Venting issues

Abstract

Introduction

A 65-year-old woman with type 3 intestinal failure secondary to scleroderma of the gut (limited cutaneous sclerosis (centromere positive) and rheumatoid arthritis (anti-cyclic citrullinated peptide (CCP) and rheumatoid factor positive)) on home parenteral nutrition since 2011 underwent a venting PEG replacement in 2015 for intractable vomiting due to gut dysmotility and small bowel bacterial overgrowth, poorly responding to cyclical antibiotics. An endoscopy was undertaken for planned PEG review for consideration of elective replacement (figure 1).

Based on this endoscopy, her case was discussed at a multidisciplinary team meeting and the anaesthetic risk of laparotomy to remove the PEG was deemed too high (previous endoscopic PEG exchange under sedation had been poorly tolerated due to tube removal through the oesophagus (possibly affected by scleroderma), and necessitated anaesthesia). Therefore, it was decided to insert a new venting PEG endoscopically alongside the previous buried PEG (cut short and clamped) with the plan to remove the old one at a later date.

Questions

1. What is shown during the initial endoscopy?

2. What is shown during follow-up endoscopy?

Answers

At initial endoscopy, the bumper was noted to be completely buried and was unable to be freed (figure 1). It appeared that the weight of the drainage bag, despite supporting apparatus and the usual PEG care of weekly moving of the tube both rotationally and advancement, had pulled on the external apparatus chronically leading to excessive granulation and leakage.

Figure 1.

Initial endoscopy.

Follow-up endoscopy surprisingly revealed that the buried bumper was now completely free from the mucosa, and therefore, the old PEG was successfully removed (figure 2).

Figure 2.

Follow-up endoscopy.

Closing remarks

We highlight spontaneous resolution of the buried bumper syndrome, not previously reported in the medical literature. Current guidance as per the British Association for Parenteral and Enteral Nutrition (BAPEN Principles of Good Nutritional Practice: Decision Trees)¹ states that if patients are suitable for endoscopic intervention a PEG tube can be replaced at a different site with endoscopic removal of buried bumper: this comprises the needle-knife technique where the mucosa is incised radially down to the central dome of the bumper to free the bumper, balloon push/pull approach courtesy of an oesophageal balloon passed through the PEG tube, snare traction on the PEG, external traction and/or Flamingo technique.² The Flamingo device comprises an angulated cutting instrument with incision towards the internal bumper, providing a limit to the cutting process as a safety feature not seen in the needle-knife device. Post removal, fistula tracts can be appropriately sealed with Ovesco clips. If endoscopic interventions fail to resolve the issue, surgery or leaving the buried bumper in place are options. However, the latter is associated with an increased risk of abscess formation and sepsis and only undertaken in cases where the above interventions are not appropriate. Prevention is always better than cure and preventive measures have been highlighted comprising external fixator position assessment on a regular basis as well as regular advancement and rotation.

Our case suggests that there may be merit in a watch-and-wait policy in those in whom the above strategies are not possible. While we live in a healthcare environment that seems to stipulate continuous action, there is potential for endoscopists to demonstrate observation and review. Releasing the tension on the original tube may have rectified the issue in this case. However, a national database for PEG complications and resolutions would be of benefit in this complex area.