Although surgeons and gastroenterologists have traditionally provided enteral access services, interventional radiologists can safely, effectively, and successfully perform these procedures as well. Experience with percutaneous radiologically guided gastrostomy and gastrojejunostomy access is extensive, and experience with direct percutaneous jejunostomy access is growing. This article reviews issues and highlights areas of controversy important to radiologists providing these services. [1, 2, 3, 4, 5, 6]
First described in 1837, surgical gastrostomy was the mainstay of direct enteral feeding access for decades. Although laparoscopic techniques for gastrostomy and jejunostomy tube access have evolved since then, their use is limited because of the acceptance of less invasive endoscopic and radiologic alternatives. Surgical gastrostomy or jejunostomy is most frequently performed when patients are already undergoing laparotomy for related or unrelated abdominal problems.
The advent in 1980 of percutaneous endoscopic gastrostomy (PEG) dramatically changed the approach to gastrostomy access, and this minimally invasive procedure largely replaced surgical gastrostomy. Endoscopic gastrostomy has been accepted widely and remains the most common form of gastrostomy access. Endoscopic gastrojejunostomy and direct endoscopic jejunostomy also have been described, but these methods are less widely used and less accepted than PEG.
In 1983, three independent interventional radiology groups described a percutaneous imaging-guided alternative to surgical and endoscopic gastrostomy. Since then, reports from multiple large series have described the procedure. Compared with endoscopy, fluoroscopic guidance allows the safe placement of gastrostomy tubes and allows easier initial placement of gastrojejunostomy tubes. More recently, direct jejunostomy access was described. The degree to which individual radiology practices offer these services varies.
Although percutaneous enterostomy catheters are most commonly placed for nutritional support, other indications have evolved for specific clinical scenarios.
As a general rule, enteral or parenteral feeding is advised when a patient is unable to eat for 7-14 days or longer. In the setting of a functional gut, enteral feeding is preferred to parenteral options.
When the need for enteral feeding is anticipated to be 30 days or shorter, feedings through a nasogastric tube or a more distal nasoenteric tube are usually appropriate. Because such tubes are associated with considerable discomfort and because sinusitis and epistaxis are common complications, direct enteral access is preferred when feeding needs extend beyond 30 days.
The choice of access route (gastrostomy, gastrojejunostomy, or jejunostomy) and the choice of placement technique (surgical, endoscopic, or radiologic) often depend on individual patient issues and the specialty, experience, and preference of the treating physician.
Patients with either functional or mechanical bowel obstructions often require tube decompression. When decompression is needed for prolonged periods (eg, in patients with severe diabetic gastroparesis or peritoneal carcinomatosis), direct enteral tube placement offers advantages over nasogastric or nasoenteric tube placement. Because the stomach and small bowel are grossly dilated in these settings, both gastrostomy and jejunostomy tube placements are technically straightforward.
Interventional radiologists may use imaging-guided access to the bowel to facilitate other gastrointestinal or biliary interventions. In the setting of previous biliary-jejunal anastomotic procedures, percutaneous access into the afferent jejunal limb can facilitate the treatment of biliary strictures and stones. In patients with obstructing esophageal neoplasms, gastrostomy access and retrograde esophageal catheterization may facilitate the placement of palliative stents.
Although the risks and potential benefits of enteral access catheter placement must be weighed in each patient, certain anatomic and pathologic conditions may increase the likelihood of complications.
Absolute contraindications for percutaneous feeding tube placement include the following:
Absence of a safe access route
Relative contraindications for percutaneous feeding tube placement include the following:
Unfavorable anatomy - Interposition of the colon between the stomach and anterior abdominal wall; interposition of the liver between the stomach and anterior abdominal wall; high (intrathoracic) position of the stomach; previous gastrectomy
Clinical comparison of alternative techniques
A meta-analysis by Wollman et al found that radiologically guided gastrostomy compared favorably with surgical and endoscopic gastrostomy, with similar or improved success and complication rates (see Table 1 below). 
Table 1. Comparisons of Procedural Success and Complication Rates (Open Table in a new window)
|Measure||Surgical Gastrostomy||PEG||Radiologic Gastrostomy|
|No. of patients||721||4,194||837|
|No. of series||11||48||9|
|Success rate, %||100||95.7||99.2|
|Procedural mortality rate, %||2.5||0.5||0.3|
|Major complication rate, %||19.9||9.4||5.9|
|Minor complication rate, %||9.0||5.9||7.8|
In a study comparing percutaneous primary jejunostomy tubes for postpyloric enteral feeding with percutaneous gastrojejunostomy tubes, Kim et al found that the two tube types were similar with regard to technical success and incidence of complications but that jejunostomy tubes had a lower rate of dysfunction and a higher rate of leakage. 
Economic comparison of alternative techniques
Although comparative analyses of procedural costs are complicated and may be difficult to reproduce, the overall costs of radiologic gastrostomy appear to be similar to those of endoscopic gastrostomy and less than those of surgical gastrostomy. For gastrojejunostomy access, radiologic methods are less expensive than either endoscopic or surgical techniques. The results of a cost analysis performed by Barkmeier and colleagues in 1998 are summarized in Table 2 (see below). 
Table 2. Procedural Costs in US Dollars (Open Table in a new window)
|Procedure||Surgical Cost, $||Endoscopic Cost, $||Radiologic Cost, $|
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