Buried Bumper Syndrome: a rare complication during radical chemoradiotherapy for head and neck cancer

Abstract

Patients undergoing radical treatment particularly chemoradiotherapy for cancer of the upper aerodigestive tract frequently experience progressive deterioration in swallow during and immediately after treatment. It is important to identify patients at high risk of compromised feeding early, following diagnosis, so that alternate feeding routes, such as percutaneous endoscopic gastrostomies (PEGs), can be promptly and prophylactically instituted, in keeping with the UK Head and Neck Cancer Guidelines (2016).

Background

Percutaneous endoscopic gastrostomy (PEG) tubes are generally safe procedures with low complication rates, however, the buried bumper syndrome (BBS) is a rare but potentially life-threatening complication if not recognised promptly. We present a case report of BBS in a patient treated with chemoradiotherapy for head and neck cancer. We discussed the clinical features, diagnostic pathway and reviewed the literature for management of BBS.

Case presentation

A 52-year-old man presented with a 3-month history of dysphagia and dysphonia. He was urgently investigated and subsequently diagnosed with stage T3N2bM0 oropharyngeal squamous cell carcinoma. Following multidisciplinary evaluation, he was planned for curative-intent therapy with concurrent chemoradiation including cisplatin. Given the high risk of side effects of chemoradiation, it was also decided that prophylactic PEG insertion should be undertaken, which was done on an elective basis with no complications.

Prior to his first cycle of cisplatin, he presented to the emergency department with pleuritic chest pain and dyspnoea. Consequently, a CT pulmonary angiogram (CTPA) was performed to exclude pulmonary embolism. The CTPA showed no embolus and normal placement of the PEG and no evidence of abscess as shown in figure 1.

Figure 1.

Normal placement of the percutaneous endoscopic gastrostomy.

He then underwent his first cycle of cisplatin, following which he presented systemically unwell, with fever and abdominal pain. On clinical examination, no clear source of sepsis was identified; however, he had a tender abdomen. He was treated empirically for sepsis with broad-spectrum antibiotics. He had a CT of his abdomen, which showed a 4×1.6×1.6 cm collection lying on the anterior serosal surface of the stomach, immediately below the level of the PEG tube, as well as a liver abscess, illustrated in figure 2.

Figure 2.

Collection surrounding the percutaneous endoscopic gastrostomy.

The decision was made to remove the PEG, following which he improved substantially. Nutrition was maintained enterally with regular dietitian input, as he declined nasogastric tube placement. The presence of the abscess was confirmed on endoscopic evaluation during the PEG tube removal (figure 3). Interval liver sonography after 2 weeks of antibiotic therapy showed complete resolution of the hepatic abscess and significant reduction of the abdominal collection, measuring 1.8×0.4 cm across (figure 4). Blood cultures showed no bacterial growth. After a month of inpatient care, with careful speech and language therapy and dietitian input, he was uneventfully discharged for outpatient review with subsequent resumption of oncological therapy.

Figure 3.

Endoscopic view of the peri-percutaneous endoscopic gastrostomy site collection.

Figure 4.

Resolving liver abscess.

In this case, endoscopic removal was feasible and successful and, thus, surgical intervention was not required. With an extended antibiotic course, the patient recovered, although the fulminant course and normal CT preceding presentation underline the challenge and importance of early recognition. Additionally, nutritional support must be maintained throughout. Following resolution, PEG tubes can often be reinserted via the same orifice, and the risk of recurrence is low with appropriate precautions and endoscopic surveillance.^{1 2}

In summary, this case reflects a rare complication of PEG insertion in a patient undergoing curative-intent chemoradiation for locally advanced oropharyngeal squamous cell carcinoma. It should serve as a reminder to all clinicians to be aware of BBS, in order to diagnose and treat this uncommon and potentially fatal syndrome.

Discussion

PEG tubes play important nutritional roles, serving as adjuncts to the oral route, particularly in patients where feeding is potentially compromised due to treatment-related oropharyngeal mucositis. PEG insertion is not without risk, and prompt recognition and management of complications are vital to reduce morbidity and mortality.

Complications can be classified as minor or major. Minor complication rates vary from 13% to 40%.^2–5 These includes maceration due to leakage of gastric contents around the tube and peristomal pain. Necrotising fasciitis and colocutaneous fistula are both major complications and have been reported in 0.4%–4.4% of procedures.^6–8 The 30-day mortality rate after PEG insertion has been reported to be in the range of 6.7%–26%.^2–4 Most studies have suggested that severe complications are more likely to occur in patients who are immunocompromised, elderly with comorbid illnesses and those with neurological disease prone to aspiration.^2–5 Some complications were apparent following PEG tube placement and these include perforation of the oesophagus or stomach, ileus and pneumoperitoneum.^2–5 In some instances, damage to the internal organs such as liver or colon may result.^2–5

Late complications, including deterioration of the mature gastrostomy site, can occur.^4–8 This ultimately results in skin ulceration and leakage, culminating in complete breakdown of the tissue around the PEG site.^4–8 The breakdown can lead to complications such as infection, bleeding and BBS, which is a very rare completion of PEG insertion that is potentially fatal without early diagnosis and intervention.

