Evaluate risk for sedation and potential problems related to pre-existing medical conditions.

Perform a focused physical examination on elements that could impact sedation (eg, history of stridor, sleep apnoea, former adverse reaction to sedation or anaesthesia, oral or neck abnormalities, tobacco use).

Presence of a sedation team with appropriate education and training with at least one person qualified in advanced life support skills throughout (propofol) sedation.

Provide age-appropriate equipment for airway management and resuscitation.

Avoid excessive tension of the external bumper against the skin. Immediately after placement of the PEG, the external bumper should be subjected to very low traction, without tension.

Rotate the tube daily but importantly: move the tube inwards (at least 2 cm, up to 10 cm) once the gastrostomy tract has been healed (after about 7–10 days).

After mobilisation, return the tube to its initial position with some free distance (1–2 cm) between the skin and the external bumper.

Correct coagulopathy before the procedure: recommended threshold for the procedure is a platelet count of 50.000/ɥL and INR <1,5.

Patients on P2Y12 receptor antagonist antiplatelet agents with low thrombotic risk:

• Discontinue P2Y12 receptor antagonists (clopidogrel, prasugrel, ticagrelor) 5 days before the procedure.

• Low-dose aspirin is no contraindication and should not be discontinued.

Patients on P2Y12 receptor antagonist antiplatelet agents with high thrombotic risk (coronary artery stents):

• Continue aspirin and liaise with a cardiologist about the risk/benefit of discontinuation of P2Y12 receptor antagonist.

Patients on direct oral anticoagulants (DOAC):

• Discontinue DOAC (dabigatran, rivaroxaban, apixaban, edoxaban) ≥48 hours before the procedure.

  • For dabigatran with CrCl (eGFR) 30–50 mL/min take last dose of drug 72 hours before procedure

Patients on warfarin with low-risk condition:

• Stop warfarin 5 days before the procedure.

  • Check INR prior to procedure to ensure INR <1.5

  • Restart warfarin evening of procedure with usual daily dose

  • Check INR 1 week later to ensure adequate anticoagulation

Patients on warfarin with high-risk condition:

• Stop warfarin 5 days before the procedure.

  • Start LMWH 2 days after stopping warfarin

  • Give last dose of LMWH ≥24 hours before the procedure

  • Restart warfarin evening of procedure with usual daily dose

  • Continue LMWH until INR adequate

Consider the use of abdominal binders, an elastic bandage and clinical restraints to prevent access to the tube.

Tailor the tube at a length that allows adequate care but also restricts access.

Assure that the external bumper is appropriately positioned (with too much free space the internal bumper can migrate forward).

Rotate the tube daily but more importantly, move the tube inwards (at least 2 cm, up to 10 cm) once the gastrostomy tract has been healed (after about 7–10 days).

Return the tube after mobilisation to its initial position with some free distance (1–2 cm) between the skin and the external bumper.

Use intravenous antibiotic (penicillin-based or cephalosporin-based) administration 30 min before the PEG procedure.

Apply standard measures for infection prevention including aseptic preparation of the surgical field and preoperative handwashing/disinfection.

Use of a mouthwash with an oral chlorhexidine solution to reduce bacterial burden.

Avoid traction on the gastrostomy and excessive pressure between the internal and external bumper.

See prevention in ‘necrotising fasciitis’.

Perform a proper risk assessment in patients with (mild) ascites.

Be extra cautious in patients with previous upper abdominal surgery or pathology.

Position the patient in a reverse or antitrendelenburg position during the procedure.

Choose an appropriate gastrostomy tube site.

Provide full gastric insufflation to displace the colon during endoscopy.

Check for proper transillumination through the abdominal wall of the light source at the distal tip of the gastroscope.

Ensure endoscopic visible imprint of a finger palpation on the skin.

Establish a ‘safe tract’ technique: endoscopic visualisation of a needle (eg, syringe filled with saline or local anaesthetic) and simultaneous return of air into the syringe. Return of fluid or gas into the syringe prior to endoscopic visualisation of the needle in the gastric lumen suggests entry into bowel interposed between the abdominal wall.

Be aware (certainly in children) that a GCF can occur after tube has been in place long term (>6 months).

Avoid the ‘pull’ technique in high-risk patients and use instead direct access through the abdominal wall, using an introducer technique.

Identify the caudal edge of the liver using percussion. The contrast between a dull and hollow sound allows for determination of the lower edge of the liver. This could be routinely done before PEG placement.