Operative management of enteral access in acute care surgery—What you need to know

Early enteral nutrition is a cornerstone of supportive care in critically ill patients, preserving gut integrity, reducing infectious complications, and improving outcomes. In acute care surgery, establishing durable enteral access remains a frequent and complex challenge, with decisions shaped by patient history, comorbidities, and operative context. This article reviews current evidence and practical considerations for operative management of enteral access, focusing on indications, timing, procedural options, and areas of ongoing controversy. Bedside percutaneous endoscopic gastrostomy (PEG) is common but limited by morbid obesity, prior surgery, or distorted anatomy. In these cases, laparoscopic-assisted PEG provides a minimally invasive and effective alternative, combining endoscopic guidance with laparoscopic visualization to ensure safe gastric access. Laparoscopic or open gastrostomy remains necessary when endoscopic access is not feasible, such as in the setting of esophageal obstruction or severe adhesions. Gastropexy techniques may reduce tube dislodgement and tract misalignment and aid tract maturation, but routine use remains debated. Timing of access must be individualized, balancing recovery potential against risks of prolonged nasogastric feeding and operative complications. Current guidelines recommend delaying PEG placement in acute stroke, while supporting earlier placement in patients with traumatic brain injury, progressive neuromuscular disease, head and neck malignancy, or anticipated prolonged critical illness. Evidence demonstrates that minimally invasive approaches achieve high success rates with low morbidity, providing an important bridge between percutaneous and open operations. Ultimately, operative management of enteral access should be tailored to patient anatomy, disease trajectory, and goals of care, requiring surgeons to remain proficient in the full spectrum of techniques and be able to anticipate potential complications.