A Novel Approach to Treating Buried Bumper Complicating PEG Gastropexy. These are our disclosures. Endoscopic methods of hiatal hernia anchorage utilizing precutaneous endoscopic gastrostomy, or PEG gastropexy, have been described in surgically challenging patients. However, PEG insertion may be complicated by buried bumper syndrome, which can be life-threatening. We describe the use of PEG, endoscopic suturing, and a repurposed JP drain bulb to manage buried bumper syndrome and promote ulcer healing in a 62-year-old female. Our patient is a 62-year-old female with morbid obesity and BMI of 36, who presented with episodic upper abdominal pain and a large type 2 paroxysophageal hernia. She underwent endoscopic PEG gastropexy due to complex anatomy and high surgical risk. One week post-procedure, the patient presented with low-grade fevers and light pink purulence around the PEG tube site. CT revealed inflammation surrounding the PEG tube site without free air, and cultures grew Klebsiella aerogenes, E. canella corrodens, and Streptococcus mitis. The patient was placed on broad-spectrum antibiotics. An endoscopy was performed, which revealed a buried bumper with associated PEG-related ulceration. A larger bumper was created, which was cut from a medical-grade JP drain bulb. The larger bumper was placed over the original bumper of a new 20-French gastrostomy tube and endoscopic suturing was used to repair the bumper ulcer. A large type 2 paroxysophageal hernia was observed on endoscopy along with a buried PEG bumper and associated ulceration. The PEG tube was removed back into the stomach and then removed entirely. The endoscopy team created a larger bumper, which was cut from a JP drain bulb, and the larger bumper was placed over the original bumper of the new gastrostomy tube. Furthermore, the PEG site ulcer was repaired with endoscopic suturing using a single-running 2-O polypropylene suture. The final location of the modified peg bumper is shown, along with a repaired ulcer by endoscopic suturing. This is the image of the larger bumper encapsulating the smaller peg bumper for the treatment of Barrett bumper syndrome. This approach for this challenging situation allowed for ongoing apposition of the stomach and the abdominal wall and the redistribution of peg traction forces to allow for ulcer healing. The patient's condition continued to improve and endorsed minimal pain post procedurally. CT prior to discharge confirmed proper placement of the peg tube and the patient was discharged home one week later on outpatient antibiotics with initial symptoms resolved. The tube is projected to stay in place for at least six months to allow for adhesions to form between the stomach and abdominal wall to create an endoscopic gastropexy. Treatment of Barrett bumper is challenging in the acute setting after peg tube placement as gastric to abdominal wall apposition is needed to prevent leak. Our novel approach to this challenging situation uses standard endoscopic suturing and a repurposed JP drain bulb to ensure ongoing apposition of the stomach to the abdominal wall and redistribution of peg traction forces to allow for ulcer healing. In conclusion, peg tube placement including peg gastropexy as shown may be complicated by Barrett bumper. Treatment of Barrett bumper may be challenging and a novel treatment approach utilizing endoscopic suturing and a repurposed JP drain bulb is presented.

case study

62-year-old female patient

endoscopic PEG gastropexy

paroxysophageal hernia

buried bumper