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.
we can pass a little tube into the opening at the intestine, inject dye, see what the problem is, and very often take care of it. That's called ERCP. We can cut the opening at the bottom and pull stones out. If we see tumors, we can often define them by biopsying them or putting in a little plastic or metal stent
we have to do a major laparotomy on these babies, uh, but we have an idea for performing this, uh, by a new technique. Uh, we don't have any idea if it'll work. We think it will, it's pretty simple, but if it doesn't, we will do the laparotomy right there and then and complete the gastrostomy
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.
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.
The endoscope is now. The vehicle, it's the car that gets us to our destination. It drives us to our destination, then we put it down, we have it fixed, and we start to operate endoscopically
clinicalBiliary dyskinesia is diagnosed with a HIDA scan showing ejection fraction less than 35% after CCK administration, when all other tests are negative.↗
▶Ep 1 · 5:00
clinicalModern practice favors early cholecystectomy within the first week for acute cholecystitis, rather than the older approach of cooling down for six weeks.↗
▶Ep 1 · 5:40
clinicalFor 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.↗
▶Ep 1 · 6:10
clinicalThere is no evidence that prophylactic antibiotics help in acute cholecystitis management.↗
▶Ep 1 · 12:12
clinicalThe sucker is a great tool for blunt dissection during difficult cholecystectomy; hydrodissection (injecting water between tissue planes) helps in tough areas.↗
▶Ep 1 · 12:40
clinicalAfter 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.↗
▶Ep 1 · 13:02
quoteEasy 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.↗
▶Ep 1 · 13:02
opinionEasy gallbladders are dangerous because surgeons become complacent; accessory cystic ducts and vascular variants can be missed.↗
▶Ep 1 · 14:50
clinicalRoutine 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.↗
▶Ep 1 · 18:33
clinicalWhen 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).↗
▶Ep 1 · 19:00
clinicalIntraoperative administration of 30mg Toradol (age-adjusted in children) before the patient wakes facilitates same-day discharge after cholecystectomy.↗
▶Ep 1 · 20:30
clinicalAny 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.↗
▶Ep 1 · 20:30
quoteIf 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.↗
▶Ep 1 · 21:11
clinicalFor suspected postoperative bile leak, obtain CT or ultrasound to identify fluid collections; if present, aspirate immediately—if bile is present, proceed to ERCP.↗
▶Ep 1 · 21:32
opinionHIDA 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.↗
▶Ep 1 · 22:37
clinicalFor 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.↗
▶Ep 1 · 23:41
clinicalBiliary dyskinesia with ejection fraction less than 35% is an indication for cholecystectomy when all other GI workup is negative.↗
▶Ep 1 · 24:11
clinicalGallstone pancreatitis is caused by small stones creating transient obstruction of both bile and pancreatic ducts while passing through the papilla.↗
▶Ep 1 · 24:40
clinicalIn the old practice, all patients with gallstone pancreatitis received ERCP on presentation, but two-thirds had normal ERCPs because the stone had already passed.↗
▶Ep 1 · 24:40
quoteThe 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.↗
▶Ep 1 · 25:10
clinicalCurrent 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.↗
▶Ep 1 · 26:27
opinionThe 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.↗
▶Ep 1 · 30:14
clinicalFor 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.↗
▶Ep 1 · 30:56
clinicalIf 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.↗
▶Ep 1 · 31:35
clinicalA 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.↗
▶Ep 1 · 32:44
clinicalModern 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.↗
▶Ep 1 · 33:27
clinicalAfter transcystic common duct exploration, place endoloops on the cystic duct stump because prolonged obstruction can blow off simple ties.↗
▶Ep 1 · 34:56
clinicalLaparoscopic 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.↗
▶Ep 1 · 35:30
clinicalFor laparoscopic choledocotomy, do not divide the cystic duct—use the gallbladder for lateral retraction while dissecting down to expose the anterior common duct surface.↗
▶Ep 1 · 37:40
clinicalT-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.↗
▶Ep 1 · 38:50
