Inclusion criteria:  Age greater than or equal to 18 years Cannot maintain adequate nutrition by mouth  Exclusion criteria:  Venting-only gastrostomy Patients with Amyotrophic Lateral Sclerosis (ALS) Coagulopathy with uncorrectable International Normalized Ratio (INR) greater than 1.5 or inability to hold anticoagulation  Structural abnormality that would prevent one or both techniques  Known severe esophageal stricture Obstructing malignancy in oropharynx or esophagus that prohibits pull-through technique Neoplastic, inflammatory, or infiltrative disease of abdominal wall or gastric wall Known hepatomegaly Abdominal wall mesh  Enteric functional abnormality  Small bowel or colonic obstruction Gastric or small bowel dysmotility Active abdominal infection/peritonitis/enterocutaneous fistula Ascites Ventriculoperitoneal shunt Inpatient status Pregnant patient