Local protocols should specify the observations to be taken in the immediate post‐operative recovery period. These should include observation of blood pressure, heart rate, respiration rate and pain score in addition to checks of the stoma site for bleeding, leakage of gastric contents or tube displacement (NHSI [116]). If the patient is complaining of pain or there are signs of peritonitis or tube displacement, contact the medical team immediately. Peritonitis manifests as abdominal pain, fever and a raised white cell count in the initial days after placement. Transient external leakage of the stomach contents from the puncture canal can also suggest that internal leakage is occurring (NHSI [116]).

If there is pain on feeding, prolonged or severe pain post‐procedure or fresh bleeding, or external leakage of gastric contents then the feed should be stopped immediately. The patient should be reviewed by a senior clinician and the following considered: computed tomography (CT) scan, contrast study or surgical review (NHSI [116]).

Additional complications that may occur in the immediate period after gastrostomy insertion include aspiration pneumonia, haemorrhage and wound infection (Taheri et al. [177]). Colonic perforation is rare but may occur during the procedure and is likely to lead to peritonitis.

All assessments and care given should be clearly documented, including details of any observations noted and dressings used. The timing of future assessments should be planned to ensure that relevant aspects of care are followed up; for example, if a swab is taken to ascertain whether there is an infection, this needs to be followed up in order to act on the results of microbiology culture.

The patient should be advised not to use moisturizing creams or talcum powder around the stoma site. The grease in creams can cause the external retention device to slip, allowing movement of the tube and increasing the risk of hypergranulation, leakage and infection (Haywood [65]). Creams and talcs can affect the tube material, causing it to stretch or leak.

Once the stoma site has healed (approximately 10 days post‐insertion), it is no longer necessary to perform an aseptic technique. Use soap and water to clean the stoma site and ensure the area around the stoma is dried thoroughly. The tube tip should be cleaned daily using water and a small brush (Loser et al. [90]).

Where the enteral feeding tube has been placed to allow nutritional support, the patient's feeding regimen should be checked. If there is no feeding regimen, liaise with dietetic staff as needed or contact the medical team.

To reduce the risk of tube blockage, the patient's medication should be reviewed where the tube is required for drug administration. Liaise with both the medical team and the pharmacist to discuss the patient's prescription and alternative routes and medications (NICE and BNF [125]).

The need for patient and/or carer teaching should be considered in patients with newly inserted enteral feeding tubes, and discharge planning should be initiated. If a patient is discharged within 72 hours of gastrostomy insertion, the patient and their carers must be provided with appropriate local and out‐of‐hours contacts for urgent aftercare advice and warned of the danger signs that need urgent attention. These include pain on feeding, new bleeding and external leakage of gastric contents (NHSI [116]).

Infection can occur at the time of placement or be due to inappropriate site care, particularly prior to tract maturation. Patients who are immunocompromised may be at increased risk of infection. Initial care after insertion should be carried out using an aseptic technique until the tract is fully mature. If there are any signs of reddened skin or infection then a swab should be taken and sent off for microbiology culture and sensitivity. Appropriate antibiotic prescribing may be required depending on the condition of the stoma site and the microbiology results from the swab (Warriner and Spruce [185]).

Excessive tightening of the external fixator device may cause pressure necrosis around the stoma site. The external fixator should be adjusted while the patient is sitting up, where possible. If the external fixator is adjusted while the patient is lying down then it is necessary to ensure that it is applied 1–2 cm from the skin surface.

The stoma site should be reviewed regularly and the patient and carer taught how to adjust and reposition the external fixator. This is particularly important if the patient has gained weight as this may cause pressure on the fixator.

In enteral feeding tubes that have a bumper as the retention device, the retention bumper may become buried in the intestinal wall. The external fixator should be released and the tube pushed in approximately 5 cm and rotated fully both clockwise and anticlockwise. Ensure it is rotated regularly according to the manufacturer's instructions (NNNG [127]).

It is important to examine the tube site for causes of peristomal leakage. Contributory factors include delayed gastric emptying, buried bumper and infection. Ensure correct management of the stoma area, including checking the internal balloon weekly if this is the method of tube retention. If there is delayed gastric emptying, investigate and treat the cause of this. Avoid use of bulky dressings under the external fixator. Consider skin care and use protective cream or spray if necessary. Liaise with medical colleagues and consider the need for antacid medication to reduce skin excoriation (Westaby et al. [188]).

This is a known complication of the insertion procedure when air is present in the abdominal cavity. The patient's medical team must be contacted immediately if the patient is complaining of increased pain or pyrexia or has signs of an acute abdomen.

A gastrostomy or jejunostomy that is accidentally removed within 14 days of insertion requires immediate attention (Westaby et al. [188]). It should be replaced endoscopically or radiologically as soon as possible as a mature tract will not have developed in this period (Lynch and Fang [92]).

The patient's medical team or nutrition nurse must be contacted immediately, as the stoma site can heal over within 2 hours. The leakage of gastric contents into an immature tract carries the risk of infection. See the section on enteral silicone plugs (below) for advice on how to minimize the risk of stoma occlusion.

There is a lack of high‐quality evidence in the management of hypergranulation and so the treatment of this condition can be difficult. It is recognized as a common problem but classed as minor in the literature and so there is no standard practice of care (Warriner and Spruce [185]).

Excess movement of the enteral feeding tube within the tract may stimulate the growth of granulation tissue. Ensure that the fixation plate is firm but not too tight on the abdomen to minimize movement of the tube. If the tube does not have an external fixator plate then consider placing one to stop excessive movement of the tube (NNNG [127]). Other factors that may influence the formation of hypergranulation include excess moisture, critical colonization or true infection, and the presence of foreign material (NNNG [127]).

Local guidance on the management of hypergranulation should be agreed and be based on current evidence and the patient population.

Silicone gastrostomy stoma plugs are designed for emergency use to keep stomas from closing when a gastrostomy device has fallen out. They are a temporary measure to minimize the risk of the stoma closing completely and come in several lengths and gauges to fit the need of the patient.

Prior to using enteral feeding tubes for medication or feed administration, it is vital to know where in the gastrointestinal tract the tube tip lies. This may be difficult in patients who have tubes placed in other organs or where there is little visible difference externally between gastrostomy, transgastric or jejunostomy tubes. Where possible, the tube size, type, insertion date and method should be clearly documented. If this information is unavailable, the tube should be aspirated and the pH used to differentiate between gastric and small bowel placement. The pH in the jejunum is usually between 7 and 9 (neutral or slightly alkaline) whereas the pH of the stomach is below 5.5. If there are sutures securing the external fixator to the patient's abdomen, these should not be removed until it has been confirmed that they are not required to keep the tube in position.