Jeffrey Ponsky

684 statements · 9 topics · summaries given as host listed separately

Colorectal / ARM & Hirschsprung · episode host Inguinal Hernia · episode host Low Cardiac Output · episode host Sarcoma (Ewing/Rhabdo) · episode host Soft Tissue Sarcoma (lymph nodes) · episode host

Featured statements

If you have a patient that you did a lap choleon, and they call you because they're having pain, something's wrong. Lap choleys don't have pain if everything went well. Now, I may be wrong in 1% of cases, but not many. The patient calls you, the mother calls you, or anybody calls you, says, you know, he's a little nausea, he's not eating well, a little bloated, and he's having pain. It's three days later. Come into the emergency room. Stat. Because in my mind, that's a bile leak, and even, God forbid, a common duct injury until proven otherwise.
quote · Acute Cholecystitis
We talk about how the cavalier fashion where we do that direct puncture of the jejunum to do a direct jejunostomy and how you can be sure you're not in another loop of bowel because you aspirate as you go in. I wasn't in another loop of bowel, but I was through the mesentery of the colon when I went into the small bowel.
quote · Foundations of Minimally Invasive & Endoscopic Surgery
The rule is, in the old days, everybody got ERCP the day they came in. Hydrate them, make them NPO, watch them in the hospital, and don't get the ERCP on the first day because when we did that, we found that two-thirds of the patients that we did the ERCPs on had normal ERCPs.
quote · Acute Cholecystitis
Surgical endoscopy is just another way to do surgery. Uh, much as we do a cystoscopy in the bladder or any other type of ear, nose, and throat surgery, the endoscope is the vehicle which gets us to the place where we have to do the surgery.
quote · Foundations of Minimally Invasive & Endoscopic Surgery
A primary end-to-end repair of the common bile duct is almost always fraught with failure. Most often, a common duct injury, unless it's just a lateral injury, is best treated with a hepatic oj genostomy.
quote · Pancreatitis
The hard part is going down on the stomach. You must go down on the stomach. I like to go down four or five centimeters when we do it because that's where the operation fails if you don't do that.
quote · Achalasia

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Jeffrey's statements about Achalasia 47 statements

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POEM by Surgeons – Dr. Jeffrey Ponsky

Statement Laparoscopic Heller myotomy is the gold standard for the treatment of achalasia. Open
Quotation It's a beautiful operation. Why screw with it? You guys do such a good job, the the general surgeons do such a good job with this. Open
Quotation The hard part is going down on the stomach. You must go down on the stomach. I like to go down four or five centimeters when we do it because that's where the operation fails if you don't do that. Open
Statement In Heller myotomy, the operation fails if the myotomy does not extend 4-5 centimeters down onto the stomach. Open
Statement A fundoplication (Dor) is added to Heller myotomy based on a Vanderbilt paper, but surgeons know in their hearts it doesn't provide significant benefit. Open
Quotation Now you guys wouldn't do a door for a real anti-reflux operation, but here you go and we do this door and we think it's going to do us a lot of good, but we really know in our heart that it doesn't. Open
Statement Dr. Inoue, a thoracic surgeon in Yokohama, performed the first POEM procedure in the world in 2010. Open
Statement In POEM, the mucosal entry is made 14 centimeters proximal to the EG junction. Open
Statement During POEM, the longitudinal muscle splits automatically when the circular muscle is divided. Open
Statement The POEM procedure takes about one hour. Open
Statement Occasionally during POEM, the mucosa cannot be separated from the submucosa; in these cases (three in seven years for the speaker), the procedure should be stopped, the entry clipped closed, and a Heller myotomy performed instead. Open
Statement POEM patients have almost a 40% incidence of abnormal reflux. Open
Statement All POEM patients should be placed on a PPI once daily indefinitely because they can develop strictures without it. Open
Statement POEM is effective in over 90% of cases. Open
Statement POEM patients have 35-40% abnormal reflux rates. Open
Statement Long-term data suggest POEM may be equal to Heller myotomy in every way after three years. Open
Quotation You know, some of you get to work in a car. Some of you take the subway. Some of you take a bus or Uber to work. That's how you get to work. But when you get to work, you all do the same thing. You cut the muscle and it doesn't matter if you get there with the laparoscope or the endoscope, the point is you're cutting the muscle, that's surgery. Open
Quotation So learn to take a different way to work. That's all I'm saying to you. Open
Quotation I call this intramural surgery, it's surgery within the wall of a viscus or an organ. Open
Statement Gastroparesis is caused by diabetes, idiopathic factors, and post-surgical complications including esophagectomy. Open
Quotation A lot of you guys create this condition. When you do your esophagectomies and such, you create gastroparesis, so did I. Open
Statement POP (peroral pyloromyotomy) involves creating a 4 cm tunnel to the pyloric ring and dividing it, and takes 15 minutes. Open
Quotation We divide it and get out of dodge, it takes 15 minutes. Open
Quotation What does this do? We don't know, but it affects gastric motility somehow. Open
Quotation What if you make a hole here? It doesn't matter. You just cover it with the mucosal flap. Open
Statement The speaker's institution has performed about 400 POP procedures. Open
Statement In the first 100 POP cases presented at a meeting, three-quarters of patients had normalized gastric emptying studies at three months, all of which were abnormal before the procedure. Open
Statement POP is an easy procedure that takes 15-20 minutes and is easy to learn, unlike ERCP. Open
Quotation So these patients are grateful and happy, and this is an easy procedure that takes 15, 20 minutes and it's easy to learn. It's not like ERCP. Open
Statement STEER (submucosal tunneling and endoscopic resection) is used to remove esophageal leiomyomas by creating a submucosal tunnel and shelling out the tumor. Open
Statement The speaker treated a 17-year-old girl with a 7 cm esophageal leiomyoma causing dysphagia using STEER, dividing the tumor in half to remove it through the tunnel. Open
Statement All esophageal leiomyomas undergo endoscopic ultrasound before STEER. Open
Statement ENT surgeons are now referring Zenker's diverticulum patients to the speaker because elderly patients with kyphoscoliosis and tight jaws are difficult to manage with general anesthesia and open neck surgery. Open
Quotation You know, we say let the ENT guys deal with this. But guess what, they're sending them to me now. Open
Statement Cricopharyngeal myotomy is the basis of treatment for Zenker's diverticulum. Open
Quotation My residents call this the Pansky maneuver. I like to stretch this submucosa a little bit. Open
Quotation Anything that's blue can be coagulated. Open
Statement Endoscopic Zenker's treatment takes 15-20 minutes. Open
Statement For endoscopic Zenker's treatment, patients are kept on clear liquids for a couple of days before the procedure to clear debris from the diverticulum. Open
Quotation What happens if you make a hole in the mucosa? Absolutely nothing. Don't worry about the mucosa because for years we just cut this without even uh making a tunnel. Open
Statement During endoscopic Zenker's myotomy, if a hole is made in the mucosa, it does not matter because the mucosal flap will cover it. Open
Quotation So the GI people like to call this third space endoscopy. It shows me where their head is. Third space endoscopy, what does that mean? I call this what I believe it is, intramural surgery. This is surgery by any account and it occurs within the wall. So it's intramural surgery. Open
Quotation So these procedures are surgery. They should be performed by surgeons. Not gastroenterologist. Open
Statement The speaker has trained gastroenterologists, thoracic surgeons, and general surgeons to perform intramural surgical procedures. Open
Quotation But I believe that we have to update our profession. Open
Statement Thoracic surgeons at the speaker's institution have embraced intramural surgery techniques. Open
Quotation I believe that thoracic surgeon should, you should have a course to teach people how to do this. This is in the realm of general thoracic surgeries. Open
Jeffrey's statements about Acute Cholecystitis 53 statements

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Gallstone Disease

Statement Biliary dyskinesia is diagnosed with a HIDA scan showing ejection fraction less than 35% after CCK administration, when all other tests are negative. Open
Statement Modern practice favors early cholecystectomy within the first week for acute cholecystitis, rather than the older approach of cooling down for six weeks. Open
Statement For stable acute cholecystitis without peritonitis, it is reasonable to wait until the next operating day (e.g., Monday if presenting Saturday) rather than operating emergently. Open
Statement There is no evidence that prophylactic antibiotics help in acute cholecystitis management. Open
Statement The sucker is a great tool for blunt dissection during difficult cholecystectomy; hydrodissection (injecting water between tissue planes) helps in tough areas. Open
Statement After isolating the cystic duct-gallbladder junction, turning the hook cautery toward the gallbladder and lifting while cauterizing gains an additional half-centimeter of cystic duct length. Open
Quotation Easy gallbladders are the ones where you can make the bad mistakes. There can be accessory cystic ducts, there can be problems with the cystic artery that you didn't realize, an anterior and posterior one, and you have to be careful. So it's real easy, make yourself slow down. You know you're going to go slow on a hard one. Go slow on an easy one. Open
Statement Easy gallbladders are dangerous because surgeons become complacent; accessory cystic ducts and vascular variants can be missed. Open
Statement Routine intraoperative cholangiography is debated; some institutions do it in every case for teaching and to improve transcystic exploration skills, while selective use based on risk factors (pancreatitis history, jaundice, dilated duct) is also acceptable. Open
Statement When contrast on cholangiogram flows only distally into the duodenum, pressing on the papilla with the laparoscope under fluoroscopy forces contrast proximally, avoiding the need for morphine to induce sphincter spasm (technique taught by Michelle Gagné). Open
Statement Intraoperative administration of 30mg Toradol (age-adjusted in children) before the patient wakes facilitates same-day discharge after cholecystectomy. Open
Quotation If you have a patient that you did a lap choleon, and they call you because they're having pain, something's wrong. Lap choleys don't have pain if everything went well. Now, I may be wrong in 1% of cases, but not many. The patient calls you, the mother calls you, or anybody calls you, says, you know, he's a little nausea, he's not eating well, a little bloated, and he's having pain. It's three days later. Come into the emergency room. Stat. Because in my mind, that's a bile leak, and even, God forbid, a common duct injury until proven otherwise. Open
Statement Any patient with pain 3-5 days after laparoscopic cholecystectomy should be assumed to have a bile leak or bile duct injury until proven otherwise; laparoscopic cholecystectomies do not cause pain if everything went well. Open
Statement For suspected postoperative bile leak, obtain CT or ultrasound to identify fluid collections; if present, aspirate immediately—if bile is present, proceed to ERCP. Open
Statement HIDA scans are useful to confirm normal biliary drainage when postoperative pain occurs without fluid collection, but are less useful than CT for detecting bile leaks. Open
Statement For bile leaks (typically cystic duct), ERCP with sphincterotomy and short stent (10 French, 5cm) decompresses the biliary system and stops drainage; stent is removed at 3-6 weeks. Open
Statement Biliary dyskinesia with ejection fraction less than 35% is an indication for cholecystectomy when all other GI workup is negative. Open
Statement Gallstone pancreatitis is caused by small stones creating transient obstruction of both bile and pancreatic ducts while passing through the papilla. Open
Quotation The rule is, in the old days, everybody got ERCP the day they came in. Hydrate them, make them NPO, watch them in the hospital, and don't get the ERCP on the first day because when we did that, we found that two-thirds of the patients that we did the ERCPs on had normal ERCPs. Open
Statement In the old practice, all patients with gallstone pancreatitis received ERCP on presentation, but two-thirds had normal ERCPs because the stone had already passed. Open
Statement Current management of gallstone pancreatitis: admit, hydrate, NPO, observe overnight and check amylase/lipase trend. If improving, proceed to cholecystectomy during that admission. If worsening or jaundice persists, perform ERCP with sphincterotomy. Open
Statement The choice between preoperative ERCP versus intraoperative common duct exploration depends on local resources, surgeon comfort with laparoscopic ductal techniques, and availability of fluoroscopy and choledocoscopy. Open
Statement For intraoperative common duct stone clearance, after cholangiogram shows a stone (meniscus sign), give 1 amp (1mg) glucagon IV, wait 1-2 minutes, flush with saline, and repeat cholangiogram. Open
Statement If glucagon fails to clear the stone, pass a soft-tip wire through the cystic duct under fluoroscopy into the duodenum to attempt to dislodge it; never push against resistance. Open
Statement A Dormia basket can be passed closed into the duodenum under fluoroscopy, opened slightly, and pulled back with jiggling to catch stones; alternatively, a #5 Fogarty catheter (vascular Fogarty works) can be inflated in the duodenum, pulled to the papilla, deflated slightly, re-inflated and pulled back. Open
Statement Modern choledocoscopes are less than 3mm diameter and can be passed through the cystic duct (sometimes requiring balloon dilation) for direct stone visualization and extraction with Dormia basket or balloon. Open
Statement After transcystic common duct exploration, place endoloops on the cystic duct stump because prolonged obstruction can blow off simple ties. Open
Statement Laparoscopic common bile duct exploration via choledocotomy should only be performed in dilated ducts (>1-1.5cm, ideally 2cm) to avoid stricture risk; small-caliber ducts with stones should be managed with ERCP. Open
Statement For laparoscopic choledocotomy, do not divide the cystic duct—use the gallbladder for lateral retraction while dissecting down to expose the anterior common duct surface. Open
Statement T-tube preparation for choledocotomy closure: cut to 1 inch on each side of the T, bevel the edges, remove half the back wall to facilitate insertion and later removal. Open
Statement T-tube cholangiogram is performed at 10 days post-choledocotomy; if clear, the T-tube is removed at 2 weeks. Open
Statement For severe pancreatitis with large phlegmon in the pancreatic head, obtain CT and consider waiting 6 weeks before cholecystectomy to allow inflammation to resolve. Open
Statement For patients with multiple stones extending up both hepatic ducts in a very dilated common duct, or stone-formers like sickle cell patients, consider choledochoduodenostomy (2cm anastomosis) as a drainage procedure to allow future stones to pass. Open
Statement Percutaneous cholecystostomy can temporize severe acute cholecystitis in high-risk patients or those with large phlegmon, allowing interval cholecystectomy at 6 weeks, but requires normal clotting studies. Open
Statement In cases where anatomy is unrecognizable intraoperatively, subtotal cholecystectomy is acceptable: remove the anterior wall or fundus, cauterize the remaining mucosa on the back wall with bovie to prevent mucocele, place drains, and accept a controlled leak. Open
Statement Common bile duct injuries typically occur during 'easy' cases when surgeons become complacent and fail to maintain vigilance. Open
Statement The common duct can come up to the gallbladder and take a bend like a knee, appearing identical to the cystic duct; only continued dissection reveals the true 2-3mm cystic duct coming off the 'knee.' Open
Statement Being able to pass an instrument around a structure does not prove it is the cystic duct—the common bile duct can be encircled and mistakenly used for retraction. Open
Quotation If you're going to do biliary surgery, this could happen to anyone. Know that. It's not an incrimination of you. Stop. Suck it out. Take a few breaths and if you have another partner, call them in. Open
Statement If common bile duct injury is recognized intraoperatively: STOP immediately, call for help, and assess. If shaken or inexperienced with hepaticojejunostomy, do not attempt repair. Open
Quotation What happens in most of these cases is the primary injury is compounded by the attempted repair. Open
Statement In most bile duct injury cases, the primary injury is compounded by the attempted repair. Open
Quotation A primary end-to-end repair of the common bile duct is almost always fraught with failure. Most often, a common duct injury, unless it's just a lateral injury, is best treated with a hepatic oj genostomy. Open
Statement Primary end-to-end repair of transected common bile duct is almost always fraught with failure; most common duct injuries (except small lateral injuries) are best treated with hepaticojejunostomy. Open
Statement For small lateral common duct injuries, place a small T-tube rather than primary suture closure, as suture alone will leak. Open
Statement For complete common duct transection, leave everything alone, place multiple drains, do not place ties or tubes that will compromise remaining duct length for the hepatobiliary surgeon, and transfer the patient. Open

