheter with a soft-tip guidewire was introduced through the
gastrostomy tube and, under fluoroscopic guidance, guided up the esophagus and
out of the mouth. The soft-tip guidewire was then exchanged for an Amplatz
Superstiff guidewire (Cook, Bloomington, IN). The directional catheter was
then removed.
Part B
An Amplatz guidewire was now passing into the mouth, down the esophagus,
into the stomach, and out through the buried gastrostomy tube. From the
outside, an angioplasty catheter was guided over the Amplatz guidewire into
the gastrostomy tube, and the balloon was inflated at or just proximal to the
buried gastrostomy bumper (Fig.
1B).
Part C
The angioplasty balloon was inflated, and, pinning the Amplatz guidewire,
the angioplasty catheter and the gastrostomy tube were pushed into the gastric
lumen, dislodging the buried gastrostomy bumper.
Part D
The angioplasty catheter and the gastrostomy tube were then pushed up the
esophagus and out of the mouth. The gastrostomy tube was removed. The Amplatz
guidewire was pulled back down through the esophagus and out through the
gastrostomy site.
In one patient it was not possible to guide the directional catheter and
soft-tipped wire up the esophagus and out of the mouth. In that patient, a
Dotter snaring device (Cook) was guided down the esophagus. The wire was
introduced through the gastrostomy tube and snared by the Dotter device, and
the wire was then drawn up the esophagus and out of the mouth. In another
patient, the angioplasty catheter, rather than being introduced from the
outside through the gastrostomy tube, was introduced through the mouth and
guided over the Amplatz Superstiff guidewire, down the esophagus, and into the
buried gastrostomy tube (Fig.
2A,2B).
View larger version (154K):
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Fig. 2A. —5-year-old boy with profound cerebral palsy and seizure
disorder. Radiograph shows angioplasty catheter introduced through mouth and
passed down esophagus. Internal bumper is buried in mound of inflammatory
tissue (arrows).
|
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View larger version (169K):
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Fig. 2B. —5-year-old boy with profound cerebral palsy and seizure
disorder. Radiograph reveals that internal bumper has been torn free of mound
of inflammatory tissue and is freely mobile within gastric lumen.
|
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Results
Six attempts were made; in all six patients the bumper was successfully
dislodged, and the tube was removed. In five patients the bumper was dislodged
with little effort. In one patient, repeated efforts and considerable force
were necessary to dislodge the bumper from a large mound of inflammatory
tissue. This patient experienced abdominal wall tenderness after the
procedure. The general surgery service was consulted, and the patient was
observed overnight. By the next morning, the findings of the patient's
physical examination had returned to normal. He was discharged and had no
subsequent problems. Two of the patients later developed gastrocolic fistulas,
seen at 4 months and 6 months, respectively, after the buried bumper had been
removed. Although it is impossible to exclude the possibility that the
radiologic intervention had caused the fistulas, fistulas have been repeatedly
described as a complication of antegrade gastrostomy tubes and of the buried
bumper itself [3].
Discussion
Most buried bumper complications have involved the Sacks-Vine tubes
[2,3,4,5].
The incidence varies between 1.6% and 6.1%
[4,
6]. An unduly tight external
bumper increases pressure on the mucosa by the internal bumper, which leads to
pressure necrosis and, in due course, to migration of the internal bumper into
deeper structures [3,
4]. Migration into the anterior
abdominal wall was first described in 1988, and the phrase "buried
bumper syndrome" was coined
[5,6,7,8].
It has been postulated that the Sacks-Vine tube, made of a 50A durometer
silicone, is more likely to harden in the acidic environment of the stomach
and thus to increase the pressure-necrosis potential of this bumper than are
the softer latex and smaller durometer silicone tubes
[2].
Our technique of removal is an adaptation for a technique previously
described for the removal of uncomplicated antegrade gastrostomy tubes (Towbin
et al., presented at the Radiological Society of North America meeting,
December 1996). With this technique, an angioplasty catheter is passed down
the esophagus, over a guidewire, and into the gastrostomy tube. The balloon is
inflated, and the tube is then pulled up the esophagus. We have used this
technique for uncomplicated tube removals, but we have been able to dislodge
only one buried bumper using this method (Fig.
2A,2B).
By introducing the angioplasty catheter from the outside, we can exert force
only a few centimeters from the buried bumper. So far our attempts have been
uniformly successful. The alternative to this approach is surgery in which
tubes will be removed either by cutting away the mucosa during endoscopy or by
performing a partial gastrectomy (Cahill A et al., Society for Pediatric
Radiology meeting, May 1999). Our technique allows us to avoid using operating
room time with its attendant costs, and we believe that it is less invasive
than its alternative, which may involve partial gastrectomy. Although the mean
age of our patients was 5.8 years, we see no reason why this technique cannot
be successfully applied to adults in whom it may be carried out under local
anesthetic.
To avoid the buried bumper complication, the external bumper should be
loosened slightly on the second day after placement. Thereafter, on a daily
basis, the tube should be pushed a short distance into the stomach and rotated
180°
[2,3,4,5].
Resistance to these movements indicates a buried bumper.
In summary, the buried bumper complication of gastrostomy tube placement
can now be treated under fluoroscopic guidance. We believe that a buried
bumper need no longer necessitate surgery.
References
-
Kaye RD, Towbin RB. Interventional procedures in the
gastrointestinal tract in children. Radiol Clin North
Am 1996;34:903
-917[Medline]
-
Klein S, Heare BR, Soloway RD. The "buried bumper
syndrome": a complication of percutaneous endoscopic gastrostomy.
Am J Gastroenterol
1990;85:448
-451[Medline]
-
Boyd JW, DeLegge MH, Shamburek RD, Kirby DF. The buried bumper
syndrome: a new technique for safe, endoscopic PEG removal.
Gastrointest Endosc
1995;41:508
-511[Medline]
-
Ma MM, Semlacher EA, Fedorak RN, et al. The buried gastrostomy
bumper syndrome: prevention and endoscopic approaches to removal.
Gastrointest Endosc
1995;41:505
-508[Medline]
-
Foutch PG, Woods CA, Talbert GA, Sanowski RA. A critical analysis
of the Sacks-Vine gastrostomy tube: a review of 120 consecutive procedures.
Am J Gastroenterol
1988;83:812
-815[Medline]
-
Mamel JJ. Percutaneous endoscopic gastrostomy: clinical review.
Am J Gastroenterol
1989;84:703
-710[Medline]
-
Shallman RW, Norflee RG, Hardache J. Percutaneous endoscopic
gastrostomy feeding tube migration and impaction in the abdominal wall.
Gastrointest Endosc
1988;34:367
-368[Medline]
-
Behrle KM, Derkovich AA, Ammon HV. Spontaneous tube extrusion
following percutaneous endoscopic gastrostomy. Gastrointest
Endosc 1989;35:56
-58[Medline]
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Introduction
Materials and Methods
