major techniques for placing PEGs have been described in the literature. The Gauderer-Ponsky technique involves performing a gastroscopy to evaluate the anatomy of the stomach. The anterior stomach wall is identified and techniques are used to ensure that there is no organ between the wall and the skin: digital pressure is applied to the abdominal wall, which can be seen indenting the anterior gastric wall by the endoscopist. transillumination (diaphanoscopy): the light emitted from the endoscope within the stomach can be seen through the abdominal wall. a small (21G, 40mm) needle is passed into the stomach before the larger cannula is passed. An angiocath is used to puncture the abdominal wall through a small incision, and a soft guidewire is inserted through this and pulled out of the mouth. The feeding tube is attached to the guidewire and pulled through the mouth, esophagus, stomach, and out of the incision. In the Russell introducer technique, the Seldinger technique is used to place a wire into the stomach, and a series of dilators are used to increase the size of the gastrostomy. The tube is then pushed in over the wire. Anesthetic management There are several techniques such as moderate sedation with left transversus abdominis plane block, and moderate sedation with local anesthetic infiltration at feeding tube site. Contraindications As with other types of feeding tubes, care must be made to place PEGs into an appropriate population. The following are contraindications to PEG use: Absolute contraindications Inability to perform an esophagogastroduodenoscopy Uncorrected coagulopathy Peritonitis Untreatable (loculated) massive ascites Bowel obstruction (unless the PEG is sited to provide drainage) Relative contraindications Massive ascites Gastric mucosal abnormalities: large gastric varices, portal hypertensive gastropathy Previous abdominal surgery, including previous partial gastrectomy: increased risk of organs interposed between gastric wall and abdominal wall Morbid obesity: difficulties in locating stomach position by digital indentation of stomach and transillumination Gastric wall neoplasm Abdominal wall infection: increased risk of infection of PEG site Intra-abdominal malignancy with peritoneal involvement (tumor seeding into formed channel with subsequent failure) In advanced dementia The American Medical Directors Association, the American Geriatrics Society and the American Academy of Hospice and Palliative Medicine recommend against inserting percutaneous feeding tubes in individuals with advanced dementia and, instead, recommend oral assisted feedings. Artificial nutrition neither prolongs life nor improves its quality in patients with advanced dementia. It may increase the risk of the patient inhaling food, it