Acute Cholecystitis

Statement Acute cholecystitis is an obstructive diverticulopathy where the cystic duct becomes obstructed by a stone, causing backup of pressure in the gallbladder with decreased blood flow in the wall that can eventually lead to rupture. Open
Quotation That's how the attending steals the case from the resident here with the sucker. Open
Statement A useful trick is to take some gallbladder just superior to the junction of the cystic duct with the gallbladder and take the back wall off the liver bed to give increased length. Open
Statement In horrible cases, opening the gallbladder, taking out all the stones, and placing a large cholecystostomy tube creates an empty gallbladder with a tube and can bail you out. Open

Acute Cholecystitis

Statement Acute cholecystitis is an obstructive diverticulopathy where the cystic duct becomes obstructed by a stone, causing backup of pressure, decreased blood flow in the wall, wall thickening, and potential rupture. Open
Statement Taking some of the gallbladder just superior to the cystic duct junction and removing the back wall from the liver bed provides increased length for dissection. Open
Statement Opening the gallbladder, removing all stones, and placing a large tube creates a cholecystostomy that can bail out a horrible case. Open
Jeffrey's statements about Choledocholithiasis 7 statements

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Acute Cholecystitis

Statement Acute cholecystitis is an obstructive diverticulopathy where the cystic duct becomes obstructed by a stone, causing backup of pressure in the gallbladder with decreased blood flow in the wall that can eventually lead to rupture. Open
Quotation That's how the attending steals the case from the resident here with the sucker. Open
Statement A useful trick is to take some gallbladder just superior to the junction of the cystic duct with the gallbladder and take the back wall off the liver bed to give increased length. Open
Statement In horrible cases, opening the gallbladder, taking out all the stones, and placing a large cholecystostomy tube creates an empty gallbladder with a tube and can bail you out. Open

Acute Cholecystitis

Statement Acute cholecystitis is an obstructive diverticulopathy where the cystic duct becomes obstructed by a stone, causing backup of pressure, decreased blood flow in the wall, wall thickening, and potential rupture. Open
Statement Taking some of the gallbladder just superior to the cystic duct junction and removing the back wall from the liver bed provides increased length for dissection. Open
Statement Opening the gallbladder, removing all stones, and placing a large tube creates a cholecystostomy that can bail out a horrible case. Open
Jeffrey's statements about Foundations of Minimally Invasive & Endoscopic Surgery 431 statements

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SAGES Stories Episode 11 – Jeff Ponsky, MD

Statement Ponsky graduated high school with a 2.027 GPA and his college counselor recommended trade school instead of college. Open
Quotation I had a 2.027 with my acu graduating from high school Open
Statement Ponsky's father sold used tires for a living and the family had no money for college. Open
Statement Ponsky attended Miami University of Ohio on loans and scholarships, studying by memorizing everything and taking copious notes. Open
Quotation look, I'm gonna do this. As best I can do. I don't know what I'm gonna do. All I know is that I'm gonna work my butt off, and I'm not gonna screw around and I'm not gonna party cause I've done that my whole life and now I was just gonna study Open
Statement Ponsky worked as an orderly at Mount Sinai Hospital during his first college summer, giving bed baths and changing bedpans, which increased his commitment to medicine. Open
Statement Ponsky was promoted to scrub tech the following summer and was allowed to close fascia, despite the head nurse objecting. Open
Quotation Are you gonna take calculus? I said, no, I'm not gonna take it cause I've already got into two medical schools. And he said, OK Open
Statement Ponsky chose Case Western Reserve medical school partly because he had to live at home due to financial constraints. Open
Statement Case Western Reserve had a 'new curriculum' with pass/fail grading (pass, fail, and honors) rather than letter grades during Ponsky's time. Open
Statement Ponsky received honors in every medical school clerkship including psychiatry, internal medicine, cardiology, OBGYN, and surgery. Open
Statement Bill Holden, chairman of surgery at Case Western, was an elegant teacher who used the Socratic method, though not the greatest technician. Open
Statement Walter Pore taught using showmanship, including having students perform pinch grafts at bedside by injecting local anesthetic, cutting postage-stamp-sized skin pieces, and placing them on scraped bedsores. Open
Statement Walter Pore made Ponsky rewrite his first paper (a letter to the New England Journal about paradoxical air embolism) six times and read German poetry to teach more poetic writing. Open
Statement During residency, residents worked 36 hours on, 12 hours off, every other night. Open
Statement The head of GI at University Hospitals refused to train surgeons in endoscopy, telling Ponsky 'we're not training any surgeons, just forget it.' Open
Statement Ponsky trained in endoscopy with Jim King in Canton, Ohio, performing about 500 cases over 5-6 months using a mid-length colonoscope not designed to reach the cecum. Open
Statement Ponsky's mother-in-law purchased his first colonoscope as a Hanukkah present after hearing he couldn't use the hospital's scope. Open
Statement In the early days of endoscopy, scopes were washed with green soap (no high-level disinfection) and Ponsky kept his scope and light source in the back of his car. Open
Statement By the end of Ponsky's senior residency year, he was performing all endoscopy cases at University Hospitals while the GI physicians were not doing cases. Open
Statement Bill Holden provided Ponsky with grant money to purchase an ERCP scope instead of repaying his mother-in-law for the colonoscope. Open
Statement SAGES was founded around 1980-1981 with approximately 300 members when Ponsky became president in 1990. Open
Statement Jacques Perissat showed a video of laparoscopic cholecystectomy in the exhibit hall at the SAGES meeting in Louisville, Kentucky. Open
Statement When laparoscopic cholecystectomy began, instruments couldn't be purchased and surgeons used GYN instruments. Open
Statement Ponsky took one of the first laparoscopic cholecystectomy courses taught by Nat Soper, George Bercy, John Hunter, and John Sackier in Salt Lake City. Open
Statement Ponsky's first laparoscopic cholecystectomy patient was a member of the Mount Sinai board of trustees, with David Dupper (who had done 8 cases) serving as proctor. Open
Statement Ponsky joined the University Hospitals staff as chief of surgical endoscopy at age 29. Open
Statement Ponsky performed endoscopy on newborn babies because there was no pediatric gastroenterologist, with Bob Ezan (head of pediatric surgery) as his supporter. Open
Statement Ponsky and Mike Gower developed the PEG (percutaneous endoscopic gastrostomy) technique in May 1979, performing it on 5 babies with birth asphyxia and psychomotor retardation, without IRB approval but with family consent. Open
Statement Ponsky became chief of surgery at Mount Sinai at age 32. Open
Statement Mount Sinai Hospital was Ponsky's favorite workplace, a small hospital where every staff member knew each other, with an animal laboratory larger than the Cleveland Clinic's. Open
Statement Mount Sinai was sold to a for-profit company after 18 years, and Ponsky left because the new owners 'could care less about quality.' Open
Statement Mike Henderson recruited Ponsky to Cleveland Clinic to be head of surgical endoscopy, and Ponsky became the first head of minimally invasive surgery there. Open
Statement Ponsky had been president of both SAGES and ASGE before joining Cleveland Clinic. Open
Statement All but one of Ponsky's children were born before he finished residency; his last son was born during his final residency year and his daughter 3 years later. Open
Statement Ponsky's wife had no partners helping her while he was on call every other night during residency. Open
Statement Ponsky believes success requires a good partner and that his family's support was essential, making it a joint success rather than individual achievement. Open
Statement Ponsky's parents saw his greatest achievement as becoming chief of surgery at Mount Sinai Hospital, which was meaningful in the Jewish community, rather than his academic positions. Open
Statement Ponsky has two sons who are surgeons, one son who is a real estate developer, and a daughter who is a professional photographer. Open
Statement During ERCP procedures, Ponsky would kick, headbutt, or nudge his fellows when his hands were busy; one fellow wore shoulder pads in response. Open
Statement Ponsky counseled fellows to choose job opportunities based on overall life factors (family location, better academic opportunities, institutional need) rather than just institutional prestige, sometimes advising them away from his own institution. Open
Quotation Don't just choose a job because it's at a great institution. Open
Statement Ponsky performed distal splenorenal shunts early in his career with Jerry Walkoff's assistance, believing it was 'the greatest thing since sliced bread' based on Dean Warren's physiologic approach to reduce variceal pressure without decreasing portal flow. Open
Statement Distal splenorenal shunts became obsolete after a couple of years when rubber band ligation of varices was introduced. Open
Statement Ponsky performed 180 vertical banded gastroplasties in one year in the mid-1980s, believing it would be a great bariatric operation, but these later required reversal. Open
Statement Ponsky predicts that in 20 years, colonoscopy for screening may become obsolete, noting he performed 1600 colonoscopies in the previous year. Open
Statement ERCP is Ponsky's favorite operation, which he compares to golf and would come in day or night to perform. Open
Statement In Ponsky's last few years at Cleveland Clinic, he didn't have fellows learning ERCP and only performed cases when young gastroenterologists requested help or coverage. Open
Statement The first ERCP was performed by surgeons at George Washington Hospital, but the procedure was really developed in Japan by Itaru Oi and others, with contributions from Germans and Peter Cotton's group in London. Open
Statement Ponsky learned ERCP by watching videos and made a deal with George Brodmerkel (a gastroenterologist in Pittsburgh): Ponsky taught him laparoscopy under local anesthesia for liver biopsy, and Brodmerkel taught Ponsky sphincterotomy. Open
Statement Hospital administrators encouraged Ponsky to get an MBA, saying he made decisions 'out of his gut' without knowing return on investment or financing, and they paid for the degree. Open
Statement The business school dean told Ponsky's MBA class: 'you won't be a good businessman when you finish this, but you'll be able to sit in a business meeting and say bullshit at the right time.' Open
Statement Ponsky states he hates business and isn't interested in his children's investments and startups, preferring horses and physical work. Open
Statement The most important aspect of business school is the people you meet and learning their thought process and approach to problems, not the business content itself. Open
Quotation It's the people you meet. It's the way they think. It's the way they approach a problem. Open
Statement Ponsky was on the ASGE governing board when SAGES started and initially felt 'like a traitor to ASGE' because surgeons were starting their own society. Open
Statement At an early SAGES meeting at the Legionnaires Hotel in Pennsylvania, Ponsky realized SAGES papers addressed surgically-specific problems (endoscopy in bowel obstruction, suture line evaluation, volvulus management) that differed from ASGE content. Open
Statement SAGES founders included upper GI surgeons, colorectal surgeons (Ted Schrock, Jerry Marks, Lee Smith), foregut surgeons, and general surgeons from different areas. Open
Statement When laparoscopy emerged, SAGES gained members who weren't involved with flexible endoscopy; today most SAGES members are laparoscopy/minimally invasive surgeons rather than flexible endoscopists. Open
Statement Ponsky advocated to the residency review committee (when Joe Fisher was head) for a minimum endoscopy requirement; the 50-case requirement was initially hated but established endoscopy as part of general surgery training. Open
Statement Ponsky advises always volunteering, never saying no, and getting involved in everything, stating 'you'll find the time' and don't have to do everything yourself—residents can help with papers. Open
Statement Ponsky's wife traveled with him to most meetings; if he went to Paris she was there, but she didn't go to Cincinnati. Open
Statement Ponsky maintains hobbies including a barn with horses, physical work (mucking stalls, fixing things, inventing watering systems), and has friends outside surgery who don't know what he does for a living. Open
Statement Ponsky's wife gave him a Harley trike (three-wheeled motorcycle) when he was 70; she would not allow a two-wheel motorcycle. They have ridden to Sturgis, South Dakota. Open
Statement Ponsky has never been tempted to move from Cleveland because his entire family lives there: his son Zach built a house on 5 acres next to Ponsky's 8 acres, his daughter bought a house 2 houses down with 5 acres, Todd lives within half a mile, and his other son Lee lives 2 miles away. Open
Statement Ponsky has owned a house in Florida for 13 years and would fly there Friday morning at 6 AM, return Monday, taking vacation days for those two days to have weekends in Florida while working full-time. Open
Statement Ponsky states his family wants to be near his wife Jackie, not him, unless something breaks; she is 'the glue that holds our family together.' Open
Statement Ponsky's favorite SAGES memories include his presidential addresses, the people he met (Barbara Bercy, Sally, Colleen, Shelly), friends like George Bercy and Jerry Marks, singing 'We Are the Sages' with the Japanese delegation (which brings him to tears), and performing 'Anything You Can Do' with his son Todd at song fest. Open
Quotation that is not just a song, that is our soul, and that song says why we are different from all other societies, that says that we are a family. Open

