Chapter 41 ■ Gastrostomy 289

Tube feeds should be started slowly and advanced to the

goal rate over the next few days.

1. Maintain fixation of gastrostomy between stomach and

abdomen.

a. Prevent gastric distention.

b. Keep the gastrostomy balloon or flange pulled

snugly against the stomach wall by maintaining the

external bolster snug against the skin (take time to

recognize and record the gastrostomy level mark at

the skin) (Fig. 41.4).

c. Avoid pressure necrosis of the abdominal wall: the

external bolster should be snug enough to be gently

twisted around but not too tight.

d. Avoid inadvertent dislodgement of the gastrostomy

(i.e., patient restraints, minimize tension on the gastrostomy tube by providing secondary fixation points

on the skin or keeping the tube secure within the

diaper). Nursing staff and parents should be

informed of the type of gastrostomy tube inserted,

how much fluid has been placed in the retention

balloon, and anticipated time of first gastrostomy

tube exchange.

2. Maintain gastrostomy immobility at the insertion site to

minimize the formation of granulation tissue.

a. Use careful fixation to maintain the perpendicular

position.

(1) This will decrease the amount of soft tissue

stretching at the stoma site.

b. Keep some slack in the tube when it is suspended.

 This prevents stoma tension and widening,

thereby decreasing the risk of stoma leak.

3. Prevent migration of gastrostomy

a. Proper fixation (Fig. 41.5)

If not fixed on the outside with a bolster or tape,

the gastrostomy tube may migrate through the pylorus or up into the esophagus.

b. Compare the length of external tube with the postoperative length (again checking and monitoring

the level at the skin).

c. Observe for signs of obstruction.

(1) Gastric distention

(2) Feeding intolerance, nausea/vomiting

(3) Increased drainage from oral gastric or gastrostomy tube

(4) Bilious drainage

(5) New-onset or increased gastroesophageal reflux

4. Minimize leak rate from the gastrostomy site

a. Maintain adequate fit of tube in stoma.

Long-term gastrostomy tubes may need to be

upsized if the stoma site increases in diameter.

b. Avoid local infection—continue meticulous wound

care.

Daily cleansing with soap and water starting

48 hours after placement.

5. Close follow-up after placement to screen for and

reduce risk of tube-related complications (see below).

K. Replacing Gastrostomy Tubes

Healing of gastrostomy sites requires 4 to 6 weeks for fibrosis to occur and create a well-epithelialized tract attaching

the stomach to the anterior abdominal wall and. This process may take several months with PEG tubes, as there is

generally no suture or fastener deployed to form a seal

between the stomach and the abdominal wall. During the

initial postoperative period (2 to 4 weeks postgastrostomy

Fig. 41.4. Latex bridge at gastronomy exit stabilizes tube perpendicular to skin, keeping stoma narrow to avoid leakage.

Rotating the bridge around the tube allows change in contact

points with the skin. Note how the flared end of the mushroom

catheter is pulled to keep the stomach apposed to the abdominal

wall.

Fig. 41.5. Modified feeding nipple. The elliptical hole at the

base allows air circulation and regular cleaning of the skin as

important factors in avoiding maceration of the site. (From

Kappell DA, Leape LL. A method of gastrostomy fixation. J Pediatr

Surg.1975;10:523, with permission.)