Update on endoscopic approaches to nutritional support.

MHD Percutaneous endoscopic gastrostomy (PEG) tubes have been used for approximately 30 years. They were originally designed for use in children and have become a fairly standard part of gastroenterology and surgical endoscopy. The various kits that have been developed for placement of PEG tubes have similar components: a PEG tube and instrumentation for making an incision to obtain access to the stomach, an external bolster for stabilizing the position of the tube, and an adapter on the end of the tube for feeding. Placement of these tubes requires 2 individuals (usually a physician and a nurse). The procedure has increased in volume over the years, most likely because the general population is becoming older, and older patients are typically the ones who develop chronic diseases that require feeding tubes. Percutaneous endoscopic gastrojejunostomy (PEG-J) is performed in patients who cannot receive food into the stomach and, thus, have to be fed via the small intestine. In this procedure, a standard PEG tube is placed, and then a smaller tube (a jejunal tube) is placed through the PEG tube and positioned down into the small intestine. The inner tube (the jejunal tube) is used for nutritional support, whereas the outer tube (the PEG tube) can be used to administer medications into the stomach or to decompress the stomach, if necessary. PEG-J systems, particularly the jejunal tubes, are more cumbersome and difficult to place than PEG tubes. Although PEG-J tubes have been shown to provide benefits, many gastroenterologists struggle with positioning this tube system and, thus, avoid doing so by referring this job to radiologists. I do not agree with this tendency; I think that the procedure can be learned quite easily with practice. The disadvantage of PEG-J systems is that the jejunal tube may migrate backward into the stomach; thus, it may appear that patients are being fed via the small intestine, but, in fact, the jejunal tube has actually migrated back into the stomach, so patients are being fed via the stomach, which is what gastroenterologists were trying to avoid in the first place. PEG-J is not the appropriate tube system for patients who will require jejunal feeding for the rest of their lives; this system is most effective as a bridge for patients who might need small bowel feeding only for several months. Another technique, which has grown in prominence over the past 10 years, is direct percutaneous jejunostomy. This procedure involves the placement of a feeding tube directly into the small bowel (rather than into the stomach via a PEG tube). As with any procedure, there is a learning curve; however, this procedure appears to be safe. Ultimately, direct percutaneous jejunostomy should become part of endoscopists’ armamentarium for therapeutic nutritional interventions.