{"id":4349,"date":"2016-03-30T10:00:10","date_gmt":"2016-03-30T10:00:10","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/buried-bumper-syndrome-diagnostico-e-manejo\/"},"modified":"2022-06-17T15:32:42","modified_gmt":"2022-06-17T15:32:42","slug":"buried-bumper-syndrome-diagnostico-e-manejo","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/buried-bumper-syndrome-diagnostico-e-manejo\/","title":{"rendered":"&#8220;BURIED BUMPER SYNDROME\u201d : Diagn\u00f3stico e manejo."},"content":{"rendered":"<p class=\"Corpo\" style=\"text-align: left;\" align=\"center\"><span style=\"text-decoration: underline;\"><strong><span lang=\"EN-US\">INTRODU\u00c7\u00c3O<\/span><\/strong><\/span><\/p>\n<p style=\"text-align: justify;\">A buried bumper syndrome (BBS) \u00e9 uma complica\u00e7\u00e3o decorrente da gastrostomia endosc\u00f3pica percut\u00e2nea, e consiste no crescimento de mucosa g\u00e1strica sobre o anteparo interno da gastrostomia com alojamento do mesmo em qualquer local no trajeto formado pela sonda, desde as camadas da parede g\u00e1strica at\u00e9 as da parede abdominal. Com incid\u00eancia variando de &nbsp;0,9 a &gt; 8,8%, \u00e9 tipicamente tardia (ap\u00f3s 3 a 6 meses), mas tamb\u00e9m foram descritos casos precoces, ap\u00f3s 15 a 30 dias da gastrostomia. (1,2)<\/p>\n<p><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/BBS.png\" data-rel=\"penci-gallery-image-content\"  rel=\"attachment wp-att-5504\"><img fetchpriority=\"high\" decoding=\"async\" class=\"wp-image-5504 size-full aligncenter\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/BBS.png\" alt=\"BBS\" width=\"976\" height=\"360\"><\/a><\/p>\n<p style=\"text-align: justify;\">Clinicamente se caracteriza pela progressiva oclus\u00e3o do orif\u00edcio interno do anteparo pela mucosa g\u00e1strica, com consequente dificuldade\/parada completa na infus\u00e3o da dieta, dor abdominal durante a infus\u00e3o, sinais flog\u00edsticos no orif\u00edcio da pele e dificuldade na mobiliza\u00e7\u00e3o manual do anteparo na tentativa de empurr\u00e1-lo para a cavidade g\u00e1strica ou realizar movimento rotacional.<\/p>\n<p style=\"text-align: justify;\">Tra\u00e7\u00e3o excessiva \u00e9 o principal fator causal, mas outros tamb\u00e9m devem ser considerados, como ganho de peso em resposta \u00e0 alimenta\u00e7\u00e3o enteral, tosse severa, etc. Na presen\u00e7a dos sinais e sintomas sugestivos, a endoscopia deve ser realizada para diagn\u00f3stico e planejamento terap\u00eautico.<\/p>\n<p style=\"text-align: justify;\">Na maioria dos casos o anteparo interno sepultado \u00e9 retirado atrav\u00e9s de uma incis\u00e3o externa no local da entrada da sonda na pele sob anestesia local ou laparotomia. Essa abordagem pode resultar em dor local, infec\u00e7\u00e3o de ferida ou f\u00edstula gastrocut\u00e2nea.<\/p>\n<p style=\"text-align: justify;\">Tendo em vista um tratamento menos invasivo nestes pacientes, foram propostas uma s\u00e9rie de alternativas endosc\u00f3picas.<\/p>\n<p style=\"text-align: justify;\"><span style=\"text-decoration: underline;\"><strong>T\u00c9CNICAS&nbsp;<\/strong><\/span><\/p>\n<p style=\"text-align: justify;\">As t\u00e9cnicas j\u00e1 descritas consistem em:<\/p>\n<ul style=\"text-align: justify;\">\n<li>Passagem de fio guia atrav\u00e9s da sonda at\u00e9 o orif\u00edcio do anteparo interno servindo de guia para dilatadores de Savary-Gilliard introduzidos pelo tubo j\u00e1 previamente cortado pr\u00f3ximo \u00e0 pele para aplicar press\u00e3o externa no anteparo e empurr\u00e1-lo pra a c\u00e2mara g\u00e1strica (3,4).