Enterostomy tubes are placed when long-term access (>4–6 weeks) is required. Routine pre-procedural testing of coagulation parameters and platelets are no longer recommended, but should be considered if there is concern for abnormal coagulation due anticoagulant medication, medical history of excessive bleeding or recent antibiotic use. Prophylactic antibiotics are administered as they have been shown to decrease peri-stomal infection rates when using endoscopic methods [14, 15]. ASGE guidelines recommend administration of IV antibiotics to all patients before PEG (and PEGJ, DPEJ) tube placement [16]. The current standard is a single dose 1 g cefazolin administered 30 min prior to the procedure.

Endoscopic placement of a percutaneous feeding tubes is considered a higher risk bleeding procedure by ASGE guidelines and has been demonstrated to have up to a 2.5% risk of severe bleeding (defined as hemorrhage requiring blood transfusion, hospital admission, or endoscopic/surgical intervention) [17]. Patients are categorized into high and low risk for thromboembolic events. Patients at low risk should have their anticoagulant agents (new oral anticoagulants (NOAC) and warfarin) stopped 2–4 half-lives before percutaneous feeding tube placement without bridging. High thromboembolic risk patients should have their anticoagulant agents held and bridged with low molecular weight or unfractionated heparin. Resumption of warfarin can occur on the same day as the procedure and when adequate hemostasis is ensured for patients on NOAC’s. For antiplatelet agents, the thienopyridines (i.e., clopidogrel) should be held for at least 5–7 days before PEG placement though it is permissible to continue NSAIDs and ASA in patients with high thromboembolic risk [17]. Consultation with other relevant specialists will be important to manage these risks in specific patients. Patients can be managed with nasoenteric tubes if a relatively short NOAC treatment duration is planned. The reader is referred to comprehensive recent ASGE guideline on this topic [17].

Percutaneous endoscopic gastrostomy (PEG) is the most common technique for obtaining long-term gastric access for enteral nutrition and is generally performed under moderate sedation [18]. There are two general indications for PEG placement; enteral feeding and gastric decompression. Absolute contraindications for endoscopic PEG placement are obstruction of the GI tract proximal to the stomach, severe coagulopathy, active peritonitis, bowel ischemia, hemodynamic instability and inability to identify a safe abdominal access site [19]. Additional relative contraindications include ascites, coagulopathy, gastric varices, active head and neck cancers, morbid obesity and neoplastic, infiltrative or inflammatory disease of the gastric or abdominal wall [20]. Reported success rates for PEG placement are greater than 95% [21]. Abnormal endoscopic findings have been identified during 10–71% of PEG procedures and have altered management in as many as 36%, showing the value of a complete EGD even in the setting of PEG placement [22]. Additional advantages of endoscopic PEG placement include the ability to perform the procedure at the bedside (i.e., in the ICU) and lack of radiation exposure.

The “pull” and “push” techniques are the most common endoscopic methods for PEG placement. The pull (or Ponsky) technique is performed much more frequently despite no documented differences in success rates or outcomes [23]. Air is insufflated into the stomach via an endoscope. The optimal site for PEG placement is determined through simultaneous endoscopic trans-illumination noted on the abdominal wall and finger indentation at the site visualized endoscopically. The abdominal wall is typically sterilized with topical agents, and a surgical drape is applied. Local anesthesia is used to reduce discomfort. A small incision is made at this site and a needle/trocar is inserted through the abdominal wall and into the stomach. A guidewire is passed through the needle/trocar and grasped endoscopically (usually with an endoscopic snare) and withdrawn through the mouth. A gastrostomy tube is then affixed to the guidewire and pulled through the esophagus into the stomach and out the abdominal wall. The gastrostomy tube is held in place by a solid “mushroom”-type internal retention device and an external bumper.

The push method is similar to the pull method except an introducer tube with a hollow central lumen is used. After the guidewire is placed, the introducer tube is threaded over the guidewire. It is then advanced over the guidewire from the mouth and pushed until it emerges from the abdominal wall. It is then grasped manually and pulled into position as described above.

Site selection and procedural technique are paramount to successful and safe PEG placement. The access site should be at least 2 cm away from the costal margin to minimize patient discomfort during respiration post-placement. The PEG site should also be >2 cm away from surgical scars as intervening bowel loops tend to adhere to scar tissue immediately deep to the scar. In addition to marking the location on the abdominal wall where trans-illumination and one-to-one finger indentation occurs, it is important to note the angle and orientation of the finger during indentation and to replicate this during the needle/trocar insertion to ensure optimal PEG placement.

