Administering artificial nutrition via a percutaneous endoscopic gastrostomy (PEG) is a well-established method for long-term enteral feeding in the UK (Figure 1). The initial PEG insertion is generally performed endoscopically and takes place in a hospital setting. The long-term care of patients is community based, either in individuals' own homes or care facilities.
Figure 1. Percutaneous endoscopic gastrostomy
Ongoing care and support of a patient with a PEG is necessary in order to prevent issues and complications. A rare but major complication of PEG is buried bumper syndrome (BBS) (Cyrany et al, 2016). PEG tubes have an internal bumper, which is generally a round disk that is positioned inside the stomach. This is the internal end of the feeding tube is where fluids, liquid artificial nutrition and medications enter the stomach. The tract which is formed during the initial endoscopic feeding tube placement is often referred to as a stoma tract. Where the PEG exits the abdomen is known as the stoma site (National Nurses Nutrition Group (NNNG), 2013).
What is buried bumper syndrome?
BBS is when the internal bumper migrates along the stoma tract outside of the stomach (Cyrany et al, 2016). BBS is thought to be caused by excessive compression of the tissue between the internal bumper and the external fixation device, which is on the outside of the patient's abdomen, suggesting that the external fixation device is positioned too tight. The mucosa of the internal stomach lining can also start to form around the internal bumper if the bumper's position is not checked and adjusted regularly (Bennell, 2018). Huynh et al (2020) also stated that patients who pull excessively at the outside of their tube can cause BBS. Malhi and Thompson (2014) suggested that inadequate daily PEG care increases the risk of BBS. However, the authors acknowledged that, despite the appropriate after-are, BBS can still develop. Bennell (2018) suggested that more data and research are required examining the level and type of aftercare associated with the prevention and incidence of BBS. A study by Dowman et al (2014) in the UK found that the incidence of BBS ranges from 4.8% to 5.8%. However, this study was limited to a specific area in the UK. In the US, the incidence of BBS has been reported to be 1–2% (Cyrany et al, 2016; Huynh et al, 2020).
BBS is often categorised as a chronic or late complication of PEG insertion (Malhi and Thompson, 2014). However, it has also been documented within days of initial insertion (Venu, 2012). This highlights the importance of specialist aftercare in the early days following initial insertion in hospital and comprehensive handover on discharge into the community setting. It is important to acknowledge that there are several different styles of artificial feeding tubes, including balloon gastrostomy tubes, but the incidence of BBS with these types of feeding tubes is much lower (Ramdass and Mann, 2013).
Signs and symptoms of buried bumper syndrome
The signs and symptoms of BBS are as follows:
- Inability to advance tube into the stoma tract (with out without ability to rotate the tube)
- Partial or full loss of patency
- Leakage of fluids administered and/or gastric contents
- Erythema
- Localised infection
- Pain
- Internal bumper (disk) is palpable.
Patients may present with erythema and pain around their stoma site. Ramdass and Mann (2013) acknowledged that recognition of BBS may be delayed in patients with impaired sensation or cognitive impairment.
Management of buried bumper syndrome
Community services overseeing the care of patients who have a PEG must manage the symptoms of BBS such as increased exudate with appropriate dressings and topical treatments, as well as monitor for signs of infection and provide pain relief where necessary. Urgent referral for gastroscopy is indicated in all cases where BBS is suspected (Bennell, 2018; Huynh et al, 2020). If the PEG cannot be flushed, the patient must attend hospital urgently to maintain hydration and nutritional needs. If left untreated, further complications resulting in serious outcomes for the patient might occur as a result of BBS, including gastrointestinal bleeding, perforation, peritonitis, abdominal wall abscess and infection.
Treatment resolution is based on the depth of internal bumper migration. Surgical dissection and removal of the PEG in situ is likely to be required, with surgical closure of the stoma tract and the insertion of a new PEG. The British Association of Parenteral and Enteral Nutrition (BAPEN) have provided a comprehensive decision tree for specialist services for management of BBS (BAPEN, 2012).
Cyrany et al (2016) suggested a conservative approach in any patients with a very high operative risk or very poor prognosis. This would need to be based on an individual patient assessment, taking a multidisciplinary decision approach. The risks and benefits of trying to resolve the BBS or leaving the bumper in place would need to be individually considered. BBS can lead to the development of an abscess or the formation of a fistula (Bennell, 2018). This puts the patient at high risk of associated complications, such as sepsis.
Where leaving the PEG with the buried bumper is assessed as the most appropriate course of action for the patient, BAPEN (2012) suggested a jejunal extension that could be passed into the PEG to maintain its patency but leaving the tip in the stomach to maintain gastric feeding. The author has successfully done this with a patient, where it was established that they were not medically stable to undergo hospital admission for PEG replacement. The patient did not have BBS, but a jejunal extension was used to maintain enteral feeding via the stomach and was the most appropriate treatment for the patient. This procedure was carried out successfully in a nursing home with no complications.