<\/li>\n<\/ul>\n<ul>\n<li style=\"text-align: justify;\">Incis\u00f5es radiais da mucosa g\u00e1strica com needle-knife para exposi\u00e7\u00e3o do anteparo quando este est\u00e1 pouco vis\u00edvel (utilizando-se fio guia, azul de metileno, pin\u00e7a de bi\u00f3psia, etc para identifica\u00e7\u00e3o do orif\u00edcio interno como refer\u00eancia), e posterior apreens\u00e3o do mesmo. Se necess\u00e1rio o orif\u00edcio feito atrav\u00e9s das incis\u00f5es pode ser ampliado com dilata\u00e7\u00e3o por bal\u00e3o (5,6,10).<\/li>\n<\/ul>\n<p><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/bbs3.png\" data-rel=\"penci-gallery-image-content\"  rel=\"attachment wp-att-5483\"><img decoding=\"async\" class=\"aligncenter wp-image-5483 size-full\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/bbs3.png\" alt=\"bbs3\" width=\"819\" height=\"609\"><\/a><\/p>\n<ul>\n<li style=\"text-align: justify;\">&#8220;Push-pull T technique\u201c &#8211; uma al\u00e7a de polipectomia \u00e9 passada atrav\u00e9s do orif\u00edcio interno do anteparo (com ou sem ajuda de um fio guia) e se exterioriza pelo tubo na parede abdominal previamente cortado. A al\u00e7a captura um peda\u00e7o do tubo removido e \u00e9 realizada uma tra\u00e7\u00e3o do conjunto para dentro do est\u00f4mago e ele \u00e9 retirado pela boca (7)<\/li>\n<\/ul>\n<p><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/bbs4.png\" data-rel=\"penci-gallery-image-content\"  rel=\"attachment wp-att-5484\"><img decoding=\"async\" class=\"aligncenter wp-image-5484 size-full\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/bbs4.png\" alt=\"bbs4\" width=\"510\" height=\"463\"><\/a><\/p>\n<ul>\n<li style=\"text-align: justify;\">Uso de novo kit de gastrostomia para retirada do anteparo e troca no mesmo tempo. Realiza-se corte da sonda de gastrostomia a 3 cm da pele e introdu\u00e7\u00e3o por ela da agulha dispon\u00edvel no kit para passagem do fio guia pelo orif\u00edcio do anteparo interno para a cavidade g\u00e1strica. Captura do fio com al\u00e7a, retirada do mesmo pela boca e introdu\u00e7\u00e3o de nova sonda guiada para o est\u00f4mago, cuja extremidade afilada se encaixa na sonda antiga e \u00e9 realizada a tra\u00e7\u00e3o do fio guia ao n\u00edvel da pele (podendo ser realizada incis\u00e3o na pele para sa\u00edda do anteparo se necess\u00e1rio) (8,9).<\/li>\n<\/ul>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter wp-image-5485 size-full\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/bbs5.png\" alt=\"bbs5\" width=\"481\" height=\"455\"><\/p>\n<ul>\n<li style=\"text-align: justify;\">Uso de bal\u00e3o dilatador. Corte da sonda de gastrostomia 3 cm acima da pele e introdu\u00e7\u00e3o de fio guia. Passagem de bal\u00e3o dilatador de 18 mm por sobre o guia, atrav\u00e9s do endosc\u00f3pio, com insufla\u00e7\u00e3o do mesmo dentro do orif\u00edcio do anteparo interno at\u00e9 sua reten\u00e7\u00e3o total dentro da sonda. Tra\u00e7\u00e3o do conjunto endosc\u00f3pio + bal\u00e3o permite a tra\u00e7\u00e3o&nbsp;do anteparo para dentro do est\u00f4mago, posterior retirada pela boca, com introdu\u00e7\u00e3o de nova sonda de gastrostomia com o mesmo fio guia durante o mesmo procedimento (11,12).<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<div style=\"width: 854px;\" class=\"wp-video\"><video class=\"wp-video-shortcode\" id=\"video-4349-1\" width=\"854\" height=\"480\" preload=\"metadata\" controls=\"controls\"><source type=\"video\/mp4\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2016\/03\/V\u00eddeo-BBS.mp4?