Residency Advice: Dr. Jeffrey Ponsky | St. George's University

Statement The interview is only a small part of the whole process of selecting residents. Open
Quotation What we want is people who What's that, uh, Friday Night Lights, Bright eyes and full hearts Open
Statement Residency programs want candidates with 'bright eyes and full hearts' - desire and enthusiasm. Open
Statement Candidates must have passed their USMLE and have good letters of recommendation. Open
Statement Requesting letters of recommendation from people who will write bad letters is an intelligence test that many candidates fail. Open
Quotation Don't ask people to write you a letter of recommendation. They're going to write you bad letters. I mean, hello, that's an intelligence test, and you'd be surprised how many people don't realize that. Open
Statement Candidates should only ask reliable people to write letters of recommendation. Open
Statement During interviews, candidates should make eye contact and look interested in what the interviewer is doing. Open
Quotation We want a partner in the education. You talk to the educators out here, there's nothing better than having a partner in the education. Somebody who looks at you and says, yes, come on, give it to me. I wanna be, I want it. Open
Statement Programs want a partner in education - someone who actively engages and participates. Open
Statement Interviewers want to know that candidates are willing to invest in their own education. Open
Statement Candidates should give interviewers a plan for their future and a vision for their career. Open
Statement Candidates should tell interviewers what they want to do and what their dreams are. Open
Quotation This guy was so electric. He really can't, you know, I know his grades were just OK, but this guy, I want to work with this guy. I like him. That's what they want to hear. Open
Statement A candidate who is 'electric' and engaging can be preferred even if their grades were just OK. Open
Statement During interviews, candidates should not be shy but also should not be a jerk. Open
Quotation Don't be, this isn't the time to be shy. OK, it's, it's not time to be a jerk, but it's not a time to be shy, so get involved. This is your chance. The interview is important. Open
Statement The interview is an important opportunity for candidates. Open

From Idea to Ubiquity - the PEG Journey

Quotation before dinner, if the whole family's there, we join hands, we lower our heads and my wife says, you should have patented the PEG. Open
Statement PEG was developed in 1979 by Jeffrey Ponsky and Michael Gauder working as equal partners, with Gauder contributing conceptual ideas and Ponsky contributing technical ideas. Open
Statement During pediatric endoscopy with room lights off, transillumination clearly showed the stomach in contact with the abdominal wall, which was the key observation leading to PEG development. Open
Statement Original indications for PEG were limited to CNS impairment, oropharyngeal tumors, and gastric atony. Open
Statement Within one year of publication, multiple other groups independently developed alternative PEG techniques because endoscopy and percutaneous techniques were evolving simultaneously. Open
Quotation if we hadn't done it, someone else would have done it. We weren't geniuses, but we were there first. Open
Quotation I said, how fast can we publish this? Will they publish it earlier? Can we get this to the publication right away? How fast? Open
Statement Ponsky approached Olympus, Ethicon, and Ross Laboratories asking them to manufacture the PEG device rather than seeking patent protection. Open
Quotation I ran to Olympus and I ran to Ethicon and I ran to Ross Laboratories. Will you please take this and make it for us? How's that for business sense, right? Open
Quotation that was the aha moment. The aha moment where we knew we could do this. Open
Statement The original PEG technique used a medicut IV catheter (without hub) as the puncture device and a snare to grasp the wire, after initial unsuccessful attempts using biopsy forceps. Open
Quotation In the beginning we tried to grab it with a biopsy forceps, it was like bobbing for apples. Open
Quotation Once we had a hammer, we wanted to use everything in the nail. Open
Statement PEG-J (percutaneous endoscopic jejunostomy) was created by tunneling a Dobhoff tube alongside the G-tube to allow distal feeding while decompressing the stomach, published in 1984. Open
Statement PEG-J tubes cause significant long-term patient problems despite continued use at the request of internists. Open
Quotation I keep hate this procedure. I keep getting asked to do it. Open
Statement Direct jejunostomy involves advancing the endoscope further and puncturing the jejunum where indentation is visible. Open
Statement Ponsky negotiated a 3% of gross sales royalty with Marlin Junker of US Endoscopy for the silicone tube design, which continued for over 20 years and provided sufficient income for housing, vehicles, and children's college education. Open
Quotation I said, can I have a small percentage, you know, of what you sell? I didn't know to not say something. I don't care. He said, I'll give you 3% of gross. Open
Quotation You live in a house. I have a nice car. My kids went to college and I did pretty good. Open
Quotation If you don't have a patent and you start to get other people trying to make this, you increase what's called primary demand. Open
Statement When a product lacks patent protection, competitors entering the market increase primary demand, and the originator with the best product can capture large market share. Open
Quotation this tube doesn't look any different today than it did 40 year, well, 38 years ago when this came out. Nobody changed it. Open
Statement The basic PEG tube design has not changed in 38 years because manufacturers make small margins on each tube and see no business incentive to redesign it despite clinical need for improvement. Open
Quotation the margin that they make on each tube is tiny. They make it, they sell it, there's 250,000 done a year in this country, something like that. But the margin is a tiny margin. Why should they change it? People use it like it is and they think it's, you know, it's good enough. Open
Statement Approximately 250,000 PEG procedures are performed annually in the United States. Open
Statement The original PEG tube was constructed from a DePezzer catheter with the end stuffed into a medicut catheter after placing a suture; stretching the tubing made it narrow enough to fit into the catheter. Open
Quotation We just fiddled and fiddled. Open
Quotation What we found is if you stretched, if you stretched the tubing, it got narrower and it popped into the catheter. Serendipity, we just figured it out. Open
Statement Bunsen burner tubing was cut and used as the external bolster on the original PEG device. Open
Statement Michael Gauder designed a one-step button device with a rip cord that peels away to create a skin-level device, but it never became mainstream for initial placement. Open
Quotation wouldn't it be nice if we could make a skin level device Open
Quotation A business firm, we figured out that if you're putting in all these things and you're pulling them out, the patients are going to need them again, a whole new line of business, right? Again, I wasn't interested in this business thing. I just was glad we could do it. Open
Statement Balloon catheters (Foley-type) are suitable for overnight use to maintain tract patency but do not work well long-term as PEG replacements. Open
Quotation Balloon catheters like a Foley, good overnight to keep the hole open, but they don't work well in the long run. Open
Statement Gauder's Genie device allowed conversion of an existing PEG to a skin-level device by cutting the external portion and inserting a plastic valve, but it never achieved commercial success and is likely no longer sold. Open
Quotation Wouldn't it be cool if you could take the existing peg, cut the end off of it, it's still through the patient's abdominal wall, and then put this plastic valve in it Open
Quotation Very clever, never caught on. I don't think it's even sold anymore. Open
Statement Mickey buttons and similar balloon-based skin-level devices have low complication rates and are widely available in multiple sizes, creating a substantial replacement device market. Open
Statement Wound infections from PEG placement were eliminated by using a single preoperative dose of antibiotic. Open
Quotation Since we use a pre-operative dose of an antibiotic, that doesn't happen. Open
Statement Excessive tension on the external bolster can cause PEG tube erosion through the abdominal wall; tubes should not be placed under tension. Open
Quotation we now know that the tube shouldn't be put under tension. This was a learning process. Open
Quotation I had one guy who was great. I would always see his complications made for great slides. Open
Statement PEG tubes can inadvertently pass through the colon; if they have been in place for an extended period, they can sometimes be removed with spontaneous closure of the colonic defect. Open
Quotation These can actually, if they've been in a long time, you can remove them and they close up spontaneously. Open
Quotation We talk about how the cavalier fashion where we do that direct puncture of the jejunum to do a direct jejunostomy and how you can be sure you're not in another loop of bowel because you aspirate as you go in. I wasn't in another loop of bowel, but I was through the mesentery of the colon when I went into the small bowel. Open
Statement During direct jejunostomy, aspiration during needle advancement does not guarantee avoidance of mesenteric injury; the needle can pass through the mesentery of the colon before entering the small bowel. Open
Quotation these are complicated procedures, these direct jejunostomies. They have a greater complication rate than the direct than the just a pegged thing Open
Statement Direct jejunostomy procedures have a higher complication rate than standard PEG placement. Open
Statement When changing a PEG tube, the stomach can be pushed away from the abdominal wall, creating a complication. Open
Quotation a problem is an opportunity. Open
Statement Ponsky and Jeff Marks published the first human NOTES (natural orifice transluminal endoscopic surgery) procedure in the United States using a displaced PEG tract to access the peritoneal cavity. Open
Statement PEG tube deterioration is thought to be caused by lipases rather than gastric acid. Open
Statement Enterostomal therapists are needed to manage complications of PEG tube leakage and peristomal skin breakdown. Open
Quotation Jeff, here's what you do. You pick a subject. You pick a subject which is really controversial. You make a statement and you say something, this is what you should do and people will say he's crazy, he's crazy, he's crazy. And then all of a sudden they say, well, maybe he can, maybe he's right. Maybe he's right. And after a while they say, he's the right, he's a genius. It's great, that's the way to do it. But then you've done 10 years of your career and you've got the other 10 years to go. What do you do? You say, I was wrong, I was wrong, I was wrong. Open
Quotation When this patient shows up on your schedule and wheels into the room, you go, why? Why are they going to really live more than a week? Open
Statement Clinicians should decline PEG placement in patients with multi-system organ failure, massive ascites, and limited life expectancy. Open
Quotation Don't be afraid to say no, and I do say no, or I did until I retired last month. Open
Quotation just say no to peg occasionally. Open
Quotation I always show this to show you that sometimes we do some good. Open
Statement The peritoneal cavity extends above the rib cage endoscopically, allowing PEG placement between ribs when the abdomen is frozen or inaccessible. Open
Quotation We know that the peritoneal cavity goes up above the rib cage endoscopically. Open
Quotation It gave him some peace. It gave and the family thanked me for that procedure. Open
Quotation anywhere I could stick it, I did. Open
Statement Percutaneous endoscopic cecostomy can be used for colonic decompression. Open
Statement Dual-site colonic fixation using PEG technique successfully detorsed sigmoid volvulus in a patient who could not undergo anesthesia; tubes were removed six weeks later with the colon remaining fixed in place, avoiding surgery. Open
Statement PEG ports can be used for transgastric surgery, with two PEG sites providing instrument access and a gastroscope providing visualization. Open
Statement Ponsky and Michel Gagné performed intragastric surgery using PEG access to remove a submucosal tumor at the esophagogastric junction. Open
Quotation Creativity, it's just a tool. Open
Quotation In essence, peg isn't just a feeding tube. Peg permitted the fixation of a hollow viscus to the abdominal wall and it created access to that viscus. Open
Statement The fundamental innovation of PEG is fixation of a hollow viscus to the abdominal wall with creation of access to that viscus, a principle that cannot be patented as a procedure. Open
Quotation You can't patent a procedure. Open
Quotation we used it, we we did fine financially and we got all the academic travel out of it that we wanted. Open