PEG care and maintenance
Care and maintenance of PEG in relation to prevention of BBS should be in line with the manufacturer's guidance (NNNG, 2013). This includes information on how to monitor PEG position, advance and rotate the tube and how often this should be carried out. This can vary from advancing weekly (BAPEN, 2012; Malhi and Thompson, 2014) to daily. Local guidance may also exist and should be followed where available. There may be conflicting recommendations between the manufacturer and the local NHS trust on how often to advance and rotate the PEG. This may be based on an individual patient care needs or where local guidance has been reviewed and amended following incidence of BBS. Bennell (2018) highlighted the limited and conflicting advice available to prevent BBS and acknowledged this gap in practice guidance, which has yet to be fully addressed. NNNG (2013) is a good practice guideline outlining the care required to try to prevent BBS from occurring, but it acknowledges that manufacturer's advice may differ depending on the PEG type.
Prevention
When the PEG insertion site is mature (usually classed as between 2 and 4 weeks), to prevent BBS, the PEG external fixation device should be undone and the PEG tubing should be advanced or pushed into the stoma tract by several centimetres and rotated 360 degrees. Then, the tube should be pulled gently to its original position and the external fixation device secured. Bennell (2018) highlighted that there is no specific guidance on how far to advance the PEG and identified differing values, from between 1 and 10 cm. This procedure is often referred to as advancing and rotating.
New feeding tubes have centimetre markers, and, where these are still visible, they can be used as a guide as to where the tube is positioned correctly (Ramdass and Mann, 2013). The literature differs on the distance to be maintained between the patient's abdomen and the external fixation device but it is generally around 0.5–1 cm (BAPEN, 2012; Cyrany et al, 2016; Huynh et al, 2020). There needs to be some flexibility to allow for the patient sitting and lying down. If the external fixation device is too tight, infection, tissue ischemia and necrosis can occur (Cyrany et al, 2016; NNNG, 2013). Conversely, if the external fixation device is left too loose, this can result in leaking of gastric contents, which can cause irritation and potential infection of the stoma site. Over-granulation of the tissue around the stoma site can also occur, leading to localised bleeding, exudate and pain.
Daily observation by the patient themselves, family or carers is essential to monitor the stoma site and identify any issues. Weight gain, for example, can increase the size of the stoma tract, requiring the external fixation device to be regularly monitored and adjusted accordingly (Bennell, 2018). Knowledge of the type of feeding tube is essential to provide the correct type of aftercare (BAPEN, 2012; NNNG, 2013). For example, rotating a jejunal placed tube could cause bowel perforation, which can be life-threatening for the patient (Roveron et al, 2018). The appropriate information and training should be provided on discharge to support ongoing care in the community (National Institute for Health and Care Excellence (NICE), 2012).
Advice on when to commence adjustment of the external fixation device and advancing the PEG into the tract differs, but is generally no earlier than 2 weeks after new PEG insertion and no later than 4 weeks. The manufacturer's advice should be referred to for specific instructions (NNNG, 2013). Daily observation is required by either the patient themselves, family, or carers to identify any such issues once discharged into the community. Effective daily stoma hygiene, which includes cleaning of the tube and the working parts, can help to prevent complications (Ramdass and Mann, 2013).
Nutrition support teams
Pre-PEG placement counselling and training should include what aftercare is required to prevent complications such as BBS (NICE, 2012). NICE (2006) stated that all community patients receiving enteral feeding should be supported by multidisciplinary teams, including dietitians, community nurses, care home nurses and homecare company nurses, as appropriate. This includes training, verbal and written information and emergency contact numbers. Patients, relatives, health professionals and formal carers in the community should also know whom to contact to escalate any identified PEG issues for timely assessment and review.
A review of the patients PEG and stoma site should also form part of their formal nutrition reviews with a dietitian and where appropriate specialist nutrition nurse. This allows a post training refresher on what is required and regular follow up by specialist dietetic services allows for reassessment of stoma site and the PEG tube identifying any specific clinical or training needs. Communication and education are important for patients, their families and those involved in the care of the PEG tubes (Ramdass and Mann, 2013).
Recommendations
Patients and their caregivers should receive clear instructions and supportive education programmes linked to locally developed protocols, based on available evidence, manufacturers' instructions and the experience of specialist services.
Where patients receive formal care, record keeping should include description of PEG care given and the outcomes. Specialist reviews should also incorporate review of the stoma site and tube and what care the patient or carers are undertaking. This should be documented (Bennell, 2018).
Further research and data collection are needed on the incidence of BBS, if different types of internal bumper increase the risks of BBS and how aftercare influences this.
National collaborative guidance is needed (Bennell, 2018). However, this may pose challenges, as there are different endoscopic and surgical techniques in practice and different brands of PEG tubes in use in the UK.
Conclusion
BBS is a known rare but severe complication of PEG feeding. Training for patients and their caregivers and the appropriate aftercare are essential to try to prevent such complications.
All suspected incidents of BBS require urgent referral to specialist hospital services. Treatment for BBS should be based on assessment and what is deemed the most appropriate for the individual patient.
A national audit/research project is required to establish the level of occurrence of BBS, including the brand of tube, the method of original insertion and resolution of the BBS.
KEY POINTS
- Percutaneous endoscopic gastrostomy (PEG) is a well-established form of artificial nutrition
- Buried bumper syndrome (BBS) is a rare but severe complication relating to this type of feeding tube
- Appropriate training, aftercare and access to support services are essential for preventing BBS and other PEG-related complications
- More research is needed on the incidence of BBS and what may influence it
CPD REFLECTIVE QUESTIONS
- What different types of feeding tubes are you aware of in your practice?
- How would you access support or advice in relation to feeding tubes in your area?
- How does buried bumper syndrome occur?