ARRS 2022 Abstracts

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E1986. Percutaneous Interventional Radiologic Gastrostomy and Buried Bumper Syndrome
Authors
  1. Aishwariya Vegunta; Yale NewHaven Health Bridgeport Hospital
  2. Rahul Hegde; Yale New Haven Hospital; Yale NewHaven Health Bridgeport Hospital
  3. Ashwin Deshmukh; Yale NewHaven Health Bridgeport Hospital
  4. Gaurav Parmar; Yale NewHaven Health Bridgeport Hospital
  5. Rasha Ismail; Yale NewHaven Health Bridgeport Hospital
  6. Amir Ali Rahsepar; Yale NewHaven Health Bridgeport Hospital
  7. Todd Schlachter; Yale New Haven Hospital; Yale NewHaven Health Bridgeport Hospital
Background
The purpose of this abstract is to briefly review the percutaneous interventional radiologic gastrostomy (PIRG) placement with attention to buried bumper syndrome (BBS). Since 1981, PIRG has become a safe alternative to traditional surgical or endoscopic gastrostomy catheter placements. Minor complications include tube occlusion, dislodgement, leakage, superficial peristomal infection. The most common major complications include peritonitis and hemorrhage, and rarely, colonic perforation, severe skin infection, BBS, and death due to procedure. Absolute contraindications are limited and include active peritonitis, uncorrectable coagulopathy, and acute bowel ischemia. The term, “buried bumper syndrome” was first coined in 1988, a condition in which the gastric mucosa grows over the internal disk or bumper, burying it in the anterior abdominal wall. Although BBS is well described in the gastroenterology literature, it is less reported in radiology.

Educational Goals / Teaching Points
The goal of this abstract is to discuss briefly PIRG placement with attention to BBS. It is essential for radiologists to be aware of BBS, to prevent, recognize early and manage successfully.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Etiology for BBS is an internal bumper pulled too tightly against the anterior abdominal wall, causing pressure necrosis or due to traction on the tube caused by an extremely tight external bumper. Obesity, dressings beneath the external bumper instead of over it, manipulation of the tube by inexperienced personnel, and chronic cough are other reported risk factors. Preventive measures include the adequate position of the external bumper, allowing some distance between the skin level and the external bumper to minimize the risk of pressure necrosis, and keeping attention to the length of the external portion of the tube to recognize migration and avoid unnecessary tube traction. BBS presents as tube blockage, peri tubal leakage, resistance to infuse feedings, and abdominal pain. It can also present as an abscess, abdominal wall infection, peritonitis, gastrointestinal bleeding, sepsis, or rarely death. A physical exam helps in differentiating the BBS from other complications. BBS causes the tube to become fixed in place, hence the tube cannot rotate within or slide through the stoma. Imaging aids in the diagnosis of BBS by confirming the exact location of the tube. Antibiotics are recommended for the treatment of BBS even in the absence of infection due to contamination of the abdominal wall with tube feeds. The treatment for BBS is mainly the removal of the buried bumper to avoid complications. Multiple techniques for gastrostomy removal by IR have been described including: cut and pass method; push removal over a wire floss; balloon-assisted removal with a pull technique; and removal with pull technique using antegrade snare placement.

Conclusion
BBS is a less commonly recognized major complication of the PIRG placement, in which the internal bumper migrates along the tract of the stoma outside the stomach. Early identification and management of BBS is crucial to prevent further complications.