POEM by Surgeons – Dr. Jeffrey Ponsky

Statement Laparoscopic Heller myotomy is the gold standard for the treatment of achalasia. Open
Quotation It's a beautiful operation. Why screw with it? You guys do such a good job, the the general surgeons do such a good job with this. Open
Statement In Heller myotomy, the operation fails if the myotomy does not extend 4-5 centimeters down onto the stomach. Open
Quotation The hard part is going down on the stomach. You must go down on the stomach. I like to go down four or five centimeters when we do it because that's where the operation fails if you don't do that. Open
Statement A fundoplication (Dor) is added to Heller myotomy based on a Vanderbilt paper, but surgeons know in their hearts it doesn't provide significant benefit. Open
Quotation Now you guys wouldn't do a door for a real anti-reflux operation, but here you go and we do this door and we think it's going to do us a lot of good, but we really know in our heart that it doesn't. Open
Statement Dr. Inoue, a thoracic surgeon in Yokohama, performed the first POEM procedure in the world in 2010. Open
Statement In POEM, the mucosal entry is made 14 centimeters proximal to the EG junction. Open
Statement During POEM, the longitudinal muscle splits automatically when the circular muscle is divided. Open
Statement The POEM procedure takes about one hour. Open
Statement Occasionally during POEM, the mucosa cannot be separated from the submucosa; in these cases (three in seven years for the speaker), the procedure should be stopped, the entry clipped closed, and a Heller myotomy performed instead. Open
Statement POEM patients have almost a 40% incidence of abnormal reflux. Open
Statement All POEM patients should be placed on a PPI once daily indefinitely because they can develop strictures without it. Open
Statement POEM is effective in over 90% of cases. Open
Statement POEM patients have 35-40% abnormal reflux rates. Open
Statement Long-term data suggest POEM may be equal to Heller myotomy in every way after three years. Open
Quotation You know, some of you get to work in a car. Some of you take the subway. Some of you take a bus or Uber to work. That's how you get to work. But when you get to work, you all do the same thing. You cut the muscle and it doesn't matter if you get there with the laparoscope or the endoscope, the point is you're cutting the muscle, that's surgery. Open
Quotation So learn to take a different way to work. That's all I'm saying to you. Open
Quotation I call this intramural surgery, it's surgery within the wall of a viscus or an organ. Open
Statement Gastroparesis is caused by diabetes, idiopathic factors, and post-surgical complications including esophagectomy. Open
Quotation A lot of you guys create this condition. When you do your esophagectomies and such, you create gastroparesis, so did I. Open
Statement POP (peroral pyloromyotomy) involves creating a 4 cm tunnel to the pyloric ring and dividing it, and takes 15 minutes. Open
Quotation We divide it and get out of dodge, it takes 15 minutes. Open
Quotation What does this do? We don't know, but it affects gastric motility somehow. Open
Quotation What if you make a hole here? It doesn't matter. You just cover it with the mucosal flap. Open
Statement The speaker's institution has performed about 400 POP procedures. Open
Statement In the first 100 POP cases presented at a meeting, three-quarters of patients had normalized gastric emptying studies at three months, all of which were abnormal before the procedure. Open
Statement POP is an easy procedure that takes 15-20 minutes and is easy to learn, unlike ERCP. Open
Quotation So these patients are grateful and happy, and this is an easy procedure that takes 15, 20 minutes and it's easy to learn. It's not like ERCP. Open
Statement STEER (submucosal tunneling and endoscopic resection) is used to remove esophageal leiomyomas by creating a submucosal tunnel and shelling out the tumor. Open
Statement The speaker treated a 17-year-old girl with a 7 cm esophageal leiomyoma causing dysphagia using STEER, dividing the tumor in half to remove it through the tunnel. Open
Statement All esophageal leiomyomas undergo endoscopic ultrasound before STEER. Open
Statement ENT surgeons are now referring Zenker's diverticulum patients to the speaker because elderly patients with kyphoscoliosis and tight jaws are difficult to manage with general anesthesia and open neck surgery. Open
Quotation You know, we say let the ENT guys deal with this. But guess what, they're sending them to me now. Open
Statement Cricopharyngeal myotomy is the basis of treatment for Zenker's diverticulum. Open
Quotation My residents call this the Pansky maneuver. I like to stretch this submucosa a little bit. Open
Quotation Anything that's blue can be coagulated. Open
Statement Endoscopic Zenker's treatment takes 15-20 minutes. Open
Statement For endoscopic Zenker's treatment, patients are kept on clear liquids for a couple of days before the procedure to clear debris from the diverticulum. Open
Quotation What happens if you make a hole in the mucosa? Absolutely nothing. Don't worry about the mucosa because for years we just cut this without even uh making a tunnel. Open
Statement During endoscopic Zenker's myotomy, if a hole is made in the mucosa, it does not matter because the mucosal flap will cover it. Open
Quotation So the GI people like to call this third space endoscopy. It shows me where their head is. Third space endoscopy, what does that mean? I call this what I believe it is, intramural surgery. This is surgery by any account and it occurs within the wall. So it's intramural surgery. Open
Quotation So these procedures are surgery. They should be performed by surgeons. Not gastroenterologist. Open
Statement The speaker has trained gastroenterologists, thoracic surgeons, and general surgeons to perform intramural surgical procedures. Open
Quotation But I believe that we have to update our profession. Open
Statement Thoracic surgeons at the speaker's institution have embraced intramural surgery techniques. Open
Quotation I believe that thoracic surgeon should, you should have a course to teach people how to do this. This is in the realm of general thoracic surgeries. Open

Jeffrey Ponsky: Portrait of a SAGES Pioneer

Statement Ponsky was told not to go to college after Cleveland Heights High School, possibly trade school instead, due to poor academic performance. Open
Quotation I was told not to go to college, uh, maybe trade school. Open
Statement Ponsky achieved Phi Beta Kappa at Miami of Ohio after working very hard and changing his persona in college. Open
Statement Ponsky worked as an orderly at age 16 and then as a surgery assistant through college and medical school summers, making him facile with surgical techniques before his surgery clerkship. Open
Statement In Ponsky's medical school era (second year), most students were already married, making him unusual for being single. Open
Quotation I found a magnificent person, and it was the luckiest choice of my life. And I say lucky because when I was 20 years old, who knew what the heck you were doing. Open
Statement Ponsky married Jackie at age 22; they have been married 48 years, which he calls the luckiest choice and biggest influence on his life. Open
Quotation Everything good that I've accomplished is with her guidance and her advice. Open
Statement Surgical residency was 36 hours on and 12 hours off (every other night call), which Ponsky describes as terrible and horrible, not fun. Open
Quotation People think you're going to love it. It was terrible. I mean, it was horrible, and I think residents who think that this is supposed to be fun are misleading their self. It's tough. It's hard work. Open
Statement Ponsky chose endoscopy as a PG-4 elective because he wanted something less demanding, thinking it would be easy after watching gastroenterologists struggle with procedures in the ICU. Open
Quotation I said, darn, I don't want to work this hard. I want to pick something that's not so tough. And I saw those gastroenterologists in the ICU trying to do an endoscopy. I said, perfect. I'll just do this endoscopy thing and I'll blow off for a few months and it'll be easy. Open
Statement The gastroenterology department at the university canceled Ponsky's endoscopy rotation one week before it was scheduled to start, saying they were not training a surgeon and had no spot. Open
Statement Jim King, a gastroenterologist in Canton, Ohio (1.5 hours from Cleveland), trained Ponsky for almost 5 months, performing about 20 procedures per day. Open
Statement After training with Jim King and completing about 500 procedures, the head of gastroenterology refused to let Ponsky touch their instruments or teach residents endoscopy. Open
Statement An endoscope cost $5,200 at the time, which the chairman Bill Holden could not afford to purchase for Ponsky. Open
Statement Ponsky's mother-in-law purchased an endoscope for him as a Christmas/Hanukkah present after hearing about his situation at a family party. Open
Quotation And that scope made all the difference. I still have it. Open
Statement By offering to come in day or night for GI bleeders and immediate procedures, Ponsky built such a strong practice that he "literally put the GI department out of business" within 2 years, with private internists calling him for every case. Open
Quotation At the end of 2 years when I had finished my residency, I literally put the GI department out of business. Open
Statement Doctor Holden provided a $5,000 American Cancer Society grant, which Ponsky used to purchase an ERCP scope rather than repaying his mother-in-law. Open
Statement Ponsky learned ERCP by watching videos, particularly from Peter Cotton, with no formal training and no nurse assistance—he and fellow residents set up the entire table themselves. Open
Statement By 1976, Ponsky was performing upper endoscopy, colonoscopy, and ERCP, and was hired as chief of surgical endoscopy at University Hospitals. Open
Statement In 1979, Ponsky and Michael Gauderer developed the PEG (percutaneous endoscopic gastrostomy) procedure after noticing light shining through babies' abdomens during upper endoscopy due to thin abdominal walls. Open
Quotation We did the first pegs together in 5 brain damaged babies who were infants who were scheduled for open gastrostomy prior to going to long-term nursing care. Open
Statement The first PEG procedures were performed on 5 brain-damaged infants scheduled for open gastrostomy, with maternal consent but no IRB review (which Ponsky does not recall existing at that time). Open
Quotation We talked to the mothers and said, Look, we're going to do a gastrostomy. We may have to open the baby, but we're going to try to poke a needle and just do it with the endoscope, and if it doesn't work, we'll just open. Open
Statement Ponsky became chairman of surgery at Mount Sinai Hospital at age 32, selected because it was a Jewish hospital, he was Jewish, and known as a good teacher. Open
Statement Ponsky served as chief of surgery at Mount Sinai for 18 years, where he performed the first adult PEG procedures and modified and improved the equipment. Open
Statement Around 1980, the American Board of Surgery mandated that surgeons must have experience in endoscopy, but most rotated to GI services where they only watched rather than performed procedures. Open
Statement Ponsky established endoscopy courses at Mount Sinai with faculty including Ken Ford, George Bercy, Rick Green, Tom Dent, Walter Gazeford, and Willie Webb, teaching basic flexible endoscopy to residents annually. Open
Statement Jerry Marks, a colorectal surgeon in Philadelphia, founded SAGES around 1980 because ASGE did not want surgical papers on their programs frequently and did not involve surgeons in leadership. Open
Statement SAGES founding members around 1980 included John Coller, Ken Ford, John Van Sant, Jim Lynn, and others who wanted a place where surgeons could discuss the surgical approach to endoscopy. Open
Statement Early SAGES meetings had a couple hundred attendees and focused on surgical applications of endoscopy, such as decompressing partial bowel obstruction and managing acute lower GI bleeding, which differed fundamentally from ASGE's medical approach. Open
Statement Barbara Saltzman became SAGES administrator early on and helped the society grow and mature, later marrying George Bercy to become Barbara Bercy; she is described as the "mother of SAGES." Open
Statement Around 1989-1990, at a SAGES meeting in Louisville, Jacques Perissat showed a video of laparoscopic cholecystectomy in the exhibit hall (not on the official program), which transformed the field. Open
Quotation And our mouths hit the floor. And the world was never the same. Open
Statement SAGES grew from 300 members at the beginning of Ponsky's presidency to 2,000 members at the end of his 18-month term, driven by the laparoscopic cholecystectomy revolution. Open
Quotation SAGES, which had 300 members at the beginning of my presidency, had 2000 at the end. So it grew that fast in 18 months because everybody wanted to get in. Open
Statement Unlike hierarchical surgical societies where older, accomplished surgeons dominated and younger members remained quiet, SAGES developed a flat organizational structure encouraging young surgeons to participate actively on committees. Open
Quotation We weren't hierarchical. We were very, uh, flat organization, and even though we had officers, every people, the people on the committee were encouraged to get involved when they were very young. Open
Statement The Japanese created the song "We Are the Sages" (based on "We Are the World"), which became the society's anthem, sung with members holding hands at the end of meetings. Open
Quotation To this day I get tears in my eyes when I hear that song. It's become our anthem because everyone holds hands and, and, and sings the song at the end of the meeting and bonds us together as a society. Open
Statement SAGES changed its name from Society of Gastrointestinal Endoscopic Surgeons to Society of Gastrointestinal and Endoscopic Surgeons, making both gastrointestinal surgery and endoscopic surgery equal parts of the organization. Open
Statement SAGES membership is close to 7,000 members. Open
Quotation SAGES is very special. It's special because of the people, especially because of its culture. Open
Quotation SAGES is a family. They know about your good days and your bad days, and they're there to support you. It's not just about a meeting. Open
Statement Japanese surgeons including Manabu Yamamoto, Dr. Suzuki, Dr. Idazuki, and Dr. Yamakawa became leaders in SAGES, teaching advanced techniques like POEM procedures and endoscopic submucosal dissection. Open
Statement The SAGES Song Fest began when Ponsky, as president, performed with "the Lap Rappers" (including John Hunter, Nat Soper, Lee Swanstrom, George Bercy) in tie-dye scrub suits, starting an annual tradition. Open
Statement Haru Inoue pioneered POEM (peroral endoscopic myotomy) procedures in Japan and helped teach these techniques at SAGES courses. Open
Statement SAGES established a Corporate Council under Jerry Marks to manage relationships with industry partners and address mutual concerns on a one-to-one basis. Open
Statement Key industry partners included Olympus (Mike Obsfeld, Mark Donahue, Mr. Moroshima, Terada), Pentax, Fuji, Karl Storz (Mrs. Stortz described as "guardian angel"), US Surgical/Covidian/Medtronic, and Ethicon, providing educational support, fellowships, and technical assistance. Open
Quotation Mrs. Stortz is just an angel. She's a guardian angel of SAGES. She's always been there when we're in trouble, when we need help. Open
Quotation We couldn't do this without our corporate partners. Ironically, our corporate partners become our friends and we depend on them and we grow old with them and mature with them. Open
Statement Ponsky's Mount Sinai endoscopy courses became official SAGES courses, then moved to the Ethicon Institute in Cincinnati with Ethicon's support for education. Open
Statement SAGES was the first organization to establish hands-on surgical training courses, which remain superior to others' programs. Open
Quotation Nobody did it before us. We were the first. Hands-on training. Now it's very common and still no one does it better than we do. Open
Statement Early SAGES courses focused on flexible endoscopy (polyp removal, colonoscopy) with simulation, but laparoscopic training (Nissen fundoplication, laparoscopic colectomy, Heller myotomy) eventually dominated as the laparoscopic revolution expanded. Open
Statement Current SAGES courses have returned to teaching advanced flexible endoscopy techniques including POEM, ESD (endoscopic submucosal dissection), and EMR (endoscopic mucosal resection). Open
Statement Ponsky's fellows who became SAGES presidents include Bruce McFadden, Brian Duncan, and Jeff Marks (future president). Open
Statement Mike Rosen, son of Arnie Rosen (who was a year ahead of Ponsky in residency), came as a research resident and became Ponsky's partner, training many fellows in abdominal wall reconstruction in addition to endoscopy. Open
Statement Walter Pore taught that department leaders should protect elder staff while simultaneously promoting younger staff, a lesson Ponsky applied as chairman. Open
Statement Walter Pore, now in his mid-80s, continues to have NIH grants and remains relevant in lecturing, demonstrating that surgeons can maintain relevance throughout their careers. Open
Statement In 1975, Ponsky performed peritoneoscopy under local anesthesia with air insufflation before switching to CO2, and contacted George Bercy in California for advice on purchasing a Storz scope with a $2,500 grant. Open
Statement George Bercy worked with Harold Hopkins and Karl Storz to develop the Hopkins rod lens system into practical surgical scopes, constantly seeking improvements in image quality, lighting, and camera technology. Open
Statement At age 96, George Bercy continues to call Ponsky monthly with new ideas, including a smaller choledochoscope with chip camera instead of fiber optics and a VTO scope mounted above the operating table for cardiac surgeons to view valve anastomoses without loupes. Open
Quotation He doesn't look at the instrument for what it is today. He looks at the instrument for what it could be with improvement. He has a unique perspective on technology, and he always asks what could be, not what is. Open
Statement Video laparoscopy transformed surgery by allowing the entire team to see the operative field on TV, unlike earlier laparoscopy where only the surgeon looking through the eyepiece could see. Open
Statement Eddie Joe Reddick and Doug Olson in Nashville, and Barry McKernan and Bill Saye in Marietta, Georgia (who did the first laparoscopic cholecystectomy in the US), were key pioneers of laparoscopic cholecystectomy in America. Open
Statement SAGES trained trainers first (John Hunter, Nat Soper, John Saker, George Bercy) before broader dissemination of laparoscopic cholecystectomy techniques. Open
Statement Instrument shortages during early laparoscopy required personal connections to obtain equipment; Ponsky obtained Storz instruments through George Bercy, and surgeons used many gynecologic instruments and trocars. Open
Statement Laparoscopic common duct exploration was one of the earliest procedures because it required minimal special technique: the dilated common duct could be identified, peritoneum wiped away, incision made with scissors, stones extracted with Fogarty balloon, and choledochoscopy performed before T-tube placement. Open
Statement Before mastering laparoscopic suturing, Ponsky closed common duct incisions by twisting the two suture ends together like a twist-tie and securing with a clip. Open
Quotation I'll tell you this, what we did in those days, is I'd hold the two ends up and twist it like a twisty, and put a clip on it. Right down where I tied it. Just pull up the two ends, twist it till it was tight, and put a clip on it. That was before I knew how to suture. Open
Statement Ponsky was selected as the first SAGES member on the American Board of Surgery after SAGES received a board seat, with the board choosing from three nominated candidates. Open
Statement Ponsky and Courtney Townsend advocated for Steve Stein's appointment to the American Board of Surgery; Michael Nussbaum and John Hunter also later joined as SAGES representatives. Open
Statement The American Board of Surgery asked Ponsky how much endoscopy surgical residents should perform; he negotiated with the Residency Review Committee under Joe Fisher to establish numerical requirements. Open
Statement Ponsky was elected chairman of the American Board of Surgery, the first SAGES member to achieve this position. Open
Statement Ponsky left work early to have dinner and study hall with his family at the dining room table, helping children with homework while doing his own work, rather than staying late at the office like colleagues. Open
Statement Two of Ponsky's four children became surgeons: Lee (urologic oncology, head of urological oncology at Case Western) and Todd (pediatric surgery, interested in surgical education). Open
Statement Ponsky has four children and ten grandchildren, all living in Cleveland, whom he sees every week. Open
Statement Marriage requires continuous work like a career, not just falling in love; partners must consider each other's experiences, help each other, and understand what makes each other tick. Open
Quotation People think that they're gonna fall in love, and this is advice I give young people, they think they're gonna fall in love like in a movie, you know, like Harry Met Sally, we're gonna fall in love and it's gonna be great, but it isn't like that. Open
Quotation You have to stop and think, wait a minute, what's the other person going through? What can I do to help them? How can I make their life better? Open
Statement Ponsky considers his 48-year marriage his crowning achievement, more important than his professional accomplishments. Open
Quotation I look at 48 years of marriage and say that's my crowning achievement. Open
Statement The future of surgery includes image-guided procedures such as needle ablation of liver tumors, requiring surgeons to embrace and test new technologies rather than remaining satisfied with current methods. Open
Quotation The future keeps changing. Laparoscopic surgery is now, and in the future we're gonna do image guided surgery. Open
Quotation People should always say, what's next? George Mercy does this every day. That's his gift. He doesn't stop now. He says that's not good enough. What are we gonna do tomorrow? Open

