When patients require nutritional support, the enteral route is always preferable if the gastrointestinal tract is functional. Tube feedings are no less effective than intravenous nutrition, and are also easier, safer, and much cheaper. Small, soft nasogastric feeding tubes work satisfactorily, especially if the need for nutritional support is expected to be short. Insertion of nasoenteric tubes can bring complications, however, such as pulmonary intubation leading to pneumothorax, hydrothorax, or pneumonia. Furthermore, nasogastric tubes are uncomfortable and certainly unsightly. With prolonged use, the tubes tend to clog, fall out, or get pulled out by the patient, who is often neurologically impaired. A tube gastrostomy, on the other hand, is more comfortable and easier to maintain. In addition, pulmonary aspiration and oesophageal reflux may occur less frequently.

When a tube gastrostomy is required, percutaneous endoscopic gastrostomy is best. Standard open gastrostomy can be carried out with an acceptably low morbidity, and when a patient requires a laparotomy for another reason, gastrostomy can readily be added. But for any other patient, the percutaneous endoscopic technique is superior. It is clearly faster and cheaper, and is perhaps associated with fewer complications. Local anaesthesia can almost always be used; this is especially advantageous in these patients, who are frequently elderly and debilitated. Open-tube gastrostomy can also be done under local anaesthesia, but exposure and patient co-operation are so unsatisfactory that surgeons rarely do this. If necessary, percutaneous endoscopic gastrostomy can be done at the bedside or in an intensive care unit, and pain after the procedure is minimal. In stable patients, it can even be done in an outpatient setting. The concomitant oesophagogastroduodenoscopy adds the advantage of excluding unsuspected upper gastrointestinal disorders, which could interfere with feeding. If needed, a thin transpyloric jejunostomy tube or a duodenostomy tube can also be placed by the percutaneous endoscopic gastrostomy route. Nevertheless, accurate placement of these tubes is tricky, and subsequent mechanical problems (occlusion, malposition) are common. They provide little extra protection against aspiration and pneumonia, since the problem in these patients is not often reflux of gastric contents, but rather inhalation of pharyngeal secretions.

Percutaneous endoscopic gastrostomy is indicated for any patient who cannot, or will not, eat and who therefore needs prolonged enteral tube feedings. Patients with neurological disorders, oropharyngeal dysfunction or tumours, or facial trauma often qualify. In addition, for anyone requiring prolonged gastric decompression, the discomfort, the difficulty in clearing pulmonary secretions, and the potential oesophagitis or even oesophageal stricture associated with nasogastric tubes can be avoided with this technique. Rarely, bile from a high-output fistula can be conveniently fed again after a percutaneous endoscopic gastrostomy.

Contraindications to percutaneous endoscopic gastrostomy are ascites, extreme obesity, oesophageal or gastric varices, anticoagulation or a coagulopathy, oesophageal obstruction severe enough to preclude passage of a paediatric endoscope, and a moribund patient. Marked oesophageal reflux, gastric outlet obstruction, and gastroparesis will defeat gastric tube feedings (by any technique) but can sometimes be circumvented by percutaneous endoscopic jejunostomy. Previous gastric surgery does not necessarily contraindicate percutaneous endoscopic gastrostomy.

The procedure begins with topical pharyngeal anaesthesia and intravenous sedation. A prophylactic antibiotic (usually cephalosporin) is given perioperatively. With the patient supine, the abdomen is swabbed with an antiseptic and draped. Sometimes oesophageal or posterior pharyngeal dilation is required before the endoscope can be passed. The gastroscope is inserted, the stomach is inflated, and oesophagogastroduodenoscopy is carried out. The normal gastric antrum is illustrated in Fig. 1 1409. Frequent pharyngeal suctioning is helpful in a supine patient with an anaesthetized throat to minimize the risk of aspiration.

The abdominal location for the gastrostomy is selected by transilluminating through the anterior stomach wall. A point in the left upper quadrant between the midline and the midclavicular line is often successful. Apposition of the stomach to the anterior abdominal wall is confirmed by finger indentation, which is readily visible through the endoscope (Fig. 2) 1410. If transillumination or finger indentation is equivocal, percutaneous gastrostomy should not proceed. After skin infiltration with local anaesthesia, a small stab incision is made at the selected site. The incision should be slightly larger than the diameter of the tube, to allow some later drainage of this inevitably contaminated wound. A needle is inserted through the incision, with simultaneous syringe suction (Fig. 3) 1411. Appearance of air in the syringe at the same time as the needle is seen entering the stomach ensures that the stomach, not the colon, is the first viscus entered. A heavy suture or a guidewire is then inserted through the needle (care must be taken not to allow the stomach to deflate through the needle) (Fig. 4) 1412. The suture or wire is snared by the endoscopist and is withdrawn through the mouth. A mushroom-tip gastrostomy tube (Fig. 5) 1413 is then drawn with the suture or guided over the wire back down through the mouth, stomach, and out through the abdominal wall (Fig. 6) 1414. The endoscope is reinserted to check the position of the tube (Fig. 7) 1415. An endoscopic technique using a peel-away introducer has also been described, which required only one insertion of the endoscope.

