Table 1

Overview of minor postprocedural percutaneous endoscopic gastrostomy complications and their prevention

Peristomal site infection Prior to the procedure (<30 min before)
  • Use an oral antiseptic mouthwash (chlorhexidine or aqueous iodine) to reduce bacterial presence.

  • Decolonise the nasopharynx if diagnosed (but not yet eradicated) of methicillin-resistant Staphylococcus aureus.

  • If body hair is abundant at the insertion site, use an electric shaver.

  • Stop a proton pump inhibitor 24 hours before the procedure.

  • Use a single intravenous dose of periprocedural antibiotics (a first-generation cephalosporin); unless in patients already receiving antibiotics covering skin-flora.

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

  • Use a checklist that serves as a reminder of all necessary steps prior to and after tube placement.

 Following the procedure
  • Alternatively, consider administering a 20 mL co-trimoxazole solution through the newly inserted PEG catheter just after placement, instead of the periprocedural intravenous dose.

  • Clean the stoma and peristomal skin with a sterile solution (normal saline or local disinfection) daily for the first week and consider applying a skin protecting film or cream.

  • Alternatively, use a glycerin hydrogel or glycogel dressing instead of classical aseptic wound care during the first week.

  • Apply a (split) gauze dressing (not too thick) to remove any discharge above or under the external bumper (with a free distance of 0.5–1 cm).

  • Protect the skin with a nonocclusive dressing.

  • Avoid excessive pressure between the skin and the external bumper.

  • Assess the stoma and peristomal skin daily for signs and symptoms of infection such as loss of skin integrity, maceration, erythema, purulent and/or malodorous exudate, fever and pain.

  • Reduce (after stoma healing) dressings to once or twice a week. The entry site can be cleansed using an additive-free pH 5.5 soap and water of drinking quality.

  • Alternatively, dressings can be omitted and the site can be left open.

Overgranulation tissue
  • Keep the gastrostomy site as dry as possible.

  • Secure the tube properly and minimise friction/movement.

  • Apply preventive actions against peristomal infection after the procedure (also see paragraph ‘Peristomal site infection’).

  • Check if a low-profile device is in situ, if the device comfortably fits in the tract and has minimal movement.

Peristomal leakage
  • Avoid side torsion on the tract wall.

  • Evaluate regularly if the tube is not fixed too loosely or too tightly to the skin and check for a potential buried bumper syndrome.

  • Check balloon inflation volume at weekly intervals (if the tube is a balloon retained gastrostomy tube) and inspect the water for evidence of stomach contents indicating balloon rupture.

  • Observe the ostomy site closely for infection or overgranulation tissue.

  • Check gastric residual volume if any signs of gastrointestinal intolerance are present (eg, nausea, vomiting, abdominal distention, constipation).

Tube blockage and replacement
  • Replace the tube feeding set every 24 hours.

  • Flush the tube using 30 mL of pure water every 4 hours during continuous tube feedings, before and after intermittent feedings and after checking gastric residuals.

  • Flush with ±15 mL of water after and between each medication through the tube.

  • Consider adapting flushing protocols in people with restricted fluid intake, for example, 10 mL every 6 hours with continuous infusions; and 5 mL before and 10 mL after administering drugs; or interrupting or starting enteral nutrition.

  • Pay particular attention to avoid obstruction with jejunal tubes because they tend to have smaller calibres than gastric tubes.

  • Never rotate a PEG with a jejunal extension (PEG-J).

  • Critically evaluate the medication: which drugs are really necessary, which medication has an alternative form (eg, liquid, effervescent tablet, syrup).

  • Crush, dissolve and administrate drugs separate from each other to prevent incompatibility.

  • Use sterile water in immunocompromised or critically ill patients if there are concerns about the safety of pure water.

  • PEG, percutaneous endoscopic gastrostomy.