Special Lecture: Dr. Jeffrey Ponsky | St. George's University

Statement Medical truth depends on the tools available to perceive it; as tools improve, our understanding of truth changes. Open
Quotation The truth is often based on what we can perceive it with. If we have tools, new tools to perceive it. Then our idea of what the truth is changes. Open
Statement In the late 1800s at Johns Hopkins, medical education focused primarily on anatomy because other fields (pharmacology, blood typing, antibiotics) did not yet exist. Open
Statement In 1889, gastric acid was believed to be the cause of peptic ulcer disease. Open
Statement H. pylori was discovered in 1990 as a cause of peptic ulcer disease by blocking prostaglandin E3 production and destroying the mucosal barrier. Open
Statement William Halsted became addicted to cocaine while experimenting with it as a local anesthetic in the 1880s. Open
Statement Gastrojejunostomy, the first operation for peptic ulcer disease, created a connection between stomach and jejunum to drain acid quickly but had a 50% recurrence rate due to marginal ulcers in the unbuffered small bowel. Open
Statement Subtotal gastrectomy (removing 80% of the stomach) had a 99% success rate in preventing ulcers by removing parietal cells that produce acid. Open
Statement Subtotal gastrectomy had high mortality due to lack of intensive care, IV fluids, and antibiotics; survivors often suffered malnutrition (inanition) and could not sustain life. Open
Statement About 15% of subtotal gastrectomy patients developed dumping syndrome with cramps, sweating, hypotension, and diarrhea. Open
Statement Early dumping syndrome (20 minutes to 2 hours post-meal) is caused by inappropriate release of vasoactive intestinal polypeptide (VIP) from the pancreas, not hypertonic fluid dumping into the bowel. Open
Statement Late dumping syndrome (2-4 hours post-meal) results from insulin-glucose imbalance: gastric inhibitory polypeptide (GIP) from the intestine stimulates excess insulin release from pancreatic islet cells, causing insulin shock. Open
Statement The subtotal gastrectomy operation was later adapted for bariatric surgery in morbidly obese patients, creating the gastric bypass procedure. Open
Statement Pavlov discovered the phases of digestion; the cephalic phase is triggered by sight or smell of food, mediated by the vagus nerve, causing salivation and gastric acid secretion. Open
Statement The gastric phase of digestion occurs when food distends the stomach and peptones stimulate G cells in the antrum to secrete gastrin, a 17-amino-acid hormone that stimulates parietal cells to produce acid. Open
Statement Lester Dragstedt designed truncal vagotomy to ablate the cephalic phase, but cutting the vagus nerves caused gastric stasis requiring drainage procedures (gastrojejunostomy or pyloroplasty). Open
Statement Truncal vagotomy with drainage had a 15% recurrence rate and was the standard operation from the 1950s through late 1970s. Open
Statement Complications of truncal vagotomy included diarrhea from bowel denervation, gallstones from liver denervation, and 15% dumping syndrome from pylorus destruction or bypass. Open
Statement Antrectomy combined with truncal vagotomy removed both the cephalic phase (via vagotomy) and gastric phase (by removing gastrin-producing G cells), achieving a 2% recurrence rate. Open
Statement Selective vagotomy denervates only the stomach while preserving the celiac and hepatic branches, eliminating gallstones and diarrhea but maintaining 15% recurrence and dumping syndrome. Open
Statement The nerve of Latarjet, described by a French anatomist 100 years earlier, is a motor nerve to the pylorus that does not stimulate acid production because it innervates the antrum, which lacks parietal cells. Open
Statement Highly selective vagotomy denervates the acid-producing body and fundus while preserving the nerve of Latarjet, eliminating the cephalic phase without causing dumping, diarrhea, or gallstones. Open
Statement Highly selective vagotomy represents a synthesis of histology (knowing where parietal cells are located) with anatomy and physiology. Open
Statement Discovery favors the prepared mind; combining old information (anatomy, physiology) with new insights enables innovation. Open
Quotation Discovery favors the prepared mind. Open
Statement Surgery for peptic ulcer disease is indicated for complications: hemorrhage, obstruction, perforation, and intractability—the same indications as 120 years ago. Open
Statement Modern management of peptic ulcer obstruction includes pyloroplasty to relieve obstruction, H. pylori treatment, and proton pump inhibitors, potentially avoiding vagotomy and its side effects. Open
Quotation What you're learning is appropriate at this time and your creativity and your insight will make the changes for the future. Open
Statement Medical truth continues to evolve; students should combine old and new information creatively to develop future treatments. Open
Statement In residency interviews, programs seek candidates with strong academic records, reliable letters of recommendation, genuine engagement, and articulated vision for their future. Open
Statement Active participation in learning—even risking wrong answers—leads to better retention than passive observation because emotional investment strengthens memory. Open
Quotation If you raise your hand and I call on you and your heart starts beating and you start flushing and you get it wrong, you won't forget the right answer. Open
Quotation This guy was so electric. He really can't, you know, I know his grades were just OK, but this guy, I wanna work with this guy. I like him. Open

Overview of Single Incision Surgery Tool Box and Technique: Jeffrey Ponsky, M.D.