_=1\" \/><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2016\/03\/V\u00eddeo-BBS.mp4\">https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2016\/03\/V\u00eddeo-BBS.mp4<\/a><\/video><\/div>\n<p>&nbsp;<\/p>\n<ul>\n<li style=\"text-align: justify;\">Uso de papil\u00f3tomo. Introdu\u00e7\u00e3o do papil\u00f3tomo via sonda de gastrostomia cortada para realizar incis\u00f5es radiais na mucosa recobrindo o anteparo para exp\u00f4-lo (13,14).<\/li>\n<\/ul>\n<ul>\n<li>ESD (endoscopic submucosal dissection). Dissec\u00e7\u00e3o submucosa at\u00e9 exposi\u00e7\u00e3o do anteparo (16).<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p style=\"text-align: justify;\">Foram propostas formas de avalia\u00e7\u00e3o do grau de migra\u00e7\u00e3o do anteparo para planejamento&nbsp; terap\u00eautico pelo poss\u00edvel risco de perfura\u00e7\u00e3o dependendo de sua localiza\u00e7\u00e3o. Branden et al. e Tanaka et al. (6,17) sugeriram avalia\u00e7\u00e3o por ultrassom endosc\u00f3pico para determina\u00e7\u00e3o de posi\u00e7\u00e3o intramural (profundamente na mucosa hipertrofiada ou dentro das camadas musculares) ou extramural (entre as paredes g\u00e1strica e abdominal), para decis\u00e3o de tratamento endosc\u00f3pico ou cir\u00fargico respectivamente.<\/p>\n<p>Publica\u00e7\u00e3o recente (15) sugere uma classifica\u00e7\u00e3o (Richter-Schrag) baseada nos achados endosc\u00f3picos para planejamento terap\u00eautico:<\/p>\n<p><strong>IA &#8211; Extracorporal parcial, localizada no subcut\u00e2neo \/&nbsp;IB &#8211; Extracorporal total :&nbsp;<\/strong>Incis\u00e3o para retirada, com cicatriza\u00e7\u00e3o e conduta dependendo da presen\u00e7a ou n\u00e3o de f\u00edstula gastrocut\u00e2nea.<\/p>\n<p class=\"Corpo\" style=\"text-align: justify;\"><span lang=\"EN-US\"><strong>II &#8211; Localizada na submucosa g\u00e1strica, anteparo parcialmente vis\u00edvel pela EDA, bom grau de mobiliza\u00e7\u00e3o por press\u00e3o externa<\/strong>. Tratamento endosc\u00f3pico &#8211; geralmente a retirada \u00e9 poss\u00edvel com enrijecimento da sonda (guia ou ba<\/span><span lang=\"EN-US\">l\u00e3o) e press\u00e3o para l\u00famen g\u00e1strico.<\/span><\/p>\n<p style=\"text-align: justify;\"><strong>III &#8211; Localizado na submucosa g\u00e1strica podendo envolver parcialmente muscular, anteparo n\u00e3o vis\u00edvel, com ou sem fistula interna, boa mobiliza\u00e7\u00e3o.<\/strong> Tratamento endosc\u00f3pico &#8211; dissec\u00e7\u00e3o da mucosa\/submucosa para exposi\u00e7\u00e3o do anteparo e realiza\u00e7\u00e3o de manobra descrita na classifica\u00e7\u00e3o anterior.<\/p>\n<p style=\"text-align: justify;\"><strong>IV &#8211; Localiza\u00e7\u00e3o fora da parede g\u00e1strica, anteparo n\u00e3o vis\u00edvel, com ou sem f\u00edstula interna (que pode ser tangencial ao \u00f3stio do anteparo), mobiliza\u00e7\u00e3o ruim ou inexistente.<\/strong> Tratamento &#8211; devido \u00e0 sua localiza\u00e7\u00e3o profunda e muitas vezes imprecisa, tem alto risco de complica\u00e7\u00f5es no tratamento endosc\u00f3pico (perfura\u00e7\u00e3o, sangramento de dif\u00edcil controle, etc). Geralmente optado por tratamento cir\u00fargico.<\/p>\n<div id=\"attachment_5522\" style=\"width: 1010px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/Buried-Bumper.png\" data-rel=\"penci-gallery-image-content\"  rel=\"attachment wp-att-5522\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-5522\" class=\"wp-image-5522 size-full\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/Buried-Bumper.png\" alt=\"A: Sonda de GTT com posicionamento adequado. B: Sonda localizada na submucosa g\u00e1strica, anteparo parcialmente vis\u00edvel, classifica\u00e7\u00e3o II de Richter-Schrag. C: Sonda localizada na submucosa g\u00e1strica, anteparo n\u00e3o vis\u00edvel, classifica\u00e7\u00e3o III de Richter-Schrag.