An outer plastic cross-bar or disc is passed around the tube and positioned over the skin to hold the gastric and abdominal walls together. To avoid pressure necrosis of the skin or gastric wall, the tube should not be drawn up too tightly. Multiple heavy anchoring sutures at the skin insertion site minimize the likelihood that the tube will become displaced. Tube feedings may be started the next day. After about 2 weeks, a fibrous track will form, and the tube may be changed as needed. Tubes with soft tips that can be extracted through the skin are usually preferable to tubes that have non-deforming ends. In order to remove the non-deformable tube, the catheter must be cut at skin level, leaving the tip in the stomach. Since the plastic end may cause bowel perforation or obstruction, repeat endoscopy for extraction is required—an avoidable inconvenience. Percutaneous endoscopic gastrostomy is unsuccessful for technical reasons in 5 to 10 per cent of patients.

The complication rate for percutaneous endoscopic gastrostomy compares favourably with gastrostomy by laparotomy. Wound infection (cellulitis, abscess) occurs in no more than 1 to 5 per cent of patients if prophylactic antibiotics are administered. A few reports of severe necrotizing fasciitis have appeared, however. Aspiration pneumonia after percutaneous endoscopic gastrostomy is occasionally a problem, especially if the patient is neurologically impaired and has a previous history of aspiration. Of course, placing a gastrostomy tube will not alter a patient's tendency to inhale oropharyngeal secretions, and it is uncertain when aspiration pneumonia can be directly attributed to the procedure. It happens perhaps 1 to 5 per cent of the time. Haemorrhage requiring transfusion or surgery occurs in up to 2 per cent of patients, and an appreciable external leak around the tube appears in up to 1 per cent. None of the above complications is unique to the percutaneous endoscopic method. Since anterior gastropexy is not achieved with the endoscopic technique, however, an early inadvertent tube extrusion is particularly troublesome; a free intraperitoneal leak results. Up to 5 per cent of patients suffer tube dislodgement requiring surgery. An internal leak (without tube extrusion) or gastric perforation occurs in up to 2 per cent. Colon puncture or gastrocolic fistula is rare in adults. Asymptomatic pneumoperitoneum after percutaneous endoscopic gastrostomy is common and of no consequence. Respiratory arrest is a risk in patients with pharyngeal tumours, who might retain only a marginal airway. Further compromise comes from the presence of the scope, throat oedema from intubation, and sedation. If there is any question about airway adequacy, it is best to perform a tracheostomy first, or to postpone percutaneous endoscopic gastrostomy until after resection of the tumour.

Davis JB, Bowden TA, Rives DA. Percutaneous endoscopic gastrostomy: do surgeons and gastroenterologists get the same results? Am Surg 1990; 56: 47–51.

DiSario JA, Foutch PG, Sanowski RA. Poor results with percutaneous endoscopic jejunostomy. Gastrointest Endosc 1990; 36: 257–60.

Grant JP. Comparison of percutaneous endoscopic gastrostomy with stamm gastrostomy. Ann Surg 1988; 207: 598– 603.

Hunter JG, Lauretano L, Shellito PC. Percutaneous endoscopic gastrostomy in head and neck cancer patients. Ann Surg 1989; 210: 42–6.

Kaplan DS, Murphy UK, Linscheer WG. Percutaneous endoscopic jejunostomy: long term followup of 23 patients. Gastrointest Endosc 1989;35: 403–6.

Larson DE, Burton DD, Schroeder KW, MiMagno EP. Percutaneous endoscopic gastroscopy: indications, success, complications, and mortality in 314 consecutive patients. Gastroenterology 1987; 93: 48–52.

Mamel JJ. Percutaneous endoscopic gastrostomy. Am J Gastroenterol 1989; 84: 703–10.

Miller RE, Kummer BA, Kotler DP, Tiszenkel HI. Percutaneous endoscopic gastroscopy: procedure of choice. Ann Surg 1986; 204: 543–5.

Ponsky JL. Percutaneous endoscopic stomas. Surg Clin N Am 1989; 69: 1227–36.

Shellito PC, Malt RA. Tube gastrostomy: techniques and complications. Ann Surg 1985; 201: 180–5.

Stern JS. Comparison of percutaneous endoscopic gastrostomy with surgical gastrostomy at a community hospital. Am J Gastroenterol 1986; 81: 1171–3.

Stiegmann GV, Goff JS, Silas D, Pearlman N, Sun J, Norton L. Endoscopic versus operative gastrostomy: final results of a prospective randomized trial. Gastrointest Endosc 1990; 36: 1–5.

Wolfsen HC, Kozarek RA, Ball TJ, Patterson DJ, Botoman VA. Tube dysfunction following percutaneous endoscopic gastrostomy and jejunostomy. Gastrointest Endosc 1990; 36: 261–3.