Meet the Master: Jeffrey L. Ponsky, MD, FACS

In 1973-1974, the chief of gastroenterology at Case Western Reserve refused to train a surgery resident in endoscopy, stating "we're not going to train a surgeon to do endoscopy."

During six months of training in Canton, Ohio in 1974, Dr. Ponsky performed almost 500 endoscopies.

Early endoscopy in the 1970s used green soap for scope disinfection with no gloves worn, even for colonoscopy, and no high-level disinfection or washing machines.

The first PEG procedures were performed in May 1979 on five babies at Rainbow Babies hospital, followed by the first adult cases at Mount Sinai.

When PEG was presented at the 1980 ASGE meeting in Salt Lake City, Peter Cotton stated "I'm only sorry that I didn't think of this."

In babies, transillumination during PEG placement showed the endoscopist and surgeon were "only a couple of millimeters away from each other," making the procedure more obvious than in adults.

Early PEG tubes were fashioned from Pezzer catheters with Bunsen burner tubing cut for side holes and a medicut IV catheter as a dilator.

The discovery that stretching rubber makes it thinner allowed easier insertion of PEG tubes through the dilating catheter.

Using a snare around the puncturing needle to grab the suture was more reliable than trying to grab it with biopsy forceps during PEG placement.

The concept behind PEG is "affixing a loop of bowel to the abdominal wall and creating a tract that was permanent."

The PEG concept was extended to cecal puncture for Ogilvie syndrome, published in 1984.

Endoscopic tattooing with India ink was first performed in 1975 using a reusable NM1K injection needle and India ink from a bookstore to mark polyp locations for surgical resection.

SAGES membership grew from 300 members to 2,000 members during Dr. Ponsky's presidency, driven by the laparoscopic cholecystectomy revolution.

Dr. Ponsky was the second surgeon to serve as president of ASGE, after Ted Schrock.

The NOSCAR consortium established that experimental NOTES procedures would only be performed under IRB protocol with informed consent.

The first human NOTES procedure in the United States was PEG rescue, where a string was passed through an existing PEG tract into the peritoneal cavity, pulled back into the stomach and out the mouth to place a new tube.

Dr. Ponsky currently performs approximately 1,200 endoscopic procedures annually at age 72.

POEM was first performed in humans by Haruo Inoue in Yokohama around 2007, though the tunneling concept was conceived earlier at IRCAD in France during the NOTES era.

After POEM procedures, patients report "you changed my life, I feel so great," providing strong positive reinforcement for the technique.

Over 300 per-oral pyloromyotomy cases have been performed at Cleveland Clinic.

Per-oral pyloromyotomy (POP) via lesser curve tunneling results in improved or normalized gastric emptying in two-thirds to three-quarters of patients, performed as an outpatient procedure.

For Zenker's diverticulum, the intramural approach involves opening the mucosa, tunneling under it, pushing it off the muscle, cutting the muscle, and clipping the mucosa closed—a "double-sided tunnel, one on each side of the muscle."

Current ESD technique is "like pushing a nickel across the room with your nose," but future robotic platforms will allow surgeons to "lift it and cut it just like we do in surgery" with knot-tying and full-thickness resection capabilities.

For tight radiation strictures preventing standard PEG placement, T-fasteners combined with a surgical step trocar (which radially expands) can be used to place a standard-sized gastrostomy tube.