\" width=\"1000\" height=\"336\"><\/a><p id=\"caption-attachment-5522\" class=\"wp-caption-text\">A: Sonda de GTT com posicionamento adequado. B: Sonda localizada na submucosa g\u00e1strica, anteparo&nbsp;parcialmente vis\u00edvel, classifica\u00e7\u00e3o II de Richter-Schrag. C: Sonda localizada na submucosa g\u00e1strica, anteparo n\u00e3o vis\u00edvel, classifica\u00e7\u00e3o III de Richter-Schrag.<\/p><\/div>\n<p>&nbsp;<\/p>\n<p><span style=\"text-decoration: underline;\"><strong>PREVEN\u00c7\u00c3O<\/strong><\/span><\/p>\n<p style=\"text-align: justify;\">Para prevenir tal complica\u00e7\u00e3o, s\u00e3o recomendadas as seguintes medidas (5,6):<\/p>\n<ul>\n<li style=\"text-align: justify;\">No momento da confec\u00e7\u00e3o da PEG, o anteparo externo deve ser fixado justo \u00e0 pele (mas o suficiente para ainda ser poss\u00edvel realizar movimento de rota\u00e7\u00e3o com o anteparo interno na vis\u00e3o endosc\u00f3pica) para boa aposi\u00e7\u00e3o da parede g\u00e1strica na abdominal. Nos pr\u00f3ximos dias o anteparo deve ser afastado aproximadamente 0,5 a 1 cm da pele para evitar isquemia e necrose por press\u00e3o.<\/li>\n<li style=\"text-align: justify;\">Os cuidadores devem ser orientados a, no momento da limpeza do local, se assegurar que a sonda se move para dentro e para fora por no m\u00ednimo 1 cm e que realiza movimentos rotacionais com um m\u00ednimo de resist\u00eancia.<\/li>\n<li style=\"text-align: justify;\">Quando a sonda n\u00e3o est\u00e1 em uso ela deve ser coberta para prevenir tra\u00e7\u00e3o inadvertida por parte do paciente.<\/li>\n<li style=\"text-align: justify;\">Qualquer restri\u00e7\u00e3o de movimento da sonda, dificuldade de passagem da dieta, vazamento ou dor local devem ser prontamente avaliados.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p><strong>REFER\u00caNCIAS<\/strong><\/p>\n<p>&nbsp;<\/p>\n<ol>\n<li style=\"text-align: justify;\">Lee TH, Lin JT. Clinical manifestations and management of buried bumper&nbsp;syndrome in patients with percutaneous endoscopic gastrostomy. Gastrointest Endosc. 2008;68:580\u2013584<\/li>\n<\/ol>\n<ol style=\"text-align: justify;\" start=\"2\">\n<li>Ma MM, Semlacher EA, Fedorak RN et al. The buried gastrostomy bumper syndrome: prevention and endoscopic approaches to removal. Gastrointest Endosc 1995;41:505\u2013508<\/li>\n<\/ol>\n<ol style=\"text-align: justify;\" start=\"3\">\n<li>Klein S, Heare BR, Soloway RD. The &#8220;buried bumper syndrome&#8221;: a complication of percutaneous endoscopic gastrostomy. Am J Gastroenterol 1990;85:448\u2013450<\/li>\n<\/ol>\n<ol start=\"4\">\n<li style=\"text-align: justify;\">Gumaste VV, Krachman M, Pottipati A, Dave P. Removal of an embedded PEG bumper. Gastrointest Endosc 1993;93:598-9.<\/li>\n<\/ol>\n<ol start=\"5\">\n<li style=\"text-align: justify;\">Ma MM, Semlacher EA, Fedorak RN et al. The buried gastrostomy bumper syndrome: prevention and endoscopic approaches to removal. Gastrointest Endosc 1995;41:505\u2013508<\/li>\n<\/ol>\n<ol style=\"text-align: justify;\" start=\"6\">\n<li>Braden B, Brandstaetter M, Caspary WF et al. Buried bumper syndrome: treatment guided by catheter probe US. Gastrointest Endosc 2003;57:747\u2013751<\/li>\n<\/ol>\n<ol style=\"text-align: justify;\" start=\"7\">\n<li>Boyd JW, DeLegge MH, Shamburek RD