Early Buried Bumper Syndrome – To Leave or Not to Leave

Buried bumper syndrome (BBS) is an uncommon adverse event of percutaneous endoscopic gastrostomy (PEG), yet it should be thoroughly managed because its consequences can be serious and life-threatening. BBS is typically a late adverse event of PEG and its management is more straightforward in these cases since a mature gastrocutaneous fistula poses fewer risks when it is necessary to remove the buried bumper. Early presentations were rarely reported and so the management in these cases remains largely on the physician’s personal experience and clinical sense. The decision of what to do in these rare cases should take into account not only the best way to avoid serious complications, but also the issue of how nutrition will be delivered if the gastrostomy is removed. In this issue of GE – Portuguese Journal of Gastroenterology, two opposite management approaches for early BBS are presented by Azevedo et al. [1] and Pinho et al. [2]. In the first case, a patient with Alzheimer disease presented with BBS 3 days after PEG placement [1]. As the bumper was totally embedded in the gastric wall and the internal orifice of the gastrocutaneous fistula was not identified, the authors decided to remove the bumper and tube as no resistance was noted. The patient was admitted for surveillance and antibiotherapy, and no adverse events were noted including on abdominal imaging. Nutrition was secured via oral route in this case as the patient maintained some oral intake. In the second case, a patient under adjuvant chemoradiotherapy for oropharyngeal cancer presented with BBS 2 weeks after the procedure, with a newly formed cavity in the abdominal wall [2]. As the patient exhibited aphagia and endoscopic access was difficult (due to anatomic deformation and patient will), a conservative approach was attempted in order to leave the gastrostomy in place. A guidewire was passed to the stomach through the gastrostomy tube without resistance and the bumper was repositioned in the stomach under gentle traction. Peri-