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Burying of a non-balloon gastrostomy button: An unusual early problem

Neil C. Featherstone, Katherine Burnand, Sulaiman Alazzawi, Thomas Tsang
Department of Paediatric Surgery, Norfolk & Norwich University Hospital, United Kingdom

 

Correspondence 

Katherine Burnand
Department of Paediatric Surgery, Norfolk & Norwich University Hospital,
Colney Lane, Norwich, NR4 7UY, UK
Tel: +44 1603 286286 / Fax: +44 1603 287584
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Abstract

Percutaneous endoscopic gastrostomy tubes are commonly used for long-term feeding in children with neurological disorders. Many are subsequently changed to balloon-button gastrostomies without anaesthesia once the gastrostomy tract is well-formed. Complications include dislodgement because of rupture of the inner balloon, or through accidental removal. As an alternative, non-balloon button gastrostomies have been developed and have greater longevity. We report a case in which burying of a non-balloon button gastrostomy occurs early causing problems with the administration of feeds, inflammation and discomfort for the patient. The insertion of non-balloon gastrostomies can be more challenging and we believe should be done under general anaesthetic to prevent similar complications.

key words: non-balloon gastrostomy button, percutaneous gastrostomy, buried-bumper syndrome

 

Introduction

Gastrostomy tube feeding is commonly used in paediatric patients with neurological disorders or chronic diseases with nutritional impairment. Percutaneous endoscopic gastrostomy was first described by Gauderer et al. in 1980[1]. Many gastrostomy tubes are changed to the balloon-button type once the gastrostomy tract is well-formed [2]. Unfortunately, these devices have limited longevity due to dislodgement through rupture of the inner balloon or accidental removal with deflation [3]. Non-balloon button gastrostomies have been developed in recent years which have a longer life span [4]. We report the case of a patient in whom a non-balloon button was buried in the gastric mucosa only three weeks after placement. This is similar to buried bumper syndrome a late complication following percutaneous gastrostomy but is due to a very different mechanism [5].

Case report

A 13 year old boy with severe learning difficulties and cerebral palsy presented with a three day history of problems with his non-balloon button gastrostomy, it had been inserted three weeks earlier. He had undergone a Nissen fundoplication for gastro-oesophageal reflux nine years earlier. Subsequently, a balloonbutton gastrostomy had been laparoscopically inserted for long-term feeding. Due to frequent dislodgement as a consequence of rupture of the balloon, his gastrostomy had been changed to a non-balloon button type (Fig. 1a) (Mini One TM Non-Balloon Button, Applied Medical Technology Inc., Cleveland, Ohio, USA). The change of gastrostomy had been performed on the paediatric day ward without general anaesthetic and it was noted to be difficult requiring ‘forceful insertion’. Initially his non-balloon button gastrostomy functioned well. However, prior to his presentation, his parents had noted leakage around the gastrostomy and discomfort during the administration of his feeds.

On examination, he appeared comfortable and was apyrexial. His gastrostomy site was slightly red, tender and there was some blood-stained discharge. Normal saline could be flushed through the gastrostomy, but there was some leakage. It was not possible to aspirate gastric contents via the gastrostomy or freely rotate the button. A decision was made to change the non-balloon button gastrostomy using endoscopic guidance under general anaesthetic as it was considered that the non-balloon button gastrostomy may have dislodged from its original position.

Upper gastrointestinal endoscopy revealed a normal oesophagus and stomach. At first, the non-balloon button could not be visualised within the stomach. The buried nonballoon button was shown when it was gently pushed from the outside of the abdominal wall (Fig. 2). The non-balloon device was removed using the insertion / removal tool. This tool normally allows the user to pre-stretch the internal bolster, locking it in the collapsed form, for insertion or removal (Fig.1b). A Hegar dilator was subsequently passed to confirm patency of the gastrostomy tract. This manoeuvre revealed that the gastric mucosa was mobile and acting as a ‘flapvalve’; permitting slow administration of feed, but not aspiration of gastric contents. A new balloon button was inserted under endoscopic guidance. The patient made an uneventful post-operative recovery and was discharged home. His new gastrostomy continues to function well.

