Buried bumper syndrome: A critical analysis of endoscopic release techniques

Buried bumper syndrome (BBS) is the situation in which the internal bumper of the gastrostomy tube, due to prolonged compression of the tissues between the external and the internal bumper, migrates from the gastric lumen into the gastric wall or further, into the tract outside the gastric lumen, ending up anywhere between the stomach mucosa and the surface of the skin. This restricts liquid food from entering the stomach, since the internal opening is obstructed by gastric mucosal overgrowth. We performed a comprehensive search of the PubMed literature to retrieve all the case-reports and case-series referring to BBS and its management, after which we focused on the endoscopic techniques for releasing the internal bumper to re-establish the functionality of the tube. From the "push" and the "push and pull T" techniques to the most sophisticated-using high tech instruments, all 10 published techniques have been critically analysed and the pros and cons presented, in an effort to optimize the criteria of choice based on maximum efficacy and safety.