clinicalT-tube cholangiogram is performed at 10 days post-choledocotomy; if clear, the T-tube is removed at 2 weeks.↗
▶Ep 1 · 39:27
clinicalFor severe pancreatitis with large phlegmon in the pancreatic head, obtain CT and consider waiting 6 weeks before cholecystectomy to allow inflammation to resolve.↗
▶Ep 1 · 40:00
clinicalFor 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.↗
▶Ep 1 · 41:04
clinicalPercutaneous 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.↗
▶Ep 1 · 41:47
clinicalIn 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.↗
▶Ep 1 · 42:29
clinicalCommon bile duct injuries typically occur during 'easy' cases when surgeons become complacent and fail to maintain vigilance.↗
▶Ep 1 · 43:00
clinicalThe 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.'↗
▶Ep 1 · 43:29
clinicalBeing 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.↗
▶Ep 1 · 44:00
clinicalIf common bile duct injury is recognized intraoperatively: STOP immediately, call for help, and assess. If shaken or inexperienced with hepaticojejunostomy, do not attempt repair.↗
▶Ep 1 · 44:00
quoteIf 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.↗
▶Ep 1 · 44:20
quoteWhat happens in most of these cases is the primary injury is compounded by the attempted repair.↗
▶Ep 1 · 44:20
clinicalIn most bile duct injury cases, the primary injury is compounded by the attempted repair.↗
▶Ep 1 · 44:37
quoteA 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.↗
▶Ep 1 · 44:37
clinicalPrimary 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.↗
▶Ep 1 · 44:56
clinicalFor small lateral common duct injuries, place a small T-tube rather than primary suture closure, as suture alone will leak.↗
▶Ep 1 · 45:37
clinicalFor 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.↗
Acute Cholecystitis
▶Ep 2 · 27:51
clinicalPonsky's bailout technique for horrible cases: open the gallbladder, remove all stones, place a large cholecystostomy tube, leaving an empty gallbladder with drainage.↗
Acute Cholecystitis
▶Ep 6 · 18:31
quoteThat's how the attending steals the case from the resident here with the sucker.↗
▶Ep 6 · 20:19
clinicalTaking the posterior gallbladder wall off the liver bed just superior to the cystic duct-gallbladder junction provides increased length for safer dissection.↗
▶Ep 6 · 28:14
clinicalA bailout technique for severe cases is to open the gallbladder, remove all stones, place a large cholecystostomy tube, creating an empty gallbladder with drainage.↗
Acute Cholecystitis
▶Ep 7 · 4:21
clinicalAcute cholecystitis is an obstructive diverticulopathy where the cystic duct becomes obstructed (usually by a stone), causing backup of pressure in the gallbladder with decreased blood flow in the wall, and the wall can eventually rupture.↗
▶Ep 7 · 20:18
clinicalTaking some of the gallbladder just superior to the cystic duct junction and removing the back wall off the liver bed gives increased length for dissection.↗
▶Ep 7 · 27:07
opinionThere is no fear of adding another trocar—they are free and there is nothing magical about one number or another; just put them where you need them.↗
Jeffrey's statements about Choledocholithiasis4 statements
clinicalPonsky's bailout technique for horrible cases: open the gallbladder, remove all stones, place a large cholecystostomy tube, leaving an empty gallbladder with drainage.↗
Acute Cholecystitis
▶Ep 7 · 18:31
quoteThat's how the attending steals the case from the resident here with the sucker.↗
▶Ep 7 · 20:19
clinicalTaking the posterior gallbladder wall off the liver bed just superior to the cystic duct-gallbladder junction provides increased length for safer dissection.↗
▶Ep 7 · 28:14
clinicalA bailout technique for severe cases is to open the gallbladder, remove all stones, place a large cholecystostomy tube, creating an empty gallbladder with drainage.↗
Jeffrey's statements about Cholelithiasis3 statements
clinicalAcute cholecystitis is an obstructive diverticulopathy where the cystic duct becomes obstructed (usually by a stone), causing backup of pressure in the gallbladder with decreased blood flow in the wall, and the wall can eventually rupture.↗
▶Ep 9 · 20:18
clinicalTaking some of the gallbladder just superior to the cystic duct junction and removing the back wall off the liver bed gives increased length for dissection.↗
▶Ep 9 · 27:07
opinionThere is no fear of adding another trocar—they are free and there is nothing magical about one number or another; just put them where you need them.↗
Jeffrey's statements about Foundations of Minimally Invasive & Endoscopic Surgery421 statements
