BURIED BUMPER SYNDROME AS A COMPLICATION OF PERCUTANEOUS ENDOSCOPIC GASTROSTOMY IN CANCER PATIENTS: THE BRAZILIAN EXPERIENCE

Background: Buried bumper syndrome (BBS) is a major complication of percutaneous endoscopic gastrostomy (PEG) in which the internal bumper migrates from the gastric lumen into the gastrostomy tract. The aim of the present study was to describe the frequency and characteristics of BBS in cancer patients. Methods: Retrospective chart review of cancer patients submitted to PEG placement. Results: Thirteen cases of BBS were diagnosed among 213 PEG procedures, with an incidence of 6.1%. The interval between PEG and BBS varied from 7 to 630 days (mean 217.5 days). All patients were treated on an outpatient basis. There were six partial, four subtotal and three total BBS. Three partial and four subtotal BBS were treated by external traction and replacement with a balloon‐tipped tube. In three cases of partial BBS the PEG tube was not removed, just repositioned. In three cases of total BBS it was necessary to redo the PEG procedure. Conclusion: BBS is an uncommon and usually late complication of PEG. Most of our cases were detected early, due to instructions provided to patients and caregivers and regular follow up. Early diagnosis permits simple treatment consisting of replacement of the original PEG tube by a balloon‐tube or repositioning the original system.     

Buried Bumper Syndrome as a Rare Complication of Percutaneous Endoscopic Gastrostomy

Abstract: Percutaneous Endoscopic Gastrostomy (PEG), which can be performed under local anesthesia and does not require laparotomy, has become an accepted means of providing long-term nutritional support for patients who cannot swallow. PEG can be successfully performed in 10–20 minutes with minimal invasion. Although the incidences are low, some complications with PEG have been reported. We describe herein a patient who developed an early complication of PEG in which the internal bumper became buried in the gastric wall. The buried bumper was immediately removed under local anesthesia, and a new PEG tube was successfully placed. There have also been reports of tube migration into the appears to result from excessive traction on the tube with subsequent ischemic necrosis of the gastric mucosa and pressure necrosis. Careful management of the tube is needed prevent this complication.     

ENDOSCOPIC SPHINCTEROTOMY ALONE IN THE MANAGEMENT OF LOW‐GRADE BILIARY LEAKS DUE TO CHOLECYSTECTOMY

Aim: Endoscopic retrograde cholangiopancreatography (ERCP) is important in the diagnosis and management of postoperative bile leaks. Endoscopic sphincterotomy (ES) alone, ES with stent or nasobiliary drain (NBD) placement and stent or NBD without ES are the methods of choice. In the present study, we aimed to show the efficacy of ES alone in the management of low‐grade (LGL) cystic duct stump (CDS) leaks due to cholecystectomy. Methods: Between September 2005 and January 2008, ES was carried out on 31 patients with LGL from the CDS due to cholecystectomy who were referred to the endoscopy unit of Izmir Ataturk Training and Research Hospital. Biliary leakage was detected by biliary discharge from a tube drain inserted during the operation. In cases of retaining common bile duct stones, balloon extraction was carried out. If bile discharge continued, a stent was introduced for cessation of the leak as a second procedure. Results: The success rate of ES alone was 87.1% (27 of 31 patients). In four patients (12.9%), ES alone was inadequate, therefore a stent was placed. The biliary leak ceased gradually and stopped in all patients at a mean of 11 (7–21) days. Balloon extraction of retained stones was carried out in six patients (19.6%). In two (6.5%) patients, mild hemorrhage and in two patients self‐limited pancreatitis was seen (6.5%) as complications. Conclusion: Endoscopic retrograde cholangiopancreatography is essential in the management of postoperative biliary leaks. Endoscopic sphincterotomy alone can be the initial procedure in the treatment of LGL from the CDS due to cholecystectomy.     

ENDOSCOPIC OCCLUSION OF CYSTIC DUCT USING N‐BUTYL CYANOACRYLATE FOR POSTOPERATIVE BILE LEAKAGE

Bile leak after cholecystectomy is well described, with the cystic duct remnant the site of the leak in the majority of cases. Endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement has a high success rate in such cases. When ERCP fails, options include surgery, and percutaneous and endoscopic transcatheter occlusion of the site of bile leak. Here, we describe a case of endoscopic transcatheter occlusion of a persistent cystic duct bile leak after cholecystectomy using N‐butyl cyanoacrylate glue. A 51‐year‐old man had persistent pain and bilious drainage following a laparoscopic cholecystectomy. The bile leak persisted after endoscopic placement of a biliary stent for a confirmed cystic duct leak. A repeat ERCP was carried out and the cystic duct was occluded with a combination of angiographic coils and N‐butyl cyanoacrylate glue. The patient's pain and bilious drainage resolved. A follow‐up cholangiogram confirmed complete resolution of the cystic duct leak and a patent common bile duct.     

PROPHYLACTIC PANCREAS STENTING FOLLOWED BY NEEDLE‐KNIFE FISTULOTOMY IN PATIENTS WITH SPHINCTER OF ODDI DYSFUNCTION AND DIFFICULT CANNULATION: NEW METHOD TO PREVENT POST‐ERCP PANCREATITIS

Introduction: The aim of the present study was to reduce post‐endoscopic retrograde cholangiopancreatography (ERCP) complications with a combination of early needle‐knife access fistulotomy and prophylactic pancreatic stenting in selected high‐risk sphincter of Oddi dysfunction (SOD) patients with difficult cannulation. Methods: Prophylactic pancreatic stent insertion was attempted in 22 consecutive patients with definite SOD and difficult cannulation. After 10 min of failed selective common bile duct cannulation, but repeated (>5×) pancreatic duct contrast filling, a prophylactic small calibre (3–5 Fr) pancreatic stent was inserted, followed by fistulotomy with a standard needle‐knife, then a standard complete biliary sphincterotomy followed. The success and complication rates were compared retrospectively with a cohort of 35 patients, in which we persisted with the application of standard methods of cannulation without pre‐cutting methods. Results: Prophylactic pancreatic stenting followed by needle‐knife fistulotomy was successfully carried out in all 22 consecutive patients, and selective biliary cannulation and complete endoscopic sphincterotomy were achieved in all but two cases. In this group, not a single case of post‐ERCP pancreatitis was observed, in contrast with a control group of three mild, 10 moderate and two severe post‐ERCP pancreatitis cases. The frequency of post‐ERCP pancreatitis was significantly different: 0% versus 43%, as were the post‐procedure (24 h mean) amylase levels: 206 U/L versus 1959 U/L, respectively. Conclusions: In selected, high‐risk, SOD patients, early, prophylactic pancreas stent insertion followed by needle‐knife fistulotomy seems a safe and effective procedure with no or only minimal risk of post‐ERCP pancreatitis. However, prospective, randomized studies are awaited to lend to support to our approach.