A percutaneous endoscopic gastrostomy was placed in 20 malnourished patients to serve as a conduit for passage of a percutaneous endoscopic jejunostomy (PEJ) catheter for delivery of alimentation directly into the small bowel. Serious complications occurred in 95% of the patients and 50% of the subjects died. Aspiration was the most common adverse event and accounted for all deaths. Ten of 15 subjects (67%) treated with a PEJ to prevent aspiration continued to aspirate after the catheter was placed. PEJ tube failures were documented in 14 subjects (70%) and occurred because of occlusion, leakage, malposition, extrusion, cracking, kinking, or rupture of the catheter. These problems rendered the PEJ nonfunctional 18% of the time. Large manpower and resource investments were required to manage the PEJ and its complications. Our results suggest that enteral feeding through a PEJ does not prevent aspiration. Serious PEJ-related morbidity (95%), mortality (50%), and catheter failures (70%) occur. Refinements in methodology and catheter design will be required before additional use of this technique can be recommended.