From
Dr. Jeffrey Ponsky
From Idea to Ubiquity - the PEG Journey
With Dr. Jeffrey Ponsky · hosted by Dr. Steven Rothenberg
Chapter 1 of 6 · Fundamentals
Introduction
Introduction of Dr. Jeffrey Ponsky
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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 was developed in 1979 by Jeffrey Ponsky and Michael Gauder working as equal partners, with Gauder contributing conceptual ideas and Ponsky contributing technical ideas.
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.
Original indications for PEG were limited to CNS impairment, oropharyngeal tumors, and gastric atony.
Within one year of publication, multiple other groups independently developed alternative PEG techniques because endoscopy and percutaneous techniques were evolving simultaneously.
Ponsky approached Olympus, Ethicon, and Ross Laboratories asking them to manufacture the PEG device rather than seeking patent protection.
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.
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.
PEG-J tubes cause significant long-term patient problems despite continued use at the request of internists.
Direct jejunostomy involves advancing the endoscope further and puncturing the jejunum where indentation is visible.
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.
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.
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.
Approximately 250,000 PEG procedures are performed annually in the United States.
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.
Bunsen burner tubing was cut and used as the external bolster on the original PEG device.
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.
Balloon catheters (Foley-type) are suitable for overnight use to maintain tract patency but do not work well long-term as PEG replacements.
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.
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.
Wound infections from PEG placement were eliminated by using a single preoperative dose of antibiotic.
Excessive tension on the external bolster can cause PEG tube erosion through the abdominal wall; tubes should not be placed under tension.
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.
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.
Direct jejunostomy procedures have a higher complication rate than standard PEG placement.
When changing a PEG tube, the stomach can be pushed away from the abdominal wall, creating a complication.
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.
PEG tube deterioration is thought to be caused by lipases rather than gastric acid.
Enterostomal therapists are needed to manage complications of PEG tube leakage and peristomal skin breakdown.
Clinicians should decline PEG placement in patients with multi-system organ failure, massive ascites, and limited life expectancy.
The peritoneal cavity extends above the rib cage endoscopically, allowing PEG placement between ribs when the abdomen is frozen or inaccessible.
Percutaneous endoscopic cecostomy can be used for colonic decompression.
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.
PEG ports can be used for transgastric surgery, with two PEG sites providing instrument access and a gastroscope providing visualization.
Ponsky and Michel Gagné performed intragastric surgery using PEG access to remove a submucosal tumor at the esophagogastric junction.
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.
Ponsky retired from clinical surgery after performing over 1,600 endoscopies in his final year at Cleveland Clinic.
In Parkinson's disease, neurologists discovered that delivering medication into the jejunum via PEG-J improves patient outcomes.