Background: Placement of a nasoenteric feeding tube (NET)beyond the pylorus in critically ill patients is desirable. Bedside methods are unreliable, and fluoroscopic methods require transport and/or radiation exposure. Traditional endoscopic methods require sedation and oronasal transfer techniques. Transnasal techniques of NET placement by using recently developed ultrathin endoscopes have been described. The object of this prospective study was to compare the efficacy of NET placement by using ultrathin transnasal endoscopy vs. fluoroscopic placement. Methods: This is a prospective randomized study of endoscopic vs. fluoroscopic NET placement. The settings of the study were intensive care units at academic medical center. The study included 100 consecutive patients who required NET placement. They received endoscopic NET placement at the bedside with a 5.1 mm, ultrathin endoscope by using a transnasal over-the-wire technique vs. fluoroscopic NET placement by using standard techniques. The procedure success was defined as postpyloric (beyond the duodenal bulb) NET placement, jejunal placement success, and procedure time. Results: Tube placement success was not significantly different between endoscopic and fluoroscopic methods (90%with both methods; p = 1.00). The endoscopic procedure duration (12.8 ±6.4 minutes) was significantly shorter than fluoroscopic procedure duration (19.3 ±12.0 minutes) (p < 0.001). Procedure duration decreased significantly (from 17.3 ±6.2 minutes to 8.0 minutes ±4.2 minutes, p = 0.04), and jejunal placement increased significantly (from 60%to 100%, p = 0.04) from the first to the last 10 endoscopic procedures. Conclusions: NET placement success with an ultrathin transnasal endoscope is equivalent to fluoroscopic placement with faster procedure times. More distal placement and procedure times improve with increasing experience with the endoscopic technique. Endoscopic NET placement can be performed at the bedside without the need for oronasal transfer, additional sedation, or fluoroscopy. Background: Placement of a nasoenteric feeding tube (NET) beyond the pylorus in critically ill patients is desirable. Bedside methods are unreliable, and fluoroscopic methods require transport and / or radiation exposure. Traditional endoscopic methods require sedation and oronasal transfer techniques. Transnasal techniques of NET placement by using recently developed ultrathin endoscopes have been described. The object of this prospective study was to compare the efficacy of NET placement by using ultrathin transnasal endoscopy vs. fluoroscopic placement. Methods: This is a prospective randomized study of endoscopic vs. fluoroscopic NET The settings of the study were intensive care units at academic medical center. The study included 100 consecutive patients who required NET placement. They received endoscopic NET placement at the bedside with a 5.1 mm, ultrathin endoscope by using a transnasal over-the- wire technique vs. fluoroscopic NET placement by using standard techniques . The procedure success was defined as postpyloric (beyond the duodenal bulb) NET placement, jejunal placement success, and procedure time. Results: Tube placement success was not significantly different between endoscopic and fluoroscopic methods (90% with both methods; p = 1.00) . The endoscopic procedure duration (12.8 ± 6.4 minutes) was significantly shorter than the fluoroscopic procedure duration (19.3 ± 12.0 minutes) (p <0.001). Procedure duration decreased significantly (from 17.3 ± 6.2 minutes to 8.0 minutes ± 4.2 minutes, p = 0.04 ), and jejunal placement increased significantly (from 60% to 100%, p = 0.04) from the first to the last 10 endoscopic procedures. Conclusions: NET placement success with an ultrathin transnasal endoscope is equivalent to fluoroscopic placement with faster procedure times. More distal placement and procedure times improve with increasing experience with the endoscopic technique. Endoscopic NET placement can be performed at the bedside without the need for oronasal transfer, additional sedation, or fluoroscopy.