8 JPSS 8 1 2010-8-1a

Figure 1a: Non-balloon button gastrostomy (Mini OneTM Non-Balloon Button, Applied Medical Technology Inc., Cleveland, Ohio, USA). 

 

8 JPSS 8 1 2010-8-1b 8 JPSS 8 1 2010-8-2
Figure 1b: The insertion / removal tool in-situ, locking the internal bolster in the collapsed form for insertion / removal of the device.  Figure 2: Endoscopic view  showing the gastric mucosa covering the non-balloon  gastrostomy button

Discussion

Advances in the design of gastrostomy feeding tubes have resulted in an improved quality of life for patients requiring longterm enteral nutrition[2]. However, patients may still experience problems. Balloon-button type gastrostomies have limited longevity [3]; this may be related to rupture of the inner balloon, accidental removal, leak, and damage to the device or obstruction. Non-balloon button low profile devices were developed to overcome problems of dislodgement through failure of the inner balloon or accidental removal [4]. This case highlights an early complication of non-balloon button gastrostomy tubes relating to their insertion and position. Irrespective of a well-formed tract, mucosal undermining could happen in a less than straightforward blind insertion of the non- balloon button gastrostomy. The bolster despite fully-stretched is still more bulky than the deflated balloon button gastrostomy. The undermined edge of the mucosa may have regenerated to give a flap nearly covering the whole internal bolster. This only permitted slow administration of feed and prevented aspiration from the stomach. This process could have happened gradually over the course of three weeks until the ‘burying’ took place.

The restricted flow consequently led to inflammation of the gastrostomy tract which explained the discomfort and blood-stained discharge reported. However, it is possible that the internal bumper (collar) is also too tight, compressing the stomach mucosa. During the endoscopy it was evident that the tube appeared only after it was pushed from outside indicating the tightness of the tube. A late complication of percutaneous inserted gastrostomies is ‘buried bumper syndrome’ within the gastric mucosa but this is due to excessive pressure on the internal bumper on the stomach wall due to over tightening of the external flange [5]. This may trigger irritation to the mucosa, leading to proliferation. High pressure could cause wall necrosis, even result in perforation. Non-balloon button gastrostomy devices require careful insertion. Greater force seems to be required for their insertion despite the internal bolster being locked in the collapsed position compared to balloon button devices. We advocate that their insertion should be performed under general anaesthetic, particularly in smaller children. Where endoscopic facilities are available, it may be advisable to check the gastric placement of the device. Subsequent care should include rotating the device 360 degrees on a daily basis; this should be easy to perform and provides confidence that the device remains in the correct position.

Professionals involved in the care of gastrostomies should be aware of potential problems, and parents or guardians should alert healthcare professionals at their earliest convenience when problems occur. In conclusion the non-balloon button gastrostomy permits gastrostomy tube changes under minimal trauma; however, it cannot be completely eliminated. It is reasonable to perform the gastrostomy tube change under general anaesthesia. The selection of proper size tube, both in length and diameter of the tube, for the patient can significantly reduce the compression, irritation and consequently the proliferation of the stomach mucosa.

 

 

References 

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  3. Michaud L, Guimber D, Blain-Stregloff AS, Ganga-Zandou S, Gottrand F, Turck D. Longevity of balloon-stabilized skin-level gastros- tomy device. J Pediatr Gastroenterol Nutr; 2004(38): 426-9
  4. Heiser M, Malaty H. Balloon-type versus non-balloon-type re- placement percutaneous endoscopic gastrostomy: which is better? Gastroenterol Nurs; 2001(24): 58-63
  5. Lee TH, Lin JT. Clinical Manifestations and management of buried bumper syndrome in patients with percutaneous endoscopic gastrostomy. Gastrointest Endosc; 2008 68(3):580-4