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mercial PEG tube is 20 Fr caliber. PEG insertion has been reportedly performed by gastroenterologists, trauma surgeons, general surgeons, and otorhinolaryn-gologists. In those patients in whom PEG is unsuccessful, there are alternatives to surgical gastrostomy. Modifications of the PEG technique have allowed inter-ventional radiologists to insert gastrostomy tubes with fluoroscopic guidance (69). Laparoscope assisted placement of gastrostomy tubes allows peritoneal visualization, to prevent accidental intestinal injury (70). Adjacent adhesions may be lysed to mobilize and clear the anticipated site for tube placement.

Overall good results are associated with the PEG procedure. Gencosmanoglu et al. (71) reported on a series of 115 patients with neuropathologic indications undergoing PEG with low procedure-related morbidity and mortality rates. One of the main concerns with PEG in neurotrauma is the subset of patients with hydrocephalus. A review of neurosurgical patients undergoing simultaneous placement of a PEG and a ventriculoperitoneal (VP) shunt revealed a high rate of peritoneal infective complications (72). A prospective study on 15 patients with VP shunt undergoing PEG after a minimum of 1 wk after VP shunt placement resulted in no septic complications or shunt malfunctions, regardless of whether the shunt was right or left sided (73). A planned delay in PEG placement after VP shunt placement, or vice-versa, would be prudent.

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