Endoscopic approaches to enteral feeding and nutrition core curriculum

Abstract

This is one of a series of documents prepared by the American Society for Gastrointestinal Endoscopy (ASGE) Training Committee. This curriculum document contains recommendations for training, intended for use by endoscopy training directors, endoscopists involved in teaching endoscopy, and trainees in endoscopy. It was developed as an overview of techniques currently favored for the performance and training of endoscopy as it relates to enteral nutrition and to serve as a guide to published references, videotapes, and other resources available to the trainer. By providing information to endoscopy trainers about the common practices used by experts in performing the technical aspects of the procedure, the ASGE intends to improve the teaching and performance of endoscopy as it relates to enteral nutrition. Acquiring the skills to successfully place nasoenteric and percutaneous endoscopic enteral feeding tubes safely and effectively requires an understanding of the indications, risks, benefits, limitations of, and alternatives to, these procedures. As a prerequisite, competence in upper endoscopy is required, including visualization of the upper GI tract, minimizing patient discomfort, proper identification of normal and abnormal findings, and mastery of basic therapeutic techniques. The ASGE core curriculum document Principles of Training in GI Endoscopy1Adler D.G. Bakis G. Coyle W.J. et al.ASGE Training CommitteePrinciples of training in GI endoscopy.Gastrointest Endosc. 2012; 75: 231-235Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar reviews requirements for endoscopic trainers and the training process itself. This document is recommended for all endoscopy trainers and trainees. Sections of the Gastroenterology Core Curriculum2Gastroenterology core curriculum, 3rd ed. 2007. American Association for the Study of Liver Diseases, American College of Gastroenterology, AGA Institute, American Society for Gastrointestinal Endoscopy. Available at: http://www.asge.org/assets/0/71328/71340/22C3A834-B607-4C41-88A2-6306B9A4BC61.pdf. Accessed September 1, 2013.Google Scholar (a combined effort of the ASGE, American College of Gastroenterology, and American Association for the Study of Liver Diseases) that review training in nutrition (pages 42-44) also are pertinent, because any decision to place enteral feeding access should be done in the setting of a full nutritional assessment and plan. GI training programs should require trainees to have formal instruction in endoscopic placement of enteral nutrition access devices. Endoscopic access for enteral nutrition training should be incorporated into the standard 3-year gastroenterology fellowship program. The case volume necessary to demonstrate competence in enteral feeding tube placement will vary among trainees. We recommend, based on expert opinion, a minimum of 20 supervised endoscopic gastrostomy procedures before assessment of competency. There is increasing awareness that proficiency should be based on competency rather than absolute number of procedures performed, reflecting differences in individual learning curves; however, objective measures for assessment of competency in enteral feeding tube placement are yet to be defined and are currently based on expert opinion. Therefore, until objective measures are developed and validated, evaluation of competency will rely on subjective evaluation of direct observation by a qualified gastroenterologist. Competency should be demonstrated in both traditional two-provider and single-provider (where the percutaneous portion is assisted by a GI technician or nurse assistant rather than a second gastroenterologist) enteral feeding tube placement. Teaching faculty should not only be expert endoscopists who are committed to the entire training process (teaching and assessment) but are facile in the skills involved in instruction. The role of faculty in the training process of endoscopy is covered in depth in the document Principles of Training in GI Endoscopy1Adler D.G. Bakis G. Coyle W.J. et al.ASGE Training CommitteePrinciples of training in GI endoscopy.Gastrointest Endosc. 