Buried bumper syndrome (BBS) occurs due to the overgrowth of gastric mucosa over the inner bumper of a gastrostomy tube. Various therapeutic approaches have been described for the management of BBS. However, no standardized clinical protocol deals with this complication. The authors describe their experience of dealing with BBS. Case notes of the patients undergoing percutaneous endoscopic gastrostomy (PEG) between February 2002 and December 2007 at their institute were reviewed retrospectively, and cases of BBS were analyzed. During this 71-month period, 356 PEG procedures were preformed. Seven patients with BBS were identified from the case note review (incidence of 1.97%). Attempts at endoscopic removal of the buried bumper were made but unfortunately failed. In view of the patients' associated comorbidity, the buried bumpers in these patients were left in situ, and a new PEG was inserted adjacent to the first site in 6 individuals. In 1 patient, a jejunal extension tube was inserted through the original PEG tube for feeding. No complications from the buried bumper arose in these patients during a median follow-up of 18 months (range, 1-46 months). Some patients being fed by a PEG tube are in poor general health and have significant comorbidities. They are therefore poor candidates for surgical or endoscopic removal of a buried bumper. In such patients, leaving the internal bumper in situ should be considered as a relatively safe treatment option.

Follow-up data provide further evidence that the "cut and push" method is a safe and cost-effective method for removing 15 Fr PEG tubes in adult patients and that an abdominal radiograph is not routinely required.

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Gastrostomy tubes can be inserted either endoscopically or radiologically, depending on practicality of insertion and clinical need (1)(2)(3) . This study aims to compare complications of PEG and RIG procedures and also to compare pain experienced post-procedure. The standard is for the patient to be pain-free post insertion. We looked at whether the presence of pain and significant complications may affect the decision as to which type of gastrostomy should be used.A retrospective 3-year study in 2004 at Ipswich Hospital NHS Trust highlighted that following 50 PEG insertions there were three complications, two minor and one major (a mesenteric bleed requiring laparotomy). Our 3-year retrospective study in 2009 highlighted that following 37 RIG insertions (78 % inserted for head and neck cancers, 22 % for stroke, other reasons included motor neurone disease and cerebral palsy), there were 13 complications of which two were major (both laparotomies for leak of gastric contents). This indicates a major complication rate of 2 % in PEGs compared to 5.4 % in RIGs. Minor complications included wound infection, gastrostomy stoma site leak, tube displacement or blockage and post-procedure pain. No 30-day mortality occurred following either procedure.A six-month prospective audit was carried out to compare pain perception with the use of a questionnaire 4 h post-procedure and on the following day. There were 13 PEG insertions (76 % stroke patients, others were for motor neurone disease, head injury and head and neck cancer) and seven RIG insertions (all for head and neck cancers). A larger proportion of RIG patients reported pain both at 4 h (43 % compared to 38 % of PEG patients) and the following day (14% compared to 8 % of PEG patients), and these patients were noted to require more analgesia. This may have been due to the type of local anaesthetic used, need for tract dilatation during RIG insertion and the use of suture anchors.At Ipswich Hospital, RIGs insertions carry a higher complication rate and cause more pain when compared to PEGs. RIGs are mostly used for patients with head and neck cancers which may carry a risk of tumour seeding if an endoscopic approach is undertaken. In conclusion, PEGs are the preferred route for enteral feeding in the majority of patients unless contra-indicated by clinical need.

Following this retrospective look at our own patient cohort, we are now reviewing all our long-term PEG feeding patients after 3 years, and if patients are deemed to need to continue with PEG feeding, they are considered for an elective change of PEG. We will be reviewing whether this elective change of PEG will reduce the incidence of BBS and will report on this in the future.