From
Dr. Jeffrey Ponsky
Lessons learned from the introduction of a new endoscopic procedure: PEG
With Dr. Jeffrey Ponsky · hosted by Dr. Todd Ponsky
Chapter 1 of 6 · Fundamentals
Development stages
Introduction and Overview of Technique Development Stages
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Host summaries · secondary, not cited in answers
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
PEG will be 40 years old in a couple of years from the time of this presentation
In the late 1970s there were very few pediatric gastroenterologists
Before PEG, babies with birth asphyxia or severe psychomotor retardation who couldn't eat required nasal feeding tubes and operative gastrostomy before going to long-term care facilities
Patients with oral pharyngeal cancers who couldn't swallow required gastrostomy
Patients with severe gastric dilatation needed gastrostomies for venting
Transillumination during endoscopy could light up the whole room in babies, enabling visualization from outside
The original PEG technique used a silk suture, an IV catheter called a medicut with no hub, and initially a foreign body grasper rather than a snare
Capturing the silk suture with a snare was easier than using a foreign body grasper because the suture would move away from the grasper
Following the tube down with the endoscope was necessary to ensure it wasn't caught at the EG junction, as feeding the esophagus rather than stomach was a concern
The first PEG tube was made from a deep mushroom catheter with Bunsen burner tubing behind it to create a bolster, with a stitch through the end pushed through the medicut catheter to create a dilator
Pulling on rubber makes it thinner, which solved the problem of inserting the rubber tube into the medicut dilator
In 1979, the developers did not practice the PEG procedure in an animal lab or on explants before performing it in patients
The fallback procedure for the first PEG cases was laparotomy
By today's standards, not practicing in an animal model before human implementation would be criticized
The first PEG was performed in 1979, but the PEG tract formation was not studied in the laboratory until 1991 when John Mellinger studied it
Over 10 years passed between the first PEG procedure and laboratory study of tract formation
The transgastric appendectomy by Rao was shown as a movie in the NOTES era but was never published
Dr. Ponsky and Michael Gauder worked together from day one on PEG development, doing every single case together
The developers published the PEG technique in three different journals—pediatric surgery, endoscopy, and general surgery—with different patient numbers in each publication
Transcolonic PEG placement was a complication, with one case sent by a gastroenterologist rather than a surgeon
Buried bumper syndrome occurs when excessive traction on the PEG tube creates a tourniquet effect, causing the tube to migrate through the abdominal wall
Incorrect PEG tube reinsertion could result in entering the peritoneal cavity and causing soilage
A silicone tube with a bigger, softer head was developed to eliminate the need for an inner bolster and allow easier removal
Dr. Gauder invented the one-step button that could be pulled through and opened like a cocoon into a skin-level device
Greg Fouch, a gastroenterologist training with Bob Sanowski, developed the safe tract technique
The safe tract technique involves poking with a finger to see the site, then aspirating slowly with fluid in the syringe; if bubbles appear before the endoscopist sees the needle in the stomach, the needle is in the colon and should be withdrawn and repositioned
The safe tract technique is still used today
Sachs and Vine described a push method technique where the tube was pushed over a wire, a few years after the original pull method
Another technique used instruments from CVP line placement with peel-away sheets
Some practitioners used T-fastener anchors to hold the stomach up during PEG placement
B Panchan and his group developed a technique using a one-step trocar from laparoscopy that expands, through which a tube could be placed directly
Percutaneous endoscopic jejunostomy with a jejunal extension tube was published in 1984
Jejunal extension tubes dropped into the duodenum don't work well and require frequent replacement, approximately every two weeks
Direct jejunostomy can be performed by advancing a pediatric colonoscope deep into the jejunum under fluoroscopy or without, though it is technically challenging
Combined gastrostomy for drainage and jejunostomy for feeding can be performed
Percutaneous endoscopic cecostomy can be used for Ogilvie syndrome
In obese patients, PEG can be performed using a spinal needle, staying in the midline where fascia is thinner, and going up under the xiphoid
Some patients would be better off without a PEG, and clinicians should have the courage to decline placement in patients who won't live two weeks, are septic, or have multi-organ failure
PEG can provide palliative benefit in terminal patients; a patient with carcinomatosis and frozen abdomen with only one to two months to live had a PEG placed between lower left ribs to decompress the stomach and prevent daily vomiting