2012; 75: 231-235Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar and is applicable to the endoscopic placement of devices for enteral nutrition as well. Program directors need to ensure that an adequate number of faculty who are qualified in the placement of enteral devices are available to ensure quality teaching and that some form of monitoring of faculty teaching occurs to ensure that the standards are maintained. Training programs must maintain an environment that is conducive to quality endoscopy education. This includes not only adequate procedural equipment, staffing, and compliance with work-hour guidelines but from a departmental and institutional standpoint as well. These issues are addressed succinctly in the joint ASGE and American College of Gastroenterology document Ensuring Competence in Endoscopy3Faigel D, Baron T, Lewis B, et al. Ensuring competence in endoscopy. American College of Gastroenterology Executive and Practice Management Committees. Available at: http://www.asge.org/assets/0/71542/71544/a59d4f7a580e466ab9670ee8b78bc7ec.pdf. Accessed September 1, 2013.Google Scholar as well as the ACGME Program Requirements for Graduate Medical Education in Gastroenterology.4ACGME program requirements for graduate medical education in gastroenterology (internal medicine). Available at: http://www.acgme.org/acgmeweb/portals/0/PFAssets/2013-PR-FAQ-PIF/144_gastroenterology_int_med_07132013.pdf. Accessed September 1, 2013. Approved by the ACGME July 1, 2012.Google Scholar Trainees should have at least basic endoscopic skills (intubation of the upper esophageal sphincter, basic endoscopic tip control, use of buttons of the endoscope, passing devices down the working channel, etc) in diagnostic upper endoscopy before receiving training in enteral feeding tube placement. Trainees should have an appropriate balance of the technical aspects of enteral feeding tube placement as well as clinical patient care and didactics in nutrition during their training. The ethics of enteral feeding remains a difficult issue, in part because the endoscopist not only performs the actual placement of the feeding device but also has to decide whether the individual patient will derive meaningful benefit from device placement for enteral nutrition. There is no evidence that tube feeding improves comfort, survival, or functional status or prevents aspiration in many patient groups, including those with dementia.5Finucane T.E. Bynum J.P. Use of tube feeding to prevent aspiration pneumonia.Lancet. 1996; 348: 1421-1424Abstract Full Text Full Text PDF PubMed Scopus (224) Google Scholar These complex issues should be introduced to the trainee during formal teaching sessions as well as during each consultation in which endoscopic enteral feeding access is considered. Assessing the expectations of patients, family, and other caregivers and weighing the risks, benefits, and alternatives of enteral feeding access is challenging, but it is the responsibility of the entire multidisciplinary care team, including the endoscopist. Trainees must understand indications and contraindications for all endoscopic techniques of enteral access. Many contraindications to percutaneous enteral gastrostomy (PEG) tube placement have been rendered relative, because careful patient selection and strict adherence to proper technique may allow successful PEG placement in some patients with ascites,6Wejda B.U. Deppe H. Huchzermeyer H. et al.PEG placement in patients with ascites: a new approach.Gastrointest Endosc. 2005; 61: 178-180Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar severe obesity,7McGarr S.E. Kirby D.F. Percutaneous endoscopic gastrostomy (PEG) placement in the overweight and obese patient.JPEN J Parenter Enteral Nutr. 2007; 31: 212-216Crossref PubMed Scopus (12) Google Scholar or peritoneal metastasis, for example. Trainees must be aware of situations in which short-term nasoenteric feeding is preferable to more permanent access and conditions in which standard PEG placement will be unsuccessful or problematic, such as with gastric resection, GI outlet obstruction, gastric dysmotility, and severe reflux. Jejunal feeding access may be preferable in some of these patients. The trainee should understand that PEG feedings or PEG with jejunal extension tube feedings (see the following) do not reduce rates of aspiration,5Finucane T.E. Bynum J.P. Use of tube feeding to prevent aspiration pneumonia.Lancet. 