The Foutch “safe tract” technique should be used when a finder needle or trocar is advanced through the abdominal wall into the stomach. Steady aspiration is applied to a saline (or 1% lidocaine) filled syringe attached to the needle to ensure that no air bubbles or blood are seen in the syringe prior to endoscopic visualization of the needle tip entering the stomach. This ensures that the needle’s path does not include adjacent vessels or bowel loops [11].

A skin incision (to potentially facilitate tube passage through the abdominal wall) should be made the same size or slightly smaller than the diameter of the feeding tube. This may require extra force to pull the PEG tube through the skin, but an overly large incision violates surgical principles allowing for increased risk of infection and potentially longer and poorer healing of the site.

Patients receiving PEG tubes are at high risk of aspiration, especially during the procedure. Minimizing procedure time, dedicating an assistant to airway care and suctioning, and elevating the head of bed to 30–45° will help minimize this risk.

The risk of the post-procedural complications of peri-stomal infection, buried bumper syndrome (wherein the bumper imbeds deeply in the gastric wall and may not be identifiable endoscopically) and necrotizing fasciitis are increased when there is excessive tension between the inner and outer bumper of the PEG [19]. Keeping 0.5–1.0 cm of “play” (position off the abdominal wall) at the time of placement and at least 1 cm after stoma tract maturation can help reduce this risk. In addition, if the patient gains significant weight after tube placement (usually due to successful nutritional therapy), the external bumper will need to be additionally loosened to prevent these complications, most notably a buried bumper.

Percutaneous endoscopic gastrojejunostomy (PEGJ) may be performed immediately or anytime after gastrostomy tube placement. Similar to NET placement multiple methods for PEGJ placement have been described. Traditionally, a guidewire is placed through the existing gastrostomy tube, grasped endoscopically, and carried into the jejunum. The endoscope is then withdrawn leaving the guidewire in place. The jejunal extension tube is then threaded over the guidewire into the small bowel with or without fluoroscopic assistance [24, 25]. This technique, while commonly performed, frequently results in displacement of the jejunal tube back into the stomach on withdrawal of the endoscope.

The “drag-and-clip” method (similar to that described for NET) can be used to prevent this initial jejuna tube displacement and reduce feeding tube migration for the duration the clip remains in place. In this method, a jejunal feeding tube with a suture on its tip is inserted through the PEG into the stomach lumen. A re-closable clip is passed through the working channel of an endoscope and used to grasp the suture and drag the tube into the jejunum. The suture is then clipped to the jejunal mucosa, securing the feeding tube to the small bowel. Withdrawing the re-closable clip back into the working channel after grasping the suture will facilitate advancement of the endoscope while decreasing trauma on the bowel wall (Fig. 9.2). Multiple clips can also be deployed on the suture to further ensure that the position of the feeding tube is maintained. In one study, the average procedure time using a variation of this method was 21 min, employing both forceps and clips, which is less than that reported when endoclips are not used [26]. A recent retrospective study showed a 93% success rate for PEGJ placement with the use of endoclips [26]. The mean functional duration of these tube was 55 days with the primary reason for tube replacement being clogging (as opposed to displacement) [26].

Another means of placing a jejuna extension through a PEG is to place the wire into the small bowel through an ultrathin endoscope advanced directly through a PEG tube. Advancing the endoscope through the PEG itself also mitigates tube displacement upon endoscope withdrawal. This through-the-PEG placement of the jejunal extension tube uses a combination of larger diameter 24–28 Fr PEG tubes and ultrathin (5–6 mm) endoscopes, and has demonstrated good success rates and acceptable tube patency. In this method, an ultrathin endoscope is inserted through the PEG tube into the stomach and advanced deep into the small bowel. A guidewire is then advanced through the working channel of the endoscope into the jejunum. The endoscope is then exchanged over the wire while taking care to avoid looping or kinking of the wire. The jejunal extension tube is then passed over the wire and the proximal end seated on the PEG tube Y-port adapter.

This technique was 99.2% successful in a recent case series of 121 procedures [27]. Jejunal extension tube dysfunction occurred in 24% of cases, with tube kinking, occlusion, and breakage as the most common problems [27]. The average lifespan of the tubes was 123.6 days, which may be partially related to the larger 12 Fr tubes used in this study [27]. Further advantages of this technique are that the jejunal extension tubes can be placed with minimal or no sedation with relatively short procedure times and without fluoroscopy. Another variation of this method uses an existing mature gastrostomy site. The PEG is removed completely and an ultrathin endoscope advanced into the jejunum and wire placed (Fig. 9.3). A one-piece gastrojejunostomy tube is then advanced over the wire as described above.