clinicalPonsky had a 2.027 GPA graduating from Cleveland Heights High School and his college counselor recommended trade school instead of college.↗
▶Ep 3 · 9:01
quoteLook, 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.↗
▶Ep 3 · 9:17
opinionPonsky's transformation in college came from memorizing everything and studying constantly, discovering he had an exceptional memory that allowed him to 'eat the book and spit it out.'↗
▶Ep 3 · 21:12
clinicalWalter Pore taught pinch grafting technique at Metro Hospital, where students would inject local anesthesia, harvest small 'postage stamp' skin grafts from the thigh, and apply them to debrided bedsores. Pore emphasized giving patients zinc supplementation.↗
▶Ep 3 · 25:21
clinicalGastroenterologists at University Hospitals refused to train surgeons in endoscopy, telling Ponsky 'we're not training any surgeons.'↗
▶Ep 3 · 25:47
clinicalPonsky trained in endoscopy with Jim King in Canton, Ohio, performing approximately 500 cases over 5-6 months during an extended elective.↗
▶Ep 3 · 26:57
clinicalEarly endoscopes were cleaned with green soap and stored in the back of cars, without high-level disinfection protocols. Operators did not wear gloves during procedures.↗
▶Ep 3 · 28:30
clinicalWhen SAGES started, it had approximately 300 members. When Ponsky became president in 1990, the society was giving courses on surgical endoscopy and its relationship to surgical problem-solving.↗
▶Ep 3 · 28:48
clinicalJacques Perissat showed the video of laparoscopic cholecystectomy in the exhibit hall at the SAGES meeting in Louisville, Kentucky, marking a pivotal moment when Ponsky was SAGES president.↗
▶Ep 3 · 29:04
clinicalWhen laparoscopic cholecystectomy was introduced, instruments could not be purchased and surgeons had to use gynecologic instruments initially.↗
▶Ep 3 · 29:10
clinicalPonsky took one of the first laparoscopic cholecystectomy courses taught by Nat Soper, George Bercy, John Hunter, and John Sackier in Salt Lake City.↗
▶Ep 3 · 29:27
clinicalPonsky's first two laparoscopic cholecystectomies at Mount Sinai were proctored by David Dupper, who had performed only 8 cases himself at that time. The first patient was a member of the hospital's board of trustees.↗
▶Ep 3 · 30:31
clinicalPonsky became director of surgical endoscopy at University Hospitals at age 29 as a new attending.↗
▶Ep 3 · 31:23
clinicalThe PEG (percutaneous endoscopic gastrostomy) was developed in May 1979 by Ponsky and pediatric gastroenterologist Mike Gower, with the first five cases performed on babies with birth asphyxia and psychomotor retardation.↗
▶Ep 3 · 31:31
clinicalThe PEG procedure was developed without IRB approval, only discussing the approach with patients' families.↗
▶Ep 3 · 31:50
clinicalPonsky became chief of surgery at Mount Sinai Hospital at age 32 in 1979.↗
▶Ep 3 · 32:54
clinicalMount Sinai Hospital had an animal laboratory that was larger than Cleveland Clinic's laboratory, providing Ponsky freedom to conduct courses and train fellows.↗
▶Ep 3 · 40:27
clinicalThe distal splenorenal shunt, once considered a great operation based on physiology to reduce variceal pressure without decreasing portal flow, became obsolete when endoscopic variceal banding was introduced.↗
▶Ep 3 · 41:05
clinicalPonsky performed 180 vertical banded gastroplasties in one year in the mid-1980s, an operation that later required reversal in many patients.↗
▶Ep 3 · 41:34
clinicalPonsky performed 1,600 colonoscopies in a single year during his practice.↗
▶Ep 3 · 43:09
clinicalERCP was developed primarily in Japan by Itaru Oi and colleagues, with contributions from German physicians and Peter Cotton's group in London.↗
▶Ep 3 · 43:40
clinicalPonsky learned ERCP primarily through watching videos and self-teaching, then traded training with George Brodmerkel in Pittsburgh—teaching him laparoscopy under local anesthesia in exchange for learning sphincterotomy.↗
▶Ep 3 · 48:24
clinicalEarly SAGES meetings focused on surgical problem-solving with endoscopy, addressing topics like managing bowel obstruction, evaluating suture lines, and treating intestinal volvulus endoscopically—distinct from ASGE's focus.↗
▶Ep 3 · 50:09
clinicalPonsky advocated to the Residency Review Committee (when Joe Fisher was head) for a minimum endoscopy requirement in general surgery training. The initial requirement of 50 cases was controversial but established endoscopy as a required component of general surgery.↗
▶Ep 3 · 51:55