1996; 348: 1421-1424Abstract Full Text Full Text PDF PubMed Scopus (224) Google Scholar, 8Kadakia S.C. Sullivan H.O. Starnes E. Percutaneous endoscopic gastrostomy or jejunostomy and the incidence of aspiration in 79 patients.Am J Surg. 1992; 164: 114-118Abstract Full Text PDF PubMed Scopus (121) Google Scholar, 9Lien H.C. Chang C.S. Chen G.H. Can percutaneous endoscopic jejunostomy prevent gastroesophageal reflux in patients with preexisting esophagitis?.Am J Gastroenterol. 2000; 95: 3439-3443Crossref PubMed Google Scholar which is thought to be related to intragastric pressure.10Kudo M. Kanai N. Hirasawa T. et al.Prognostic significance of intragastric pressure for the occurrence of aspiration pneumonia in the patients with percutaneous endoscopic gastrostomy (PEG).Hepatogastroenterology. 2008; 55: 1935-1938PubMed Google Scholar The trainee should recognize when the patient would be better served by either a surgically or interventional radiology placed feeding tube such as in patients with severe obesity or multiple prior abdominal surgeries that may increase the risk of intestinal perforation. The trainee needs to understand that special attention must be paid to issues of moderate sedation and airway assessment in these patients, many of whom have head and neck malignancies, stroke, altered mental status, or are elderly. ASGE clinical guidelines on Training in Patient Monitoring and Sedation and Analgesia11Vargo J.J. Ahmad A.S. Aslanian H.R. et al.Training Committee of the American Society for Gastrointestinal EndoscopyTraining in patient monitoring and sedation and analgesia.Gastrointest Endosc. 2007; 66: 7-10Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar and Modifications in Endoscopic Practice for the Elderly12Chandrasekhara V. Early D.S. Acosta R.D. et al.ASGE Standards of Practice CommitteeModifications in endoscopic practice for the elderly.Gastrointest Endosc. 2013; 78: 1-7Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar are important for trainees and trainers to review. As with all endoscopic procedures, a thorough understanding of the informed consent process, patient education, anticoagulation issues,13Anderson M.A. Ben-Menachem T. Gan S.I. et al.ASGE Standards of Practice CommitteeManagement of antithrombotic agents for endoscopic procedures.Gastrointest Endosc. 2009; 70: 1060-1070Abstract Full Text Full Text PDF PubMed Scopus (390) Google Scholar and antibiotic prophylaxis14Banerjee S. Shen B. Baron T.H. et al.ASGE Standards of Practice CommitteeAntibiotic prophylaxis for GI endoscopy.Gastrointest Endosc. 2008; 67: 791-798Abstract Full Text Full Text PDF PubMed Scopus (283) Google Scholar is required of every endoscopy trainee. A thorough discussion of these issues is beyond the scope of this document and is covered in the respective ASGE guidelines referenced earlier. The ASGE Technology Committee Technology Status Evaluation Report on Enteral Nutrition Access Devices15Kwon R.S. Banerjee S. Desilets D. et al.ASGE Technology CommitteeEnteral nutrition access devices.Gastrointest Endosc. 2010; 72: 236-248Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar describes in detail the techniques of performing the various procedures that follow and thus, will not be reiterated. During endoscopic enteral access procedures, communication between the endoscopist and assistants is vital to ensure safety of the patient. It is important for the supervising endoscopist to recognize that this skill may be underdeveloped by the early trainee who is focused on the technical aspects of the procedure. As with any medical encounter, patient comfort, dignity, and privacy are of paramount importance and are skills best taught to the trainee by example and supplemented with constructive feedback. Trainees should be exposed to and aware of the variety of PEG tube sizes (12F-28F), numerous PEG manufacturers with varying kits, and the techniques used for PEG placement, including peroral “pull”16Gauderer M.W. Ponsky J.L. Izant Jr., R.J. Gastrostomy without laparotomy: a percutaneous endoscopic technique.J Pediatr Surg. 1980; 15: 872-875Abstract Full Text PDF PubMed Scopus (1747) Google Scholar and “push”17Foutch P.G. Woods C.A. Talbert G.A. et al.A critical analysis of the Sacks-Vine gastrostomy tube: a review of 120 consecutive procedures.Am J Gastroenterol. 1988; 83: 812-815PubMed Google Scholar methods (direct percutaneous technique18Campoli P.M. Cardoso D.M. Turchi M.D. et al.Assessment of safety and feasibility of a new technical variant of gastropexy for percutaneous endoscopic gastrostomy: an experience with 435 cases.BMC Gastroenterol. 2009; 9 (48-230X-9-48)Crossref PubMed Scopus (25) Google Scholar, 19Russell T.R. Brotman M. Norris F. Percutaneous gastrostomy: a new simplified and cost-effective technique.Am J Surg. 1984; 148: 132-137Abstract Full Text PDF PubMed Scopus (349) Google Scholar is another option less commonly used by gastroenterologists in the United States). Most manufacturers offer both push and pull kits, allowing for individual preferences, and there is little data to support use of one technique over another.20Kozarek R.A. Ball T.J. Ryan Jr., J.A. When push comes to shove: a comparison between two methods of percutaneous endoscopic gastrostomy.Am J Gastroenterol. 1986; 81: 642-646PubMed Google Scholar A step-by-step description of the various PEG techniques and available gastrostomy tubes is outlined in the ASGE Technology Review on enteral nutrition access devices.15Kwon R.S. Banerjee S. Desilets D. et al.ASGE Technology CommitteeEnteral nutrition access devices.Gastrointest Endosc. 2010; 72: 236-248Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar Whichever technique is used, the trainee must be made familiar with the contents of the particular kit, so that the procedure may proceed efficiently and safely. Trainers should emphasize the importance of a proper endoscopic examination prior to placement of the gastrostomy tube itself. This should include evaluation for gastric outlet obstruction, evidence of gastric dysmotility, postoperative anatomy, and gastric ulcer or malignancy, which may alter the decision to place the gastrostomy tube. Techniques used to identify a safe percutaneous site for PEG placement also must be mastered by the trainee, with emphasis on the importance of one-to-one finger indentation and transillumination in assessing any potential site. The trainee should use the “safe tract” syringe aspiration technique during abdominal wall penetration. This involves applying continuous suction through a fluid-filled syringe attached to the angiocatheter or trocar as it passes through the abdominal wall. If bubbles are seen in the syringe prior to visualizing the trocar in the gastric lumen, the presence of bowel between the abdominal and gastric wall is assumed. Once the PEG tube has been inserted via the chosen technique, the trainee should be educated specifically on noting the exact location of the external bolster on the PEG tube for ensuring correct positioning of the tube and for future reference. The trainee should be counseled on the pitfalls of improper placement of the external bolster, including buried bumper syndrome (discussed later) and bumper migration with resultant obstruction. Additionally, the trainee should be aware of the various replacement tubes available, including low profile or button tubes that are available in several diameters and lengths.15Kwon R.S. Banerjee S. Desilets D. et al.ASGE Technology CommitteeEnteral nutrition access devices.Gastrointest Endosc. 2010; 72: 236-248Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar Over the course of training, the trainee not only should master the endoscopic and percutaneous aspects of the procedure but also develop the ability to direct the procedure step-by-step. In training institutions, most PEGs are done by two physicians. The trainee should be aware that many endoscopists in community practice have adopted a method whereby the GI assistant performs the percutaneous portion of the PEG procedure, a practice supported by the Society for Gastrointestinal Nurses and Assistants.21Society of Gastrointestinal Nurses and Assistants (SGNA) position statement: the role of the nurse/associate in the placement of percutaneous endoscopic gastrostomy (PEG) tube. Available at: http://www.sgna.org/Portals/0/Education/Position%20Statements/PEGPlacementPositionStatement.pdf. Accessed September 1, 2013.Google Scholar If appropriate assistant expertise is available, the trainee may benefit from experience leading this so-called one-physician approach during the training period. Jejunal feeding can be accomplished by placing a jejunal extension tube through a pre-existing PEG tube. This is referred to as a PEG-J.22Bumpers H.L. Luchette F.A. Doerr R.J. et al.A simple technique for insertion of PEJ via PEG.Surg Endosc. 