Despite high technical success rates for placement of PEGJ, the clinical success is considerably lower with reported malfunction rates of 53–84% [28]. Failure is most commonly due to retrograde migration or tube occlusion secondary to kinking or clogging of these smaller (8–12 Fr) jejunal extension tubes [28].

Technical tips to achieve maximal depth of the jejunal extension into small bowel can help optimize functional success. The antrum should be considered for the gastrostomy insertion site as this allows a shorter and straighter track to the small intestine for the jejunal extension tube [11]. Directing the puncture of the stomach with the needle/trocar angled toward the pylorus will also help achieve this goal. Minimizing dead space (i.e., excessive intra-gastric length of the tube) reduces coiling and allows maximal length of jejunal placement beyond the pylorus [11]. Cutting the external length of the PEG short (<10 cm) also allows maximal length of the jejunal tube by minimizing its length outside the body [11]. Using an extension tube of longer length will also allow for a deeper and more stable position in the jejunum. Finally, it is important that the jejunal extension tube should be advanced far enough into the small bowel to minimize looping in the stomach (not advancing far enough) without creating excess tension (advancing too far), both of which can lead to retrograde migration. While fluoroscopy is not absolutely required for PEGJ placement, the authors have found it useful to reduce looping in the stomach and achieve more distal (and stable) placement.

DPEJ is indicated for jejunal feeds when an existing PEG is not present, for persistent dysfunction of PEGJ tubes and, most importantly, when expertise in placing a DPEJ exists. DPEJ tubes have greater durability as the larger bore tubes clog less and do not migrate or kink as frequently when compared to PEGJ [28, 29]. DPEJ may also reduce aspiration in high-risk patients [30]. DPEJ, however, is performed much less frequently than PEGJ, at least in part due to the perceived risk and need for greater technical expertise. Direct percutaneous jejunostomy is considerably more difficult technically than percutaneous gastrostomy despite similar methods. Success rates are lower and complications rates are higher when compared to PEG tubes [5: 4–8]. Success rates for endoscopic jejunostomy range from 68 to 100% [31].

Direct percutaneous endoscopic jejunostomy (DPEJ) is a modification of the pull PEG technique. A pediatric colonoscope or enteroscope is advanced into the small bowel. Transillumination and finger palpation is performed over the jejunum instead of the stomach. A sounding needle and/or trocar is passed through the anterior abdominal wall into the jejunum. An insertion wire is advanced through the trocar and grasped. The procedure is then completed as per the pull type PEG (Figs. 9.4, 9.5, video 9.1) [32, 33]. Both single balloon enteroscopy (SBE) and double balloon enteroscopy (DBE) allow for deeper intubation of the small bowel, compared to standard push enteroscopy, increasing the likelihood of reaching an appropriate site for DPEJ insertion. A recent study showed successful DPEJ placement in 10/10 patients using the DBE under general anesthesia (GA) after failed conventional placement with a pediatric colonoscope using conscious sedation [34]. In another study, Despott et al. also reported successful DPEJ tube placement by DBE under GA in nine of the ten consecutive cases, with failure in one case secondary to inadequate trans-illumination [35]. The mean procedure time was 35 min, and no procedure-related complications were reported [35]. Similarly, in yet another study single balloon enteroscopy (SBE) demonstrated success in 11 of 12 DPEJ procedures attempted with conscious sedation [36]. Initial data suggest that balloon assisted enteroscopy is a safe and effective innovation for DPEJ.

Despite the similarity in the technique of PEG and DPEJ placement, DPEJ is a considerably more difficult procedure. Several technical tips can help identify a safe access site and stabilize the small bowel to increase success. Using the trans-illumination function on the light processor maximizes potential for localizing an access site [30]. Surgical scars do not need to be avoided (as opposed to this case when placing a PEG tube, where they are usually avoided). In patients undergoing DPEJ placement, scars may represent ideal sites to attempt to access the small bowel as they are often where adhesions fix small bowel loops to the anterior abdominal wall [28]. Once an access site has been identified, it is important to stabilize the small bowel. The finder needle is inserted into the jejunum and grasped with the endoscopic snare to anchor the jejunum to the abdominal wall [37]. The trocar is then passed through the abdominal wall and into the small bowel at a location adjacent to the finder needle, and the snare is transferred off the needle to the trocar to minimize bowel movement and the risk of interposed bowel (Fig. 9.5). Glucagon or hyoscine may also be administered to reduce intestinal peristalsis. Consideration should be given to general anesthesia for all DPEJ placements given prolonged procedure times (compared with the time required for PEG tube placement) with increased aspiration risk while patients are supine [28].