quoteAlways volunteer, never say no, get involved in everything. And you know what, you'll find the time. You don't have to belabor decisions. Make a decision and move on.↗
Residency Advice: Dr. Jeffrey Ponsky | St. George's University
▶Ep 4 · 0:21
opinionThe interview is a small part of the whole process of selecting people for residency.↗
▶Ep 4 · 0:29
opinionResidency programs want candidates with bright eyes and full hearts, meaning desire and enthusiasm.↗
▶Ep 4 · 0:29
quoteWhat we want is people who What's that, uh, Friday Night Lights, Bright eyes and full hearts↗
▶Ep 4 · 0:46
guidelineCandidates must have passed their USMLE and have good letters of recommendation as baseline requirements.↗
▶Ep 4 · 0:52
opinionAsking people who will write bad letters of recommendation to write for you is an intelligence test that many candidates fail.↗
▶Ep 4 · 0:52
quoteDon'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.↗
▶Ep 4 · 1:08
guidelineDuring interviews, candidates should make eye contact and look interested in what the interviewer is doing.↗
▶Ep 4 · 1:21
quoteWe 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.↗
▶Ep 4 · 1:21
opinionResidency programs want a partner in the education process.↗
▶Ep 4 · 1:37
opinionInterviewers want to know that candidates are willing to invest in their own education.↗
▶Ep 4 · 1:42
guidelineCandidates should give interviewers a plan and vision for their future during the interview.↗
▶Ep 4 · 1:58
opinionAn enthusiastic, engaged candidate can overcome merely adequate grades in the selection process.↗
▶Ep 4 · 1:58
quoteThis 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.↗
▶Ep 4 · 2:09
quoteDon'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.↗
▶Ep 4 · 2:09
guidelineDuring interviews, candidates should not be shy but also should not be a jerk.↗
SAGES Stories: Dr. Jeffrey Ponsky on surgical endoscopy and the PEG tube legacy
▶Ep 5 · 6:49
clinicalPonsky graduated Cleveland Heights High School with a 2.027 GPA and was advised by his counselor to consider trade school instead of college.↗
quoteI had a 2.027 with my with my acu graduating from high school↗
▶Ep 5 · 9:01
quotelook, 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↗
▶Ep 5 · 9:44
opinionPonsky's transformation in college came from memorizing everything and studying constantly, discovering he had an 'unbelievable' memory that allowed him to 'eat the book and spit it out.'↗
clinicalWorking as an orderly at Mount Sinai Hospital, Ponsky gave bed baths, changed bedpans, and cared for a high school classmate who became paraplegic after an auto accident, which deepened his commitment to medicine.↗
▶Ep 5 · 12:15
clinicalPonsky was promoted to scrub tech and surgeons allowed him to close fascia, despite the head nurse objecting that he wasn't permitted to do so.↗
▶Ep 5 · 12:43
clinicalPonsky never took calculus, using logarithms to work around it in physics, and the Case Western dean of admissions accepted him despite this after he stated he had already been admitted to two other medical schools.↗
▶Ep 5 · 14:14
clinicalPonsky chose Case Western Reserve (then Western Reserve) over Northwestern and Cincinnati primarily because his family lacked money and he needed to live at home rather than pay rent elsewhere.↗
▶Ep 5 · 19:43
opinionBill Holden, chairman of surgery at Case, was an 'elegant' teacher who used the Socratic method and prioritized teaching over technical skill.↗
▶Ep 5 · 20:20
clinicalWalter Parry taught using theatrical methods, including having students smell a room to perceive 'the smell of death' (though there was no actual smell) and performing bedside pinch grafts on bedsores at Metro Hospital.↗
clinicalParry made Ponsky rewrite his first paper—a letter to the New England Journal about paradoxical air embolism—six times and read German poetry to him to encourage more poetic medical writing.↗
▶Ep 5 · 25:08
clinicalWhen Ponsky requested an endoscopy elective as a resident, the head of GI at University Hospitals refused, stating 'we're not training any surgeons.'↗
▶Ep 5 · 25:47
clinicalCharles Hube arranged for Ponsky to train with Jim King in Canton, Ohio, where Ponsky performed approximately 500 colonoscopy cases over 5-6 months using a mid-length scope not designed to reach the cecum.↗
▶Ep 5 · 26:19
clinicalAfter returning from Canton, the head of gastroenterology told Ponsky 'you're not gonna touch this scope,' so he used the VA's Olympus colonoscope instead.↗
▶Ep 5 · 26:51