1994; 8: 121-123Crossref PubMed Scopus (12) Google Scholar PEG-J may be indicated for patients intolerant of gastric feedings or at higher risk for aspiration of gastric feedings, including those with gastroparesis, severe GERD, repeated aspiration in the past, gastric resection, or gastric outlet obstruction. The trainee should be aware that data regarding aspiration risk of gastric and jejunal feedings are conflicting. With this in mind, the trainee should understand that decisions to place a PEG-J should be individualized. Although technical success rates are as high as 93%,23Udorah M.O. Fleischman M.W. Bala V. et al.Endoscopic clips prevent displacement of intestinal feeding tubes: a long-term follow-up study.Dig Dis Sci. 2010; 55: 371-374Crossref PubMed Scopus (17) Google Scholar, 24Zopf Y. Rabe C. Bruckmoser T. et al.Percutaneous endoscopic jejunostomy and jejunal extension tube through percutaneous endoscopic gastrostomy: a retrospective analysis of success, complications and outcome.Digestion. 2009; 79: 92-97Crossref PubMed Scopus (41) Google Scholar retrograde dislodgement of the jejunal extension has been reported to occur in as many as 33% of cases.24Zopf Y. Rabe C. Bruckmoser T. et al.Percutaneous endoscopic jejunostomy and jejunal extension tube through percutaneous endoscopic gastrostomy: a retrospective analysis of success, complications and outcome.Digestion. 2009; 79: 92-97Crossref PubMed Scopus (41) Google Scholar Endoscopic clip fixation of the distal portion of the tube to the jejunum may prevent dislodgement.23Udorah M.O. Fleischman M.W. Bala V. et al.Endoscopic clips prevent displacement of intestinal feeding tubes: a long-term follow-up study.Dig Dis Sci. 2010; 55: 371-374Crossref PubMed Scopus (17) Google Scholar The trainee should be aware of this issue as well as the generally short functional duration of such tubes (approximately 55 days23Udorah M.O. Fleischman M.W. Bala V. et al.Endoscopic clips prevent displacement of intestinal feeding tubes: a long-term follow-up study.Dig Dis Sci. 2010; 55: 371-374Crossref PubMed Scopus (17) Google Scholar) in consideration of performing PEG-J placement. The trainer should alert the trainee to the wide variety of techniques available for PEG-J placement, including endoscopically grasping the jejunal tube and dragging it into the jejunum (“drag and pull” method), advancing the extension tube over an endoscopically placed guidewire or stiffening catheter, or using an ultra-thin (5.3-mm) endoscope through the PEG for wire placement in the jejunum. Fluoroscopy may guide wire and tube placement. Endoscopic clips have varying success rates. Attention to the details of proper endoscope selection (pediatric colonoscope, enterscope) and proper kit selection (9F vs 12F, built-in plug to occlude PEG lumen, etc) are important for trainees. These procedures can be technically challenging. Therefore, experience in therapeutic upper endoscopy and enteroscopy is helpful because control of endoscope movement while inside the mobile small bowel under suboptimal visual conditions frequently can be encountered during these procedures. Direct percutaneous endoscopic jejunostomy (DPEJ) is an alternative to PEG-J for jejunal feeding and may provide more stable jejunal access.25Fan A.C. Baron T.H. Rumalla A. et al.Comparison of direct percutaneous endoscopic jejunostomy and PEG with jejunal extension.Gastrointest Endosc. 