PTH-062 Endoscopic management of buried bumper syndrome (BBS) using a dedicated resection device: the ‘Flamingo Set’

Introduction Buried bumper syndrome (BBS) is an uncommon complication of percutaneous endoscopic gastrostomy (PEG) placement, with an incidence of 1%. Several techniques for endoscopic management of BBS have been described, given the absence of a dedicated device to date. Methods A 94-year-old man presented with fever and PEG obstruction. A PEG had been placed in 2014 for enteral feeding in the context of dysphagia, secondary to Parkinson’s disease. On examination, the cutaneous side of the PEG tract appeared erythematous and oedematous, with seepage of purulent mucus; any attempt to mobilise the PEG tube though external manipulation proved futile. Results At upper gastrointestinal (GI) endoscopy, a 4 cm elevated area of granulomatous tissue with a central depression was identified on the proximal anterior wall of the gastric antrum, confirming the suspected diagnosis of BBS. A 2.5 mm ball-tip, needle-type knife was initially used to incise the granulomatous tissue, allowing intra-gastric passage of a guidewire, pushed through the cutaneous aspect of the PEG tract. The use of a novel, sphincterotome-like, dedicated device, designed for radial incision of BBS-related intra-gastric granulomatous tissue (Flamingo Set, Medwork, Hochstadt, Germany) was then applied. This device was inserted over the guidewire into the stomach, through the external aspect of the partially cut PEG tube. The guidewire was subsequently withdrawn and the distal part of the Flamingo device was flexed by 180°, exposing the bow-string, sphincterotome-like, cutting wire. External traction was then applied to the Flamingo device from the cutaneous side of the PEG tract. Optimal apposition of the cutting wire and the granulomatous tissue was achieved through direct endoscopic visualisation. The overgrown tissue was then incised by a series of radial cuts until the plastic bumper was exposed. The PEG bumper and remnant of the externally cut PEG tube was then released into the gastric lumen through gentle, external manipulation. As a pre-cautionary measure, the excision site was partially closed by deployment of through-the-scope endoclips. The whole procedure was performed under conscious sedation and broad-spectrum, intravenous antibiotic prophylaxis; no immediate, early or late adverse events were encountered. A new PEG insertion was successfully achieved at an alternative site, 2 weeks later. Conclusions To the best of our knowledge, this is the first use of the ‘Flamingo Set’ for BBS. Through our preliminary experience, this novel, dedicated device appears to be user-friendly, safe, quick and effective for minimally invasive, endoscopic management of BBS and warrants further study.