Percutaneous Gastrostomy and Jejunostomy

Feeding tubes are tubes inserted into the gastrointestinal tract to provide a route for enteral nutrition, though they can also be used for decompression of the gastrointestinal tract. Tubes come in a variety of sizes, lengths, and materials, depending on their longevity, placement method, and location. Among feeding tubes, percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic gastrojejunostomy (PEG-J) tube placement are widely performed procedures for long-term enteral nutritional support. These techniques offer minimally invasive alternatives to nasoenteric feeding and surgically placed feeding tubes via laparotomy. First introduced in 1980, PEG tube placement demonstrates a technical success rate exceeding 95%. The procedure is typically performed under moderate sedation, with an estimated procedure-related mortality of approximately 0.5%. PEG and PEG-J tubes play a critical role in patients who are unable to maintain adequate oral intake due to a variety of conditions. These include benign and malignant obstructive processes, iatrogenic causes such as radiation-induced esophageal injury leading to mechanical obstruction, esophageal motility disorders, and neurologic conditions resulting in oropharyngeal dysphagia. Additional indications include cognitive and psychosocial disorders, such as dementia, as well as developmental disabilities that impair safe and effective oral feeding. In PEG tube placement, a tube is inserted directly into the stomach through the abdominal wall. In PEG-J tube placement, an extension is placed via the existing PEG tube into the jejunum to allow jejunal feeding. The latter is particularly useful in patients at high risk of aspiration from gastric feedings, eg, those with gastroparesis, gastric outlet obstruction, severe gastroesophageal reflux disease (GERD), gastric resection, a history of repeated aspiration, or who cannot tolerate gastric feeding. The placement of a PEG-J tube, however, has not been shown to prevent aspiration. Once the PEG tube is placed, a fistulous gastrocutaneous tract forms in approximately 2 to 4 weeks, although this may be delayed in patients with severe malnutrition, immunocompromised patients, or significant ascites. If a PEG tube is dislodged within a month after placement when the tract isn't mature, then endoscopic replacement is recommended. Otherwise, bedside replacement is usually sufficient. If the tube is dislodged within 4 weeks of initial placement, patients are at significant risk of peritonitis and perforation due to peritoneal spillage of gastric contents through the immature track, and replacement should not be attempted without expert consultation. A blind attempt to reinsert the tube or even a Foley placement in an immature tract can lead to inadvertent placement of the tube into the peritoneal cavity. Replacement of a PEG-J tube requires either endoscopic guidance with or without fluoroscopy or interventional radiology.