2002; 56: 890-894Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar In general, DPEJ is becoming a more common procedure; however, this procedure still is performed much less commonly than is PEG. This method of long-term jejunal feeding tube placement is a modification of the basic PEG technique but is more technically difficult, given the mobile small bowel, and therefore should be reserved for trainees with sufficient enteroscopy and gastrostomy proficiency and may be more optimally suited for therapeutic endoscopy fellowships. Experience in placement of DPEJs is not currently a requirement for successful GI fellowship completion. The trainee should, however, be familiar with the increased risks associated with this procedure over PEG placement26Maple J.T. Petersen B.T. Baron T.H. et al.Direct percutaneous endoscopic jejunostomy: outcomes in 307 consecutive attempts.Am J Gastroenterol. 2005; 100: 2681-2688Crossref PubMed Scopus (139) Google Scholar (ie, bowel perforation, bleeding, jejunal volvulus, death) and the overall lower technical success rate, although high technical success rates have been reported with DPEJ performed with single-balloon enteroscopy.27Aktas H. Mensink P.B. Kuipers E.J. et al.Single-balloon enteroscopy-assisted direct percutaneous endoscopic jejunostomy.Endoscopy. 2012; 44: 210-212Crossref PubMed Scopus (24) Google Scholar The trainee should be aware that in contrast with PEGs, the success of DPEJ placement may be increased by altered surgical anatomy.24Zopf Y. Rabe C. Bruckmoser T. et al.Percutaneous endoscopic jejunostomy and jejunal extension tube through percutaneous endoscopic gastrostomy: a retrospective analysis of success, complications and outcome.Digestion. 2009; 79: 92-97Crossref PubMed Scopus (41) Google Scholar, 26Maple J.T. Petersen B.T. Baron T.H. et al.Direct percutaneous endoscopic jejunostomy: outcomes in 307 consecutive attempts.Am J Gastroenterol. 2005; 100: 2681-2688Crossref PubMed Scopus (139) Google Scholar There are no current guidelines to recommend a minimum number of DPEJs to perform prior to achieving competence. However, the consensus of the ASGE Training Committee is that each program needs to determine this threshold number to provide adequate experience to fellows wishing to perform DPEJs on completion of training, recognizing that some programs may not have available expertise or case volume for this procedure. Nasoenteric tubes (NETs) are widely used for short-term nutritional support, considered to be ≤4 to 6 weeks. The placement of NETs may be performed unassisted at the bedside or with the use of endoscopy nasoenteric tubes (ENETs) or fluoroscopy. The trainee should be aware of these various options for placement. A wide variety of endoscopic methods has been developed, with no predominant single technique prevailing to date.28Byrne K.R. Fang J.C. Endoscopic placement of enteral feeding catheters.Curr Opin Gastroenterol. 2006; 22: 546-550Crossref PubMed Scopus (44) Google Scholar, 29DiSario J.A. Endoscopic approaches to enteral nutritional support.Best Pract Res Clin Gastroenterol. 2006; 20: 605-630Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar With respect to ENETs, the trainee should be aware of the challenges of retrograde movement of the feeding tube during endoscope withdrawal with the traditional drag and pull method and that, in general, accidental or purposeful dislodgement is common, particularly in the very young, elderly, or disoriented.30Meer J.A. Inadvertent dislodgement of nasoenteral feeding tubes: incidence and prevention.JPEN J Parenter Enteral Nutr. 1987; 11: 187-189Crossref PubMed Scopus (49) Google Scholar Attempts to prevent dislodgement include use of an endoscopically placed stiff guidewire over which the NET will be advanced, securing the NET to the jejunal mucosa with an endoscopic clip, and bridling the NET at the nose.31Seder C.W. Stockdale W. Hale L. et al.Nasal bridling decreases feeding tube dislodgment and may increase caloric intake in the surgical intensive care unit: a randomized, controlled trial.Crit Care Med. 2010; 38: 797-801Crossref PubMed Scopus (53) Google Scholar The trainee should be aware that given the concern for retrograde dislodgement, postprocedure confirmation of placement by abdominal radiograph may be necessary. The trainee should be aware that similar risks of aspiration have been found with gastric and post-pyloric gastric feeding.32Ho K.M. Dobb G.J. Webb S.A. A comparison of early gastric and post-pyloric feeding in critically ill patients: a meta-analysis.Intensive Care Med. 2006; 32: 639-649Crossref PubMed Scopus (127) Google