Laparoendoscopic approaches to enteral access

Access to the stomach for long-term enteral feeding or decompression can be achieved with numerous methods. The methods include laparotomy, gastroscopy, laparoscopy, and fluoroscopy. All methods have been shown to be safe and effective. Percutaneous endoscopic gastrostomy (PEG) was introduced by Ponsky in 1990, and laparoscopic gastrostomy was introduced 10 years later. PEG rapidly replaced open gastrostomy as the method of choice for enteral nutrition. The laparoscopic alternative was ideal for patients who were not candidates for PEG placement. The laparoscopic or laparoendoscopic placement of enteral tubes allows visualization of the intestinal tract to ensure proper tube positioning. Many patients are not candidates for a PEG because of head and neck cancer, esophageal obstruction from stricture or carcinoma, large hiatal hernia, gastric volvulus, overlying intestine or liver, facial trauma with wired mandible, or severe stomatitis secondary to radiation therapy. Lastly, laparoscopy lessens the chance of injury to the surrounding structures, adhesions can be safely lysed, and metastatic or concomitant disease may be identified. This report will review the numerous methods available to the laparoscopic surgeon for gaining access to the stomach or intestine.