Endoscopic management of enteral tubes in adult patients – Part 2: Peri- and post-procedural management. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Abstract

Main recommendationsESGE recommends the “pull” technique as the standard method for percutaneous endoscopic gastrostomy (PEG) placement.Strong recommendation, low quality evidence.ESGE recommends the direct percutaneous introducer (“push”) technique for PEG placement in cases where the “pull” method is contraindicated, for example in severe esophageal stenosis or in patients with head and neck cancer (HNC) or esophageal cancer.Strong recommendation, low quality evidence.ESGE recommends the intravenous administration of a prophylactic single dose of a beta-lactam antibiotic (or appropriate alternative antibiotic, in the case of allergy) to decrease the risk of post-procedural wound infection.Strong recommendation, moderate quality evidence.ESGE recommends that inadvertent insertion of a nasogastric tube (NGT) into the respiratory tract should be considered a serious but avoidable adverse event (AE).Strong recommendation, low quality evidence.ESGE recommends that each institution should have a dedicated protocol to confirm correct positioning of NGTs placed “blindly” at the patient’s bedside; this should include: radiography, pH testing of the aspirate, and end-tidal carbon dioxide monitoring, but not auscultation alone.Strong recommendation, low quality evidence.ESGE recommends confirmation of correct NGT placement by radiography in high-risk patients (intensive care unit [ICU] patients or those with altered consciousness or absent gag/cough reflex).Strong recommendation, low quality evidence.ESGE recommends that EN may be started within 3 – 4 hours after uncomplicated placement of a PEG or PEG-J.Strong recommendation, high quality evidence.ESGE recommends that daily tube mobilization (pushing inward) along with a loose position of the external PEG bumper (1 – 2 cm from the abdominal wall) could mitigate the risk of development of buried bumper syndrome.Strong recommendation, low quality evidence.

Prevention and management of major complications in percutaneous endoscopic gastrostomy

“…In this regard, the presence of a multidisciplinary nutritional support team can play a very important role in decreasing morbidity and mortality. 14 15 30 65 66 This review was written from a clinical viewpoint and focused on evidence-based recommendations to prevent and manage major adverse events.…”

“…Recent guidelines consider patient age, the presence of stroke as an indication and preprocedural nutritional and inflammatory status as risk factors for early and long-term PEG-related mortality. 14 In the entire PEG care pathway, but mainly in recognising the complexities of making decisions about PEG placement, the presence of a Nutritional Support Team can offer an important added value where wider issues can be discussed in detail and depth in an ongoing process. 15 Extensive preprocedural preparation and assessment before sedation and intraprocedural patient monitoring during (propofol) sedation are essential prerequisites 11 :…”

“… 5 7 Treatment depends on patient condition, type of PEG-tube and degree of migration (in or outside the stomach or complete versus incomplete covering). 14 16–23 …”

“…If after PEG placement the stomach serosa has not had time to adhere to the parietal peritoneum (inadequate sealing) gastric content can leak into the peritoneal cavity and can result in consequent peritonitis. 14 44 Patients with diabetes and malnutrition are at risk. In the case of tube dislodgment (see also complication ‘tube dislodgement’) within the first 4 weeks of its insertion, there is a risk of peritonitis.…”

“… 44 46 Minimising the risk for this complication can be achieved by paying careful attention to safe procedure technique during placement. 14 …”