Quotation This is my son Todd, who is one of you as a pediatric surgeon, so he said, I'm busy, I'm going to Chile, would you please uh present my talk? Open
Quotation many of these uh instruments were developed uh in in preparation for notes. Open
Statement Many single-port surgery instruments were originally developed in preparation for NOTES (natural orifice transluminal endoscopic surgery). Open
Statement Laparoscopic incisions are hardly noticeable a month after surgery. Open
Statement Single-port surgery may make it difficult in the ER or clinical care to determine what procedures patients have had done due to lack of visible scars. Open
Quotation I dare say that this is going to make working in the ER or taking care of patients a little difficult in trying to figure out what they've had done Open
Statement There is no question that single-port laparoscopy has caught on and is this year's hot topic. Open
Quotation There's no question here today that single port laparoscopy has caught on. It's a it's this year's hot topic Open
Statement The speaker is not sure that single-port surgery results in less pain than standard laparoscopy. Open
Quotation Less pain than laparoscopic, uh, I'm not sure that's true. Uh, less morbidity, I'm not sure that's true. Less expensive, I certainly don't think that is true. Uh, improved cosmetics, you bet. Open
Statement The speaker is not sure that single-port surgery results in less morbidity than standard laparoscopy. Open
Statement The speaker does not think single-port surgery is less expensive than standard laparoscopy. Open
Statement Improved cosmetics is the whole selling point of single-port surgery, and patients want this, particularly in certain subsets of the population. Open
Quotation That's the whole selling point here is improved cosmetics and although we poo poo this, our patients want this and in particular subsets of our population, it becomes very important. Open
Statement Right transverse incisions from pyloromyotomy are not very nice incisions when seen years later in older patients. Open
Quotation I trained in an era when I did laparoscopy with room air under local anesthesia and with one eye to the scope. Open
Statement The speaker trained in an era when laparoscopy was performed with room air under local anesthesia with one eye to the scope. Open
Statement Laparoscopy became much easier after the advent of the video camera adapted to the scope. Open
Quotation right now, everybody's banging into one another trying to do the laparoscopic single site surgery and it's very difficult. Open
Statement Single-site laparoscopic surgery is currently very difficult with surgeons banging into one another. Open
Statement With modified trocars, instruments, and laparoscopes, single-site surgery will become easier, and techniques may improve in the future. Open
Quotation with modified trocars and modified laparoscopic instruments and modified laparoscopes, it will become easier and our technique, although this at this time, we're using the same techniques, in the future, the techniques may get better. Open
Statement Traditional trocars placed through a single site move independently of one another (advantage), but their big heads bump into one another (disadvantage). Open
Quotation The advantage of this is that they all move independent of one another and that is an advantage. The disadvantage is because of their big heads, they bump into one another. Open
Statement The Advanced Surgical multi-port trocar (now distributed by Olympus) now has a quad port with four ports instead of three and is very easy to use and effective. Open
Statement The Advanced Surgical multi-port trocar used to leak out of the valves because the gel leaked, but this has been improved. Open
Statement The SurgiQuest trocar has no valve and uses rapid flow of CO2 so that there is no loss of pneumoperitoneum and no smudging of the lens regardless of what is inserted. Open
Statement The SurgiQuest trocar makes a little bit of noise in the operating room, which some people may not like. Open
Statement Applied Medical's gel port allows insertion of multiple trocars wherever desired, a concept taken from hand-assist laparoscopy. Open
Statement Covidien has developed a single-piece expandable port that is squeezed down small, popped in, and then expands, with the number of openings being modified from three to four. Open
Statement The Covidien expandable ports wiggle around a little bit, allowing them to function somewhat like multiple independent devices. Open
Statement Paul Kerchelow and his wife Stephanie King developed a technique using multiple low-profile Apple trocars for single-site surgery. Open
Statement The Apple trocar technique involves raising a flap above the fascia, inserting the first trocar, then raising more tissue and inserting additional trocars. Open
Statement With single-site surgery using the Apple trocar technique, you never see your additional trocars coming in, requiring extra caution. Open
Quotation with single site surgery, you have to be a little bit careful. Open
Statement The anchor port is small, distended, popped in, then released to lock in place, and these trocars could be used in many situations beyond single-site surgery. Open
Statement Optical entry, used for a long time in standard laparoscopy, can be used in single-site surgery. Open
Statement The low-profile Apple trocars used by Paul Kerchelow and Stephanie King are very small and allow movement in multiple directions when placed. Open
Statement Many surgeons are very good at using rigid instruments for single-port surgery, and some are even good at crossing their hands, which is sometimes necessary. Open
Statement Rigid instruments sometimes bang into the scope and into each other during single-port surgery. Open
Quotation they're not intuitive necessarily, they don't always work the way you think they're going to work, but they're a great advancement Open
Statement Novare's real hand instruments allow maneuvering but are not necessarily intuitive and don't always work as expected, though they represent a great advancement. Open
Statement Covidien has rigid rotating graspers, scissors, and other instruments that articulate and are very good for dissecting and retracting. Open
Statement Curved instruments provide a new concept where the curved portion goes out of the visual field and back in, potentially obviating the need to cross instruments, and can be rotated around. Open
Quotation if they're not the right length, they get in your way and they frustrate you because they're good for a particular focal length, but then they're not good again. Open
Statement If curved instruments are not the right length, they get in the way and are frustrating because they work well at a particular focal length but not at others. Open
Statement Two-millimeter minilap instruments for needlescopic surgery can be used for single-port surgery to add another port without taking up much space. Open
Statement The EndoGrab device, developed by an Israeli company for NOTES, does not require a trocar and can be clipped to tissue (such as the gallbladder) and then to the parietal peritoneum to provide retraction. Open
Statement The EndoGrab device could be used for regular laparoscopy, single-site surgery, or NOTES in the future. Open
Statement Rigid laparoscopes get in the way during single-port surgery, leading to use of flexible-tip laparoscopes by companies like Olympus and Stryker. Open
Statement Todd Ponsky found he was banging into himself with standard scopes and ports, so he used a 50-centimeter, 5-millimeter bronchoscope with a horizontal cord orientation to get the scope out of the way. Open
Statement The bronchoscope approach got the scope out of the way but had inferior optics compared to chip cameras. Open
Statement The TransEnterix system uses curved instruments that operate outside the visual field, and when used in the laboratory, it feels like doing regular laparoscopic surgery. Open
Quotation when I've used this system in the laboratory, this is sort of cool because it it sort of feels like you're doing regular laparoscopic surgery and you don't see what's outside your field. Open
Statement The TransEnterix system has cost implications. Open
Quotation Innovation is expensive. Open
Statement Innovation is expensive, leading some to advocate for reusable instruments. Open
Statement Storz is developing a multi-port single-site port with curved instruments of various shapes as a reusable option. Open
Statement When the speaker used some Storz curved instruments in the lab, sometimes they worked and sometimes it was unclear where to place them. Open
Quotation I don't know why to buy this thing right now, but eventually I'll probably end up buying one. I don't know why yet. Open
Quotation is single port surgery a game changer? I don't know. This game works pretty good, particularly when it's needlescopic with two millimeter instruments. I don't know if it's as good if single ports is good. Open
Statement The speaker does not know whether single-port surgery is a game changer, noting that needlescopic surgery with two-millimeter instruments works pretty well. Open
Statement Single-port surgery is being used today for almost every procedure imaginable. Open
Statement The speaker's head of colorectal surgery now prefers single-port surgery for colectomies in adults because they make a single incision to remove the colon anyway. Open
Quotation My head of colorectal surgery loves this for doing colectomies now in adults and because they make a single incision to take the colon out anyhow, they don't worry about making it a little bit bigger Open
Statement An operative laparoscope can be used to remove the appendix, grasp it, and pull it out through the umbilicus very easily. Open
Quotation people talk about robotics, that's another way to waste money. It's may be very good in the future, but this looks a little busy to me for taking out an appendix Open
Statement Robotics for single-port surgery may be very good in the future, but the speaker considers it another way to waste money currently. Open
Quotation notes went to single port surgery and and maybe it's going to go the other way. Maybe single port surgery after we get a little better at it, will let us do notes. Open
Statement NOTES initially led to single-port surgery, and single-port surgery may eventually enable NOTES procedures after techniques improve. Open
Statement Danny Scott's magnetic instruments may be dropped through a single port and controlled from outside to perform sophisticated operations including camera insertion. Open
Statement Single-port surgery provides a great cosmetic result and does add that benefit without question. Open
Quotation keep your eyes peeled and don't write this off right now. Great cosmetic result. It does add that. There's no question about it, but first we have to do no harm. Open

All About Advanced Surgical Endoscopy

Statement In the early 20th century, rigid tubes were used for gastrointestinal examination, requiring patient contortion to align with the tubes to look inside the esophagus and colon. Open
Quotation years ago, in the beginning of the last century, people were interested in what was going on in the gastrointestinal tract, and they took rigid tubes and had to contort the patient to, uh, to align with these tubes so that they could look inside the esophagus and the colon. And it was quite uncomfortable. Open
Statement Fiber optic technology developed midway through the 20th century allowed endoscopic tubes to become flexible. Open
Statement Therapeutic endoscopy began with pinch biopsies to assess disease activity, then progressed to polypectomy using electrocautery snares to remove polyps that previously required surgical removal. Open
Statement Endoscopic coagulation of bleeding ulcers can prevent the need for surgery. Open
Statement Gallstones can be removed from the bile duct endoscopically by opening the bottom of the bile duct through the endoscope. Open
Statement Balloon-assisted enteroscopy uses balloons on the outside of endoscopes that inflate and deflate to walk down the intestine farther than normal scopes, allowing visualization and treatment of lesions in the small bowel. Open
Statement Video capsule endoscopy involves swallowing a pill-sized capsule with a flashing light that takes pictures frequently, recording to a hip-worn monitor to assess the small intestine for hidden bleeding sources. Open
Statement ERCP allows access to the bile duct opening in the duodenum, enabling injection of dye to visualize problems, cutting of the opening to remove stones, and placement of plastic or metal stents for tumors. Open
Statement Endoscopic ultrasound allows visualization beyond the intestinal wall to assess adjacent organs including the bile duct, pancreas, stomach wall, and vessels, enabling recognition and biopsy of tumors not visible by direct visualization. Open
Statement POEM (per oral endoscopic myotomy) allows treatment of esophageal motility disorders by making a tiny incision in the inner esophageal wall, tunneling down through the esophagus, cutting the lower esophageal muscles, and closing the esophagus internally, avoiding abdominal surgery. Open
Statement Endoscopic mucosal resection (EMR) can shave out tumors seen during endoscopy. Open
Statement Endoscopic submucosal dissection (ESD) allows removal of flat, long, broad tumors by lifting tissue and shaving down to the next layer, providing better cancer or pre-cancer resection than EMR. Open
Statement EMR and ESD have been proven safe and effective and avoid the need for open surgery. Open
Statement Percutaneous endoscopic gastrostomy (PEG) was developed 40 years ago by Michael Gauer and Dr. Ponsky to place feeding tubes in patients who cannot eat due to neurological or oral problems, using endoscopic guidance for needle puncture without open surgery. Open
Statement The PEG procedure was developed after observing bright transillumination through the abdomen of brain-damaged infants during endoscopy, realizing the stomach was in close contact with the abdominal wall and could be accessed with a needle. Open
Quotation the light bulb is a good analogy because we actually were doing this in very little babies who had brain damaged births. And they required endoscopy for some reason or other. The room lights were dimmed and we saw this bright shining light coming through their abdomen, and we pushed with our finger. We realized we were in close contact with the stomach, and we realized that if we put a needle through there, we could accomplish the procedure. So the light did lead us to the method. Open
Statement All endoscopic procedures carry risks of bleeding, perforation, or infection. Open
Quotation this is surgery, as I said before. The endoscope is the vehicle that gets us there, but now you're dealing with surgery, and everything we do to anybody has certain risks, and always bleeding or puncture or perforation are those risks or infection. Open
Statement Endoscopic pyloric myotomy can be performed as an outpatient procedure by opening the pyloric muscle in the intramural space, cutting the thick muscle, and clipping it closed, with patients going home the same day with improved gastric emptying. Open
Statement Endoscopic pyloric myotomy requires only a liquid diet for 2 days before the procedure and one week afterward. Open
Statement Zenker's diverticulum, which previously required major neck surgery, can now be treated through the mouth by making a small incision in the back of the throat, cutting the thick muscle, and clipping it closed, allowing same-day discharge. Open
Statement Zenker's diverticulum repair requires a liquid diet for a couple of days before surgery and one week after. Open
Statement Advanced endoscopic procedures are being performed as outpatients or with overnight stays in almost every case. Open
Statement Every surgical procedure is being evaluated for less invasive, endoscopically guided approaches. Open
Statement Robotics will play a future role in endoscopic surgery, including image-guided and robotically controlled surgery for more precise movements and better results. Open
Statement Cleveland Clinic is conducting ongoing evaluation and improvement of endoscopic procedures, integrating new technology to improve results. Open
Quotation Surgical endoscopy is just another way to do surgery. Uh, much as we do a cystoscopy in the bladder or any other type of ear, nose, and throat surgery, the endoscope is the vehicle which gets us to the place where we have to do the surgery. Open
Jeffrey's statements about Gastroparesis 47 statements

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POEM by Surgeons – Dr. Jeffrey Ponsky

Statement Laparoscopic Heller myotomy is the gold standard for the treatment of achalasia. Open
Quotation It's a beautiful operation. Why screw with it? You guys do such a good job, the the general surgeons do such a good job with this. Open
Statement In Heller myotomy, the operation fails if the myotomy does not extend 4-5 centimeters down onto the stomach. Open
Quotation The hard part is going down on the stomach. You must go down on the stomach. I like to go down four or five centimeters when we do it because that's where the operation fails if you don't do that. Open
Statement A fundoplication (Dor) is added to Heller myotomy based on a Vanderbilt paper, but surgeons know in their hearts it doesn't provide significant benefit. Open
Quotation Now you guys wouldn't do a door for a real anti-reflux operation, but here you go and we do this door and we think it's going to do us a lot of good, but we really know in our heart that it doesn't. Open
Statement Dr. Inoue, a thoracic surgeon in Yokohama, performed the first POEM procedure in the world in 2010. Open
Statement In POEM, the mucosal entry is made 14 centimeters proximal to the EG junction. Open
Statement During POEM, the longitudinal muscle splits automatically when the circular muscle is divided. Open
Statement The POEM procedure takes about one hour. Open
Statement Occasionally during POEM, the mucosa cannot be separated from the submucosa; in these cases (three in seven years for the speaker), the procedure should be stopped, the entry clipped closed, and a Heller myotomy performed instead. Open
Statement All POEM patients should be placed on a PPI once daily indefinitely because they can develop strictures without it. Open
Statement POEM patients have almost a 40% incidence of abnormal reflux. Open
Statement POEM patients have 35-40% abnormal reflux rates. Open
Statement POEM is effective in over 90% of cases. Open
Statement Long-term data suggest POEM may be equal to Heller myotomy in every way after three years. Open
Quotation You know, some of you get to work in a car. Some of you take the subway. Some of you take a bus or Uber to work. That's how you get to work. But when you get to work, you all do the same thing. You cut the muscle and it doesn't matter if you get there with the laparoscope or the endoscope, the point is you're cutting the muscle, that's surgery. Open
Quotation So learn to take a different way to work. That's all I'm saying to you. Open
Quotation I call this intramural surgery, it's surgery within the wall of a viscus or an organ. Open
Statement Gastroparesis is caused by diabetes, idiopathic factors, and post-surgical complications including esophagectomy. Open
Quotation A lot of you guys create this condition. When you do your esophagectomies and such, you create gastroparesis, so did I. Open
Statement POP (peroral pyloromyotomy) involves creating a 4 cm tunnel to the pyloric ring and dividing it, and takes 15 minutes. Open
Quotation We divide it and get out of dodge, it takes 15 minutes. Open
Quotation What does this do? We don't know, but it affects gastric motility somehow. Open
Quotation What if you make a hole here? It doesn't matter. You just cover it with the mucosal flap. Open
Statement The speaker's institution has performed about 400 POP procedures. Open
Statement In the first 100 POP cases presented at a meeting, three-quarters of patients had normalized gastric emptying studies at three months, all of which were abnormal before the procedure. Open
Quotation So these patients are grateful and happy, and this is an easy procedure that takes 15, 20 minutes and it's easy to learn. It's not like ERCP. Open
Statement POP is an easy procedure that takes 15-20 minutes and is easy to learn, unlike ERCP. Open
Statement STEER (submucosal tunneling and endoscopic resection) is used to remove esophageal leiomyomas by creating a submucosal tunnel and shelling out the tumor. Open
Statement The speaker treated a 17-year-old girl with a 7 cm esophageal leiomyoma causing dysphagia using STEER, dividing the tumor in half to remove it through the tunnel. Open
Statement All esophageal leiomyomas undergo endoscopic ultrasound before STEER. Open
Statement ENT surgeons are now referring Zenker's diverticulum patients to the speaker because elderly patients with kyphoscoliosis and tight jaws are difficult to manage with general anesthesia and open neck surgery. Open
Quotation You know, we say let the ENT guys deal with this. But guess what, they're sending them to me now. Open
Statement Cricopharyngeal myotomy is the basis of treatment for Zenker's diverticulum. Open
Quotation My residents call this the Pansky maneuver. I like to stretch this submucosa a little bit. Open
Quotation Anything that's blue can be coagulated. Open
Statement Endoscopic Zenker's treatment takes 15-20 minutes. Open
Statement For endoscopic Zenker's treatment, patients are kept on clear liquids for a couple of days before the procedure to clear debris from the diverticulum. Open
Statement During endoscopic Zenker's myotomy, if a hole is made in the mucosa, it does not matter because the mucosal flap will cover it. Open
Quotation What happens if you make a hole in the mucosa? Absolutely nothing. Don't worry about the mucosa because for years we just cut this without even uh making a tunnel. Open
Quotation So the GI people like to call this third space endoscopy. It shows me where their head is. Third space endoscopy, what does that mean? I call this what I believe it is, intramural surgery. This is surgery by any account and it occurs within the wall. So it's intramural surgery. Open
Quotation So these procedures are surgery. They should be performed by surgeons. Not gastroenterologist. Open
Statement The speaker has trained gastroenterologists, thoracic surgeons, and general surgeons to perform intramural surgical procedures. Open
Quotation But I believe that we have to update our profession. Open
Statement Thoracic surgeons at the speaker's institution have embraced intramural surgery techniques. Open
Quotation I believe that thoracic surgeon should, you should have a course to teach people how to do this. This is in the realm of general thoracic surgeries. Open
Jeffrey's statements about Inguinal Hernia 2 statements