The PEG tube is held in place by the positioning of the internal and external bumpers, which sites the PEG inside the stomach.⁸ BBS is where there is a growth of the gastric mucosa either partially or completely over the internal fixation device (internal bumper), which has migrated outside the stomach.⁸ BBS reflects a severe complication of PEG insertion.⁸ The onset of BBS from the insertion of PEG tube is usually months or years but has been rarely reported as soon as 6 days after the insertion of PEG insertion.⁸

The presenting clinical features of BBS can be non-specific and can vary in severity, from mild inflammation and infection to perforation, peritonitis, haemorrhage or abscess, which can be fatal.³ Therefore, in a patient with an indwelling PEG who developed feverish, rigour and other features of sepsis with no obvious source and abdominal pain or discomfort, clinicians should include BBS as a differential diagnosis. Clinical features suggestive of BBS are pain on feeding, pain over PEG site, tube blockage, extravasation on feeding, site breakdown and peristomal infection.¹

The risk factors that contribute to BBS include failure to adjust the external bumper of the PEG due to anatomical changes when patient’s nutritional state improves, persistent and excessive friction between the internal and external bumper of the PEG, malnutrition, poor wound site healing as well as due to PEG tube features such as stiff tubes (polyurethene), silicon internal retention disc, small inner bumper and sharp tapered flange.⁸

The diagnostic pathway of BBS begins with identifying clinical features as above and clinical suspicion in a patient with PEG tube. If the PEG tube can be pushed into the stomach, then it is unlikely to be BBS. If in the occasion where the PEG tube is not able to be pushed into the stomach, BBS should be suspected.⁸ Clinicians should then consider investigations including radiological imaging (ultrasound or CT) and gastroscopy.^{9 10}

Gastroscopy is mandatory in confirming BBS diagnosis.¹⁰ The endoscopic features supporting a BBS diagnosis encompass the varying degrees of mucosa growth surrounding the internal bumper from a partly covered bumper to a heaped mucosa surrounding the internal bumper, which can be completely covered.¹⁰ In cases where the internal bumper is completely covered in mucosa growth, features indicating BBS are oozing pus from the pimple of the mucosa mound and fluid trickling from the crevices when the tube is flushed.⁹

Management of BBS, therefore, depends on the severity of symptoms. Clinical management strategy would include conservative management with antibiotics and close monitoring to surgical intervention (favoured in severe cases of BBS with deep migration and firm adherence to overgrowing tissue).¹⁰

Clinicians need to determine whether the PEG tube is still required for ongoing management of patient’s symptoms. Next, clinician needs to determine whether patient is clinically fit for gastroscopy procedure. If patient is unfit for gastroscopy, the recommendation is for conservative management of leaving the tube in situ and manage arising complications. A number of small case series have reported that leaving BBS in situ while establishing a new feeding site has not increased morbidity and mortality at 18 months of follow-up.⁴

In patients who are fit for gastroscopy, the recommendations are to replace the PEG tube at a different site to prevent the development of BBS.¹⁰ In terms of managing the diagnosed BBS site, multiple strategy and techniques are available for BBS removal and discussion with multidisciplinary team, which includes upper gastrointestinal surgeons, dieticians and nutrition team that is essential to identify the optimal strategy to remove the buried bumper site. Endoscopic removal techniques of the bumper sites vary across different hospital trusts. These techniques include removal via endoscopy, needle knife removal, ballon push or pull technique and snare technique.¹⁰ Radiological removal of buried bumper has also been described but is not widely available. Surgical removal with laparoscopy has also been used in some cases.⁹

Following successful treatment and placement of alternative site of PEG tube, BBS prevention strategy should be used, which includes regular weekly rotation of PEG tube, regular checking to ensure external bumper is not attached too tightly and maintaining a 1 cm gap between the external bumper and skin.⁹

In summary, clinicians need to determine whether the PEG tube is still required for ongoing management of patient’s symptoms. The next step involved determining whether patient is clinical fit for gastroscopy procedure. If patient is unfit for gastroscopy, the recommendation is for conservative management of leaving the tube in situ and to manage arising complications. A number of small case series have reported that leaving BBS in situ while establishing a new feeding site has not increased morbidity and mortality at 18 months of follow-up.⁴

Patient’s perspective.

Early presentation to healthcare professionals with subtle signs of abdominal discomfort or nonspecific symptoms, likewise in this case, is vital to allow early intervention of procedure-related complication. This will allow prompt investigation with appropriate imaging modality and/or gastroscopy with the ultimate aim to resolve the problem in a timely manner. Symptomatic patients should have a low threshold to seek consultation from healthcare professionals, especially when receiving chemoradiotherapy in the curative setting as this will ultimately reduce unnecessary interruption to life-saving treatment.

Learning points.

• Buried bumper syndrome is a very rare complication of percutaneous endoscopic gastrostomy (PEG) insertion but can be highly life threatening if not recognised promptly. It should be a differential diagnosis in patients who present with sepsis and in presence of a PEG tube. Meticulous and careful examination of PEG site as a potential site of sepsis should be recommended.

• All clinicians managing patients with PEG tubes should be aware of the associated complications of insertion and discuss these when consenting patients for PEG placement. Clinical features suggestive of buried bumper syndrome (BBS) include pain on feeding, pain over PEG site, tube blockage, extravasation on feeding, site breakdown and peristomal infection.

• Gastroscopy is mandatory in the diagnosis of BBS. An alternative PEG site should be established if PEG is still required. Management depends on the extent of migration and associated clinical severity and includes conservative, endoscopic and surgical approaches. Multidisciplinary team including the upper Gastrointestinal surgeons, dietitian and nutrition team is essential. Prevention strategies of BBS should also be practised.