Scholar, 33Strong R.M. Condon S.C. Solinger M.R. et al.Equal aspiration rates from postpylorus and intragastric-placed small-bore nasoenteric feeding tubes: a randomized, prospective study.JPEN J Parenter Enteral Nutr. 1992; 16: 59-63Crossref PubMed Scopus (180) Google Scholar Prior to removal of any enteral nutrition device, the trainee must ensure that the indication for which the device was placed has resolved. Furthermore, the trainer must underscore the importance of knowing who initially placed the device (ie, surgery, interventional radiology, or gastroenterology) because there are differences in the internal bumper or securing devices (ie, sutures) among different methods. However, most currently available endoscopic PEG kits are designed for external traction removal; some are removed by simply deflating the internal balloon, and yet others with a fixed, rigid bumper require endoscopic removal. The trainee should be exposed to the amount of physical force (10-14 pounds of external pull pressure) necessary to remove a PEG tube with traction and also how to counsel the patient in anticipation of PEG removal. The trainee should be aware that PEG removal can be performed in an outpatient clinic visit, or, if sedation is necessary, in the endoscopy suite. The interval between PEG placement and safe traction removal has not been determined definitively by study, but many clinicians recommend at least 6 weeks from the date of PEG placement to allow for maturation of the gastrocutaneous fistula. The trainee should know to notify the patient that leakage from the gastrocutaneous fistula can be expected for up to 2 to 4 weeks, after which minimal to no gastric output should be seen through the fistula (persistent fistula may be present for PEG tubes in place for greater than 1 year). PEG replacement is necessary in cases of unintentional PEG dislodgement or tube dysfunction and deterioration. When notified of an unintentional PEG dislodgement, the trainee must know to inquire about when the PEG was placed. If dislodgement occurs within 14 days of insertion, the track may not be mature and “blind” reinsertion of a tube via the fistula (without endoscopic or radiologic guidance) should not be attempted.34Taheri M.R. Singh H. Duerksen D.R. Peritonitis after gastrostomy tube replacement: a case series and review of literature.JPEN J Parenter Enteral Nutr. 2011; 35: 56-60Crossref PubMed Scopus (26) Google Scholar The trainee should be aware that the gastrocutaneous track is prone to closure within hours of dislodgement, even in the case of a mature fistulous track, and thus the trainee should be aware of efforts to maintain fistula patency (ie, place a Foley catheter, ask the patient to proceed immediately to the local emergency department) until PEG replacement can be performed. The trainee should be well-versed in the types of replacement tubes available at the institution and have an understanding of other options available. A complete and updated list of all types of enteral feeding devices, including replacement tubes, is contained within the ASGE Technology Committee Review on enteral nutrition devices.15Kwon R.S. Banerjee S. Desilets D. et al.ASGE Technology CommitteeEnteral nutrition access devices.Gastrointest Endosc. 2010; 72: 236-248Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar Techniques for tract measurement and safe placement must be carefully taught to the trainee. The need for verification of proper tube position by examination, aspiration of gastric contents, and possibly a radiographic contrast study prior to the initiation of feeding should be part of this training. The trainee should be taught about the possible adverse events of PEG replacement, including fistula disruption, misplacement of the tube into the peritoneal cavity, and hemorrhage.35Nishiwaki S. Araki H. Fang J.C. et al.Retrospective analyses of complications associated with transcutaneous replacement of percutaneous gastrostomy and jejunostomy feeding devices.Gastrointest Endosc. 2011; 74: 784-791Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Following endoscopic enteral feeding access procedures, communication of findings and planning for follow-up care is extremely important. The trainee should be taugh