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Inguinal Hernia: Adult

Quotation I say the word simple because it's anything but simple. This is a topic which has challenged surgeons for a century, and every generation really believes that they have the correct answer to hernia repair. Open
Quotation I say the word simple because it's anything but simple. This is a topic which has challenged surgeons for a century, and every generation really believes that they have the correct answer to hernia repair. Open
Jeffrey's statements about Low Cardiac Output 2 statements

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Inguinal Hernia: Adult

Quotation I say the word simple because it's anything but simple. This is a topic which has challenged surgeons for a century, and every generation really believes that they have the correct answer to hernia repair. Open
Quotation I say the word simple because it's anything but simple. This is a topic which has challenged surgeons for a century, and every generation really believes that they have the correct answer to hernia repair. Open
Jeffrey's statements about Pancreatitis 93 statements

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Gallstone Disease

Statement Biliary dyskinesia is diagnosed with a HIDA scan showing ejection fraction less than 35% after CCK administration, when all other tests are negative. Open
Statement Biliary dyskinesia is diagnosed with a HIDA scan showing ejection fraction less than 35% after CCK administration, when all other tests are negative. Open
Statement Modern practice favors early cholecystectomy within the first week for acute cholecystitis, rather than the older approach of cooling down for six weeks. Open
Statement Modern practice favors early cholecystectomy within the first week for acute cholecystitis, rather than the older approach of cooling down for six weeks. Open
Statement For stable acute cholecystitis without peritonitis, it is reasonable to wait until the next operating day (e.g., Monday if presenting Saturday) rather than operating emergently. Open
Statement For stable acute cholecystitis without peritonitis, it is reasonable to wait until the next operating day (e.g., Monday if presenting Saturday) rather than operating emergently. Open
Statement There is no evidence that prophylactic antibiotics help in acute cholecystitis management. Open
Statement There is no evidence that prophylactic antibiotics help in acute cholecystitis management. Open
Statement The sucker is a great tool for blunt dissection during difficult cholecystectomy; hydrodissection (injecting water between tissue planes) helps in tough areas. Open
Statement The sucker is a great tool for blunt dissection during difficult cholecystectomy; hydrodissection (injecting water between tissue planes) helps in tough areas. Open
Statement After isolating the cystic duct-gallbladder junction, turning the hook cautery toward the gallbladder and lifting while cauterizing gains an additional half-centimeter of cystic duct length. Open
Statement After isolating the cystic duct-gallbladder junction, turning the hook cautery toward the gallbladder and lifting while cauterizing gains an additional half-centimeter of cystic duct length. Open
Quotation Easy gallbladders are the ones where you can make the bad mistakes. There can be accessory cystic ducts, there can be problems with the cystic artery that you didn't realize, an anterior and posterior one, and you have to be careful. So it's real easy, make yourself slow down. You know you're going to go slow on a hard one. Go slow on an easy one. Open
Statement Easy gallbladders are dangerous because surgeons become complacent; accessory cystic ducts and vascular variants can be missed. Open
Statement Easy gallbladders are dangerous because surgeons become complacent; accessory cystic ducts and vascular variants can be missed. Open
Quotation Easy gallbladders are the ones where you can make the bad mistakes. There can be accessory cystic ducts, there can be problems with the cystic artery that you didn't realize, an anterior and posterior one, and you have to be careful. So it's real easy, make yourself slow down. You know you're going to go slow on a hard one. Go slow on an easy one. Open
Statement Routine intraoperative cholangiography is debated; some institutions do it in every case for teaching and to improve transcystic exploration skills, while selective use based on risk factors (pancreatitis history, jaundice, dilated duct) is also acceptable. Open
Statement Routine intraoperative cholangiography is debated; some institutions do it in every case for teaching and to improve transcystic exploration skills, while selective use based on risk factors (pancreatitis history, jaundice, dilated duct) is also acceptable. Open
Statement When contrast on cholangiogram flows only distally into the duodenum, pressing on the papilla with the laparoscope under fluoroscopy forces contrast proximally, avoiding the need for morphine to induce sphincter spasm (technique taught by Michelle Gagné). Open
Statement When contrast on cholangiogram flows only distally into the duodenum, pressing on the papilla with the laparoscope under fluoroscopy forces contrast proximally, avoiding the need for morphine to induce sphincter spasm (technique taught by Michelle Gagné). Open
Statement Intraoperative administration of 30mg Toradol (age-adjusted in children) before the patient wakes facilitates same-day discharge after cholecystectomy. Open
Statement Intraoperative administration of 30mg Toradol (age-adjusted in children) before the patient wakes facilitates same-day discharge after cholecystectomy. Open
Statement Any patient with pain 3-5 days after laparoscopic cholecystectomy should be assumed to have a bile leak or bile duct injury until proven otherwise; laparoscopic cholecystectomies do not cause pain if everything went well. Open
Quotation If you have a patient that you did a lap choleon, and they call you because they're having pain, something's wrong. Lap choleys don't have pain if everything went well. Now, I may be wrong in 1% of cases, but not many. The patient calls you, the mother calls you, or anybody calls you, says, you know, he's a little nausea, he's not eating well, a little bloated, and he's having pain. It's three days later. Come into the emergency room. Stat. Because in my mind, that's a bile leak, and even, God forbid, a common duct injury until proven otherwise. Open
Statement Any patient with pain 3-5 days after laparoscopic cholecystectomy should be assumed to have a bile leak or bile duct injury until proven otherwise; laparoscopic cholecystectomies do not cause pain if everything went well. Open
Quotation If you have a patient that you did a lap choleon, and they call you because they're having pain, something's wrong. Lap choleys don't have pain if everything went well. Now, I may be wrong in 1% of cases, but not many. The patient calls you, the mother calls you, or anybody calls you, says, you know, he's a little nausea, he's not eating well, a little bloated, and he's having pain. It's three days later. Come into the emergency room. Stat. Because in my mind, that's a bile leak, and even, God forbid, a common duct injury until proven otherwise. Open
Statement For suspected postoperative bile leak, obtain CT or ultrasound to identify fluid collections; if present, aspirate immediately—if bile is present, proceed to ERCP. Open
Statement For suspected postoperative bile leak, obtain CT or ultrasound to identify fluid collections; if present, aspirate immediately—if bile is present, proceed to ERCP. Open
Statement HIDA scans are useful to confirm normal biliary drainage when postoperative pain occurs without fluid collection, but are less useful than CT for detecting bile leaks. Open
Statement HIDA scans are useful to confirm normal biliary drainage when postoperative pain occurs without fluid collection, but are less useful than CT for detecting bile leaks. Open
Statement For bile leaks (typically cystic duct), ERCP with sphincterotomy and short stent (10 French, 5cm) decompresses the biliary system and stops drainage; stent is removed at 3-6 weeks. Open
Statement For bile leaks (typically cystic duct), ERCP with sphincterotomy and short stent (10 French, 5cm) decompresses the biliary system and stops drainage; stent is removed at 3-6 weeks. Open
Statement Biliary dyskinesia with ejection fraction less than 35% is an indication for cholecystectomy when all other GI workup is negative. Open
Statement Biliary dyskinesia with ejection fraction less than 35% is an indication for cholecystectomy when all other GI workup is negative. Open
Statement Gallstone pancreatitis is caused by small stones creating transient obstruction of both bile and pancreatic ducts while passing through the papilla. Open
Statement Gallstone pancreatitis is caused by small stones creating transient obstruction of both bile and pancreatic ducts while passing through the papilla. Open
Statement In the old practice, all patients with gallstone pancreatitis received ERCP on presentation, but two-thirds had normal ERCPs because the stone had already passed. Open
Quotation The rule is, in the old days, everybody got ERCP the day they came in. Hydrate them, make them NPO, watch them in the hospital, and don't get the ERCP on the first day because when we did that, we found that two-thirds of the patients that we did the ERCPs on had normal ERCPs. Open
Statement In the old practice, all patients with gallstone pancreatitis received ERCP on presentation, but two-thirds had normal ERCPs because the stone had already passed. Open
Quotation The rule is, in the old days, everybody got ERCP the day they came in. Hydrate them, make them NPO, watch them in the hospital, and don't get the ERCP on the first day because when we did that, we found that two-thirds of the patients that we did the ERCPs on had normal ERCPs. Open
Statement Current management of gallstone pancreatitis: admit, hydrate, NPO, observe overnight and check amylase/lipase trend. If improving, proceed to cholecystectomy during that admission. If worsening or jaundice persists, perform ERCP with sphincterotomy. Open
Statement Current management of gallstone pancreatitis: admit, hydrate, NPO, observe overnight and check amylase/lipase trend. If improving, proceed to cholecystectomy during that admission. If worsening or jaundice persists, perform ERCP with sphincterotomy. Open
Statement The choice between preoperative ERCP versus intraoperative common duct exploration depends on local resources, surgeon comfort with laparoscopic ductal techniques, and availability of fluoroscopy and choledocoscopy. Open
Statement The choice between preoperative ERCP versus intraoperative common duct exploration depends on local resources, surgeon comfort with laparoscopic ductal techniques, and availability of fluoroscopy and choledocoscopy. Open
Statement Some experts (George Bursey, Joe Peatland) advocate taking patients with persistent common duct stones directly to the operating room for intraoperative cholangiogram and transcystic or laparoscopic common duct exploration, with postoperative ERCP only if unsuccessful. Open
Statement For intraoperative common duct stone clearance, after cholangiogram shows a stone (meniscus sign), give 1 amp (1mg) glucagon IV, wait 1-2 minutes, flush with saline, and repeat cholangiogram. Open
Statement For intraoperative common duct stone clearance, after cholangiogram shows a stone (meniscus sign), give 1 amp (1mg) glucagon IV, wait 1-2 minutes, flush with saline, and repeat cholangiogram. Open
Statement If glucagon fails to clear the stone, pass a soft-tip wire through the cystic duct under fluoroscopy into the duodenum to attempt to dislodge it; never push against resistance. Open
Statement If glucagon fails to clear the stone, pass a soft-tip wire through the cystic duct under fluoroscopy into the duodenum to attempt to dislodge it; never push against resistance. Open
Statement A Dormia basket can be passed closed into the duodenum under fluoroscopy, opened slightly, and pulled back with jiggling to catch stones; alternatively, a #5 Fogarty catheter (vascular Fogarty works) can be inflated in the duodenum, pulled to the papilla, deflated slightly, re-inflated and pulled back. Open
Statement A Dormia basket can be passed closed into the duodenum under fluoroscopy, opened slightly, and pulled back with jiggling to catch stones; alternatively, a #5 Fogarty catheter (vascular Fogarty works) can be inflated in the duodenum, pulled to the papilla, deflated slightly, re-inflated and pulled back. Open
Statement Modern choledocoscopes are less than 3mm diameter and can be passed through the cystic duct (sometimes requiring balloon dilation) for direct stone visualization and extraction with Dormia basket or balloon. Open
Statement Modern choledocoscopes are less than 3mm diameter and can be passed through the cystic duct (sometimes requiring balloon dilation) for direct stone visualization and extraction with Dormia basket or balloon. Open
Statement After transcystic common duct exploration, place endoloops on the cystic duct stump because prolonged obstruction can blow off simple ties. Open
Statement After transcystic common duct exploration, place endoloops on the cystic duct stump because prolonged obstruction can blow off simple ties. Open
Statement Laparoscopic common bile duct exploration via choledocotomy should only be performed in dilated ducts (>1-1.5cm, ideally 2cm) to avoid stricture risk; small-caliber ducts with stones should be managed with ERCP. Open
Statement Laparoscopic common bile duct exploration via choledocotomy should only be performed in dilated ducts (>1-1.5cm, ideally 2cm) to avoid stricture risk; small-caliber ducts with stones should be managed with ERCP. Open
Statement For laparoscopic choledocotomy, do not divide the cystic duct—use the gallbladder for lateral retraction while dissecting down to expose the anterior common duct surface. Open
Statement For laparoscopic choledocotomy, do not divide the cystic duct—use the gallbladder for lateral retraction while dissecting down to expose the anterior common duct surface. Open
Statement T-tube preparation for choledocotomy closure: cut to 1 inch on each side of the T, bevel the edges, remove half the back wall to facilitate insertion and later removal. Open
Statement T-tube preparation for choledocotomy closure: cut to 1 inch on each side of the T, bevel the edges, remove half the back wall to facilitate insertion and later removal. Open
Statement T-tube cholangiogram is performed at 10 days post-choledocotomy; if clear, the T-tube is removed at 2 weeks. Open
Statement T-tube cholangiogram is performed at 10 days post-choledocotomy; if clear, the T-tube is removed at 2 weeks. Open
Statement For severe pancreatitis with large phlegmon in the pancreatic head, obtain CT and consider waiting 6 weeks before cholecystectomy to allow inflammation to resolve. Open
Statement For severe pancreatitis with large phlegmon in the pancreatic head, obtain CT and consider waiting 6 weeks before cholecystectomy to allow inflammation to resolve. Open
Statement For patients with multiple stones extending up both hepatic ducts in a very dilated common duct, or stone-formers like sickle cell patients, consider choledochoduodenostomy (2cm anastomosis) as a drainage procedure to allow future stones to pass. Open
Statement For patients with multiple stones extending up both hepatic ducts in a very dilated common duct, or stone-formers like sickle cell patients, consider choledochoduodenostomy (2cm anastomosis) as a drainage procedure to allow future stones to pass. Open
Statement Percutaneous cholecystostomy can temporize severe acute cholecystitis in high-risk patients or those with large phlegmon, allowing interval cholecystectomy at 6 weeks, but requires normal clotting studies. Open
Statement Percutaneous cholecystostomy can temporize severe acute cholecystitis in high-risk patients or those with large phlegmon, allowing interval cholecystectomy at 6 weeks, but requires normal clotting studies. Open
Statement In cases where anatomy is unrecognizable intraoperatively, subtotal cholecystectomy is acceptable: remove the anterior wall or fundus, cauterize the remaining mucosa on the back wall with bovie to prevent mucocele, place drains, and accept a controlled leak. Open
Statement In cases where anatomy is unrecognizable intraoperatively, subtotal cholecystectomy is acceptable: remove the anterior wall or fundus, cauterize the remaining mucosa on the back wall with bovie to prevent mucocele, place drains, and accept a controlled leak. Open
Statement Common bile duct injuries typically occur during 'easy' cases when surgeons become complacent and fail to maintain vigilance. Open
Statement Common bile duct injuries typically occur during 'easy' cases when surgeons become complacent and fail to maintain vigilance. Open
Statement The common duct can come up to the gallbladder and take a bend like a knee, appearing identical to the cystic duct; only continued dissection reveals the true 2-3mm cystic duct coming off the 'knee.' Open
Statement The common duct can come up to the gallbladder and take a bend like a knee, appearing identical to the cystic duct; only continued dissection reveals the true 2-3mm cystic duct coming off the 'knee.' Open
Statement Being able to pass an instrument around a structure does not prove it is the cystic duct—the common bile duct can be encircled and mistakenly used for retraction. Open
Statement Being able to pass an instrument around a structure does not prove it is the cystic duct—the common bile duct can be encircled and mistakenly used for retraction. Open
Quotation If you're going to do biliary surgery, this could happen to anyone. Know that. It's not an incrimination of you. Stop. Suck it out. Take a few breaths and if you have another partner, call them in. Open
Statement If common bile duct injury is recognized intraoperatively: STOP immediately, call for help, and assess. If shaken or inexperienced with hepaticojejunostomy, do not attempt repair. Open
Statement If common bile duct injury is recognized intraoperatively: STOP immediately, call for help, and assess. If shaken or inexperienced with hepaticojejunostomy, do not attempt repair. Open
Quotation If you're going to do biliary surgery, this could happen to anyone. Know that. It's not an incrimination of you. Stop. Suck it out. Take a few breaths and if you have another partner, call them in. Open
Quotation What happens in most of these cases is the primary injury is compounded by the attempted repair. Open
Statement In most bile duct injury cases, the primary injury is compounded by the attempted repair. Open
Statement In most bile duct injury cases, the primary injury is compounded by the attempted repair. Open
Quotation What happens in most of these cases is the primary injury is compounded by the attempted repair. Open
Quotation A primary end-to-end repair of the common bile duct is almost always fraught with failure. Most often, a common duct injury, unless it's just a lateral injury, is best treated with a hepatic oj genostomy. Open
Statement Primary end-to-end repair of transected common bile duct is almost always fraught with failure; most common duct injuries (except small lateral injuries) are best treated with hepaticojejunostomy. Open
Quotation A primary end-to-end repair of the common bile duct is almost always fraught with failure. Most often, a common duct injury, unless it's just a lateral injury, is best treated with a hepatic oj genostomy. Open
Statement Primary end-to-end repair of transected common bile duct is almost always fraught with failure; most common duct injuries (except small lateral injuries) are best treated with hepaticojejunostomy. Open
Statement For small lateral common duct injuries, place a small T-tube rather than primary suture closure, as suture alone will leak. Open
Statement For small lateral common duct injuries, place a small T-tube rather than primary suture closure, as suture alone will leak. Open
Statement For complete common duct transection, leave everything alone, place multiple drains, do not place ties or tubes that will compromise remaining duct length for the hepatobiliary surgeon, and transfer the patient. Open
Statement For complete common duct transection, leave everything alone, place multiple drains, do not place ties or tubes that will compromise remaining duct length for the hepatobiliary surgeon, and transfer the patient. Open
Jeffrey's statements about Sarcoma (Ewing/Rhabdo) 2 statements