et al. The buried bumper syndrome: a new technique for safe, endoscopic PEG removal. Gastrointest Endosc 1995;41:508\u2013511<\/li>\n<\/ol>\n<ol start=\"8\">\n<li style=\"text-align: justify;\">Venu RP, Brown RD, Pastika BJ, Erikson LW (2002) The buried bumper syndrome: a simple management approach in two patients. Gastrointest Endosc 56:582\u2013584<\/li>\n<\/ol>\n<ol start=\"9\">\n<li style=\"text-align: justify;\">Fay DE, Luther R, Gruber M. A single procedure endoscopictechnique for replacing partially extruded percutaneousendoscopic gastrostomy tubes. Gastrointest Endosc 1990;36:298-300.<\/li>\n<\/ol>\n<ol style=\"text-align: justify;\" start=\"10\">\n<li>Sauer B, Staritz M. Buried bumper: a new method of non-surgical removal. Z Gastroenterol 2004;42:227\u2013232<\/li>\n<\/ol>\n<ol style=\"text-align: justify;\" start=\"11\">\n<li>Strock P, Weber J (2005) Buried bumper syndrome: endoscopic management using a balloon dilator. Endoscopy 2005;37:279<\/li>\n<\/ol>\n<ol start=\"12\">\n<li style=\"text-align: justify;\">Christiaens P, Bossuyt P, Cuyle P-J et al (2014) Buried bumper syndrome: single-step endoscopic management and replacement. Gastrointest Endosc 2014;80:336<\/li>\n<\/ol>\n<ol start=\"13\">\n<li style=\"text-align: justify;\">M\u00fcller-Gerbes D, Aymaz S, Dormann AJ. Management of the buried bumper syndrome: a new minimally invasive technique \u2013 the push method. Z Gastroenterol 2009;47:1145\u20131148<\/li>\n<\/ol>\n<ol style=\"text-align: justify;\" start=\"14\">\n<li>Cyrany R, Repak T, Douda T et al. Cannulotome introduced via a percutaneous endoscopic gastrostomy (PEG) tube. Endoscopy 2012;44:E422\u2013E423<\/li>\n<\/ol>\n<ol style=\"text-align: justify;\" start=\"15\">\n<li>Richter-Schrag H J, Fischer A. Buried bumper syndrome: a new classification and therapy algorithm. Chirurg 2015;86(10):963-9<\/li>\n<\/ol>\n<ol start=\"16\">\n<li style=\"text-align: justify;\">Curcio G, Granata A, Ligresti D, Tarantino I, Barresi L, Traina M. Buried bumper syndrome treated with HybridKnife endoscopic submucosal dissection. Gastrointest Endosc 2014; 80: 916-7<\/li>\n<\/ol>\n<ol start=\"17\">\n<li style=\"text-align: justify;\">Tanaka Y, Akahoshi K, Motomura Y et al. Pretherapeutic evaluation of buried bumper syndrome by endoscopic ultrasonography. Endoscopy 2012;44:E162<\/li>\n<\/ol>\n<p>&nbsp;<\/p>\n<p><strong><i>Postado<\/i> <i>por<\/i><\/strong><\/p>\n<p><strong>Thienes Maria da Costa Lima<\/strong><\/p>\n<p>M\u00e9dica do Servi\u00e7o de Endoscopia Digestiva do Hospital Nossa Senhora das Gra\u00e7as &#8211; Curitiba\/PR<\/p>\n<p>Especializa\u00e7\u00e3o em Endoscopia Digestiva pelo Hospital das Cl\u00ednicas da Universidade de S\u00e3o Paulo (USP)<\/p>\n","protected":false},"excerpt":{"rendered":"<p>INTRODU\u00c7\u00c3O A buried bumper syndrome (BBS) \u00e9 uma complica\u00e7\u00e3o decorrente da gastrostomia endosc\u00f3pica percut\u00e2nea,&hellip;<\/p>\n","protected":false},"author":4831,"featured_media":4411,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[151],"tags":[],"ano":[281],"tipo":[153],"volume":[263],"class_list":["post-4349","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-assuntosgerais","ano-281","tipo-endoscopia-digestiva-alta","volume-volume-i"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.2 (Yoast SEO v27.4) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>&quot;BURIED BUMPER SYNDROME\u201d : Diagn\u00f3stico e manejo. &#8226; Endoscopia Terapeutica<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" 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