Comparison of removal techniques in the management of buried bumper syndrome: a retrospective cohort study of 82 patients.

BACKGROUND AND STUDY AIMS: Buried bumper syndrome is an infrequent complication of percutaneous endoscopic gastrostomy (PEG) that can result in tube dysfunction, gastric perforation, bleeding, peritonitis or death. The aim of this study was to compare the efficacy of different PEG tube removal methods in the management of buried bumper syndrome in a large retrospective cohort. PATIENTS AND METHODS: From 2002 to 2013, 82 cases of buried bumper syndrome were identified from the databases of two endoscopy referral centers. We evaluated the interval between gastrostomy tube placement and diagnosis of buried bumper syndrome, type of treatment, success rate and complications. Four methods were analyzed: bougie, grasp, needle-knife and minimally invasive push method using a papillotome, which were selected based on the depth of the buried bumper. RESULTS: The buried bumper was cut free with a wire-guided papillotome in 35 patients (42.7 %) and with a needle-knife in 22 patients (26.8 %). It could be pushed into the stomach with a dilator without cutting in 10 patients (12.2 %), and was pulled into the stomach with a grasper in 12 patients (14.6 %). No adverse events (AEs) were registered in 70 cases (85.4 %). Bleeding occurred in 7 patients (31.8 %) after cutting with a needle-knife papillotome and in 1 patient (8.3 %) after grasping. No bleeding was recorded after using a standard papillotome or a bougie ( P  < 0.05). Ten of 22 patients (45.5 %) treated with the needle-knife had a serious AE and 1 patient died (4.5 %). CONCLUSIONS: We recommend that incomplete buried bumpers be removed with a bougie. In cases of complete buried bumper syndrome, the bumper should be cut with a wire-guided papillotome and pushed into the stomach.

Acute phase reaction to gadolinium-DTPA in dialysis patients.

BACKGROUND: Several late sequelae of the administration of gadolinium (Gd)-containing MRI contrast agents have been described in patients with advanced renal failure. In an observational series, we found a remarkable frequency of peracute reactions after administration of Gd-DTPA used for cardiovascular evaluation before renal transplantation. METHODS: In a 26-month observational period, 13 of 136 haemodialyzed or CAPD patients exhibited onset of fever, chills and nausea within hours after administration of Gd-DTPA peracute. A minority showed persistent cessation of residual diuresis. We performed blood cultures in most patients and evaluated white blood cell (WBC) counts, eosinophils, CRP, heart rate and blood pressure. RESULTS: Within an average of 12 h (range 12-36 h) after Gd administration, the 13 patients (9 males, 4 females; median age 61 years, range 47-79) developed consistent symptomatology with fever (median 39.0 degrees C, range 37.5-39.5), chills, malaise, hypotension, vomiting, dyspnoea-initially raising suspicion of septicaemia. Subsequent blood cultures on bacterial contamination of the injected product remained negative throughout; bacterial or endotoxin contamination of the reagent was excluded. Steroids were tried in the first two patients without a noticeable effect. In all subsequent patients, symptoms were attenuated during the first 5 h dialysis (F60HPS with 280 ml/min blood flow) and disappeared within 72 h. CRP levels remained markedly elevated up to 14 days. Lymphopenia was seen in all patients, and polymorphic neutrophils (PMN) remained normal. Two polyuric patients developed persistent anuria. After a median of 16 months, none of these patients developed nephrogenic systemic fibrosis. CONCLUSION: This series with unusually severe acute phase reactions was caused by one specific preparation. Such peracute reactions may be relevant for the so-far largely unresolved pathogenesis of the skin reaction to some Gd products in end-stage renal disease (ESRD) patients. It remains unresolved whether the reaction observed with Gd-DTPA do in principle also occur with other Gd reagents.