With an incidence ranging between 0.3 % and 2.4 %, buried bumper syndrome (BBS) is
a relatively rare complication after percutaneous endoscopic gastrostomy (PEG) in
which the internal fixation device of the cannula – the retention bumper – migrates
partially (incomplete BBS) or completely (complete BBS) into the gastric wall with
subsequent mucosal overgrowth [1]
[2]. Management of complete BBS can be challenging, and a variety of endoscopic devices
have been described for endoscopic treatment, including needle-knives, wire-guided
papillotomes, the sphincterotome-like Flamingo device, or a combination of different
techniques [3]
[4]
[5].
The Clutch Cutter is a forceps-type resection device with a serrated cutting edge
that allows simultaneous grasping and cutting or coagulating of tissue. The outer
edge of the Clutch Cutter is insulated; electrosurgical current energy is concentrated
at the closed blade to avoid unintentional incision. We present the first case of
endoscopic removal of a complete BBS with the Clutch Cutter.
A 77-year-old man with a known radiation-induced esophageal stricture requiring intermittent
enteral feeding through a PEG presented with obstruction of his PEG tube. Esophagogastroduodenoscopy
showed a 4-cm area of granulomatous – fibrotic tissue with a central retraction in
the anterior wall of the gastric antrum, thereby confirming complete BBS ([Fig. 1 a]). A .035-inch Jagwire was inserted through the gastrostomy to identify the center
of the retention bumper and was used as a guide for subsequent incisions. Next, granulomatous
tissue was grasped with the opened Clutch Cutter and, with tissue inside the forceps,
the Clutch Cutter was gently pulled back in order to avoid cutting too deep ([Video 1]). During pull-back, electrocautery was applied using an Erbe Vio 200 D-system with
the following settings: forced coagulation 30 W, Endo Cut Q with effect 1, duration
3, interval 1. The granulomatous tissue overgrowing the buried bumper was radially
incised at two sites on opposite sides of the Jagwire, leading to the creation of
a slit-like mucosal pocket ([Fig. 1 b, c]). The PEG tube was then mobilized and gently pushed towards the gastric lumen from
externally, leading to release of the buried bumper and the PEG tube remnant from
the overgrown tissue into the gastric lumen ([Fig. 1 d]; [Video 1]). Total procedure time from insertion to withdrawal of the endoscope was 11 minutes,
and the whole procedure was performed with the patient under conscious sedation with
midazolam and with broad-spectrum antibiotic prophylaxis.
Fig. 1 Different steps of endoscopic management of a complete buried bumper with the Clutch
Cutter. a Endoscopic appearance of complete buried bumper syndrome (BBS): the internal fixation
device (“bumper”) is completely overgrown by granulomatous and fibrotic mucosa. A
.035-inch Jagwire was inserted to identify the center of the retention bumper and
used as a guide for subsequent incisions. b, c The granulomatous tissue overgrowing the retention bumper was radially cut at two
sites on opposite sides of the Jagwire to create a slit-like mucosal pocket. d The external percutaneous endoscopic gastrostomy tube was mobilized and, while undergoing
360° rotation, pushed through the incised mucosa into the gastric lumen.
Video 1 Endoscopic removal of a completely buried bumper with the Clutch Cutter.
In conclusion, our case illustrates the potential of the Clutch Cutter for rapid and
safe endoscopic treatment of BBS.
Endoscopy_UCTN_Code_CPL_1AH_2AI
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.
This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos