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Inguinal Hernia: Adult

Quotation I say the word simple because it's anything but simple. This is a topic which has challenged surgeons for a century, and every generation really believes that they have the correct answer to hernia repair. Open
Quotation I say the word simple because it's anything but simple. This is a topic which has challenged surgeons for a century, and every generation really believes that they have the correct answer to hernia repair. Open

Summaries Jeffrey gave as host · 40 summaries

Recaps of other experts' statements, not Jeffrey's own clinical position.

Summaries Jeffrey gave as host · Achalasia 7 summaries

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POEM by Surgeons – Dr. Jeffrey Ponsky

Host summary Jeffrey Ponsky summarizing a resource: J Pasca at Hopkins originated the idea of creating a submucosal tunnel in the esophagus to avoid gastric leaks during NOTES procedures, and realized the esophageal muscle could be cut endoscopically like a Heller myotomy. Open
Host summary Jeffrey Ponsky summarizing a resource: Early European studies of 70 patients showed POEM was effective at one year. Open
Host summary Jeffrey Ponsky summarizing a resource: Eric Hungness and Nat Soper reported POEM was effective in an early study of 18 patients. Open
Host summary Jeffrey Ponsky summarizing a resource: Lee Swanström's 2014 study of 100 patients showed excellent POEM results but increased reflux compared to Heller myotomy. Open
Host summary Jeffrey Ponsky summarizing a resource: Marco Patti's study showed less dysphagia with POEM than with Heller myotomy, but more reflux. Open
Host summary Jeffrey Ponsky summarizing a resource: A prospective randomized controlled trial presented in Europe at the end of 2018 compared Heller myotomy with Dor fundoplication versus POEM and found both were effective in controlling dysphagia. Open
Host summary Jeffrey Ponsky summarizing a resource: In the 2018 RCT, POEM patients had higher reflux rates than Heller patients at two months, but at three years the reflux rates equalized. Open
Summaries Jeffrey gave as host · Acute Cholecystitis 7 summaries

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Gallstone Disease

Host summary Jeffrey Ponsky summarizing a resource: Some experts (George Bursey, Joe Peatland) advocate taking patients with persistent common duct stones directly to the operating room for intraoperative cholangiogram and transcystic or laparoscopic common duct exploration, with postoperative ERCP only if unsuccessful. Open

Acute Cholecystitis

Host summary Jeffrey Ponsky summarizes what Dr. John Rodriguez said: Acute cholecystitis is an obstructive diverticulopathy where cystic duct obstruction by a stone causes pressure backup, decreased wall blood flow, and potential rupture with wall thickening Open
Host summary Jeffrey Ponsky summarizes what Dr. John Rodriguez said: Dissection should occur at the junction of the cystic duct and gallbladder, not as close to the common duct as possible, to avoid injury Open
Host summary Jeffrey Ponsky summarizes what Dr. John Rodriguez said: There is nothing magical about a specific number of trocars; additional ports should be placed where needed for adequate exposure Open
Host summary Jeffrey Ponsky summarizes what Dr. John Rodriguez said: There's nothing magical about, uh, one number or another. You just put them where you need them. Open
Host summary Jeffrey Ponsky summarizes what Dr. John Rodriguez said: Operating early in uncomplicated acute cholecystitis is recommended, while patients with cardiac or pulmonary disease may benefit from percutaneous cholecystostomy with delayed elective surgery Open

Acute Cholecystitis

Host summary Jeffrey Ponsky summarizes what Dr. John Rodriguez said: There is no hesitation to add additional trocars as needed during difficult cases, as port number is not magical and they should be placed where needed. Open
Summaries Jeffrey gave as host · Choledocholithiasis 1 summary

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Acute Cholecystitis

Host summary Jeffrey Ponsky summarizes what Dr. John Rodriguez said: There is no hesitation to add additional trocars as needed during difficult cases, as port number is not magical and they should be placed where needed. Open
Summaries Jeffrey gave as host · Foundations of Minimally Invasive & Endoscopic Surgery 17 summaries

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SAGES Stories Episode 11 – Jeff Ponsky, MD

Host summary Jeffrey Ponsky summarizing a resource: Jeff, I think you should consider, uh, just going to trade school because I don't think you're gonna do well in college and your parents don't have much money. Open
Host summary Jeffrey Ponsky summarizing a resource: we're not training any surgeons, just forget it Open
Host summary Jeffrey Ponsky summarizing a resource: you're not gonna touch this scope Open
Host summary Jeffrey Ponsky summarizing a resource: go buy yourself a Hanukkah present. You got the scope. Open
Host summary Jeffrey Ponsky summarizing a resource: you won't be a good businessman when you finish this, but you'll be able to sit in a business meeting and say bullshit at the right time Open

From Idea to Ubiquity - the PEG Journey

Host summary Jeffrey Ponsky summarizing a resource: In Parkinson's disease, neurologists discovered that delivering medication into the jejunum via PEG-J improves patient outcomes. Open

POEM by Surgeons – Dr. Jeffrey Ponsky

Host summary Jeffrey Ponsky summarizing a resource: J Pasca at Hopkins originated the idea of creating a submucosal tunnel in the esophagus to avoid gastric leaks during NOTES procedures, and realized the esophageal muscle could be cut endoscopically like a Heller myotomy. Open
Host summary Jeffrey Ponsky summarizing a resource: Early European studies of 70 patients showed POEM was effective at one year. Open
Host summary Jeffrey Ponsky summarizing a resource: Eric Hungness and Nat Soper reported POEM was effective in an early study of 18 patients. Open
Host summary Jeffrey Ponsky summarizing a resource: Lee Swanström's 2014 study of 100 patients showed excellent POEM results but increased reflux compared to Heller myotomy. Open
Host summary Jeffrey Ponsky summarizing a resource: Marco Patti's study showed less dysphagia with POEM than with Heller myotomy, but more reflux. Open
Host summary Jeffrey Ponsky summarizing a resource: A prospective randomized controlled trial presented in Europe at the end of 2018 compared Heller myotomy with Dor fundoplication versus POEM and found both were effective in controlling dysphagia. Open
Host summary Jeffrey Ponsky summarizing a resource: In the 2018 RCT, POEM patients had higher reflux rates than Heller patients at two months, but at three years the reflux rates equalized. Open

Jeffrey Ponsky: Portrait of a SAGES Pioneer

Host summary Jeffrey Ponsky summarizing a resource: They said there was a mistake. We're not training a surgeon to do this. We don't have a spot for you. Open
Host summary Jeffrey Ponsky summarizing a resource: He said, You will not touch our instruments. We are not going to let a surgeon do endoscopy. Open
Host summary Jeffrey Ponsky summarizing a resource: She said to me, Go buy yourself a Christmas present, Hanukkah present. She said, go buy yourself a scope. We're buying it for you. Open
Host summary Jeffrey Ponsky summarizing a resource: When you run a department and you're a leader, you should protect your elders there, the elder staff, make sure they're protected and they're not threatened, but at the same time promote your younger staff. Open
Summaries Jeffrey gave as host · Gastroparesis 7 summaries

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POEM by Surgeons – Dr. Jeffrey Ponsky

Host summary Jeffrey Ponsky summarizing a resource: J Pasca at Hopkins originated the idea of creating a submucosal tunnel in the esophagus to avoid gastric leaks during NOTES procedures, and realized the esophageal muscle could be cut endoscopically like a Heller myotomy. Open
Host summary Jeffrey Ponsky summarizing a resource: Early European studies of 70 patients showed POEM was effective at one year. Open
Host summary Jeffrey Ponsky summarizing a resource: Eric Hungness and Nat Soper reported POEM was effective in an early study of 18 patients. Open
Host summary Jeffrey Ponsky summarizing a resource: Lee Swanström's 2014 study of 100 patients showed excellent POEM results but increased reflux compared to Heller myotomy. Open
Host summary Jeffrey Ponsky summarizing a resource: Marco Patti's study showed less dysphagia with POEM than with Heller myotomy, but more reflux. Open
Host summary Jeffrey Ponsky summarizing a resource: A prospective randomized controlled trial presented in Europe at the end of 2018 compared Heller myotomy with Dor fundoplication versus POEM and found both were effective in controlling dysphagia. Open
Host summary Jeffrey Ponsky summarizing a resource: In the 2018 RCT, POEM patients had higher reflux rates than Heller patients at two months, but at three years the reflux rates equalized. Open
Summaries Jeffrey gave as host · Pancreatitis 1 summary

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Gallstone Disease

Host summary Jeffrey Ponsky summarizing a resource: Some experts (George Bursey, Joe Peatland) advocate taking patients with persistent common duct stones directly to the operating room for intraoperative cholangiogram and transcystic or laparoscopic common duct exploration, with postoperative ERCP only if unsuccessful. Open