clinicalPonsky's mother-in-law purchased his first colonoscope after hearing at a family dinner that he couldn't get access to equipment; in that era, scopes were washed with green soap and stored in car trunks.↗
▶Ep 5 · 27:13
clinicalAs a senior resident, Ponsky performed emergency endoscopy cases day and night with Bob Zollinger Junior signing the paperwork, eventually doing all cases while GI physicians stopped performing them.↗
▶Ep 5 · 28:30
clinicalWhen SAGES started, it had approximately 300 members; when Ponsky became president in 1990, the society was giving courses on surgical endoscopy and its relationship to surgical problem-solving.↗
▶Ep 5 · 28:48
clinicalAt the 1990 SAGES meeting in Louisville, Kentucky, Jacques Perissat showed video of laparoscopic cholecystectomy in the exhibit hall; Ponsky was SAGES president at the time and 'right in on the ground floor.'↗
▶Ep 5 · 29:06
clinicalEarly laparoscopic instruments were unavailable for purchase, so surgeons used gynecology instruments. Ponsky took one of the first training courses taught by Nat Soper, George Berci, John Hunter, and John Sackier in Salt Lake City.↗
▶Ep 5 · 29:27
clinicalPonsky's first two laparoscopic cholecystectomy cases at Mount Sinai were performed on a board of trustees member, proctored by David Dupper who had completed only eight cases himself.↗
▶Ep 5 · 31:11
clinicalThe PEG tube was invented in May 1979 when Ponsky and pediatric surgeon Michael Gower used transillumination (seeing light shine through the abdominal wall during endoscopy in neonates) to develop a minimally invasive gastrostomy technique, performing it on five babies with birth asphyxia and psychomotor retardation.↗
▶Ep 5 · 31:31
clinicalThe PEG tube procedure was performed without IRB approval; Ponsky and Gower only spoke with the patients' families before proceeding.↗
▶Ep 5 · 31:50
clinicalPonsky became chief of surgery at Mount Sinai Hospital at age 32, shortly after inventing the PEG tube.↗
▶Ep 5 · 32:44
opinionMount Sinai was Ponsky's 'favorite place I ever worked in my life'—a small hospital where every staff member knew each other, with an animal research laboratory larger than Cleveland Clinic's.↗
▶Ep 5 · 32:44
quotethe favorite place I ever worked in my life was Mount Sinai.↗
▶Ep 5 · 33:36
opinionPonsky left Mount Sinai in 1997 after 18 years when the hospital was sold to a for-profit company whose leadership 'could care less about quality.'↗
▶Ep 5 · 33:36
quoteThey were for-profit guys who could care less about quality.↗
▶Ep 5 · 34:21
clinicalPonsky had all but one of his children before finishing residency; his last son was born during his final year of residency, and his daughter was born three years later after he joined Mount Sinai.↗
▶Ep 5 · 34:43
opinionPonsky's wife had no partners helping her while he was on call every other night, but he credits his family—wife, children, and in-laws—as essential to his success, stating 'our success was a joint success, not just my success.'↗
▶Ep 5 · 34:49
quoteYou know, here's the important part. You, you gotta have a good partner. To have all the success doesn't come down cause you're a genius. You have to either destroy your family as many people did in the past, or use that to bolster your success↗
▶Ep 5 · 35:09
quoteour success was a joint success, not just my success.↗
▶Ep 5 · 35:30
quoteWho's watching our patients when we go? We all have a partner who's making rounds and taking our patients back when we have Complications↗
▶Ep 5 · 36:32
opinionPonsky's greatest academic achievement was becoming chairman of the Department of Surgery at Case Western Reserve, though his parents were most proud of his role as chief of surgery at Mount Sinai because it was meaningful within the Jewish community they knew.↗
▶Ep 5 · 36:39
quoteI think that, uh, I was chair of the board of the board of surgery. They wouldn't have understood that. That to them didn't mean anything. They saw it as the chief of surgery at Mount Sinai, that's enough.↗
▶Ep 5 · 38:47
opinionPonsky has counseled fellows away from positions at his own institutions when he believed better opportunities existed elsewhere, considering factors like family proximity, academic opportunity, and institutional need rather than institutional prestige.↗
▶Ep 5 · 38:58
quotethat is not the best opportunity for you. There is a great opportunity here because they need you more, because this is a better academic opportunity, because the people you'll be working with are more uh akin to what you need, or your family is in that city, your husband or wife's family is in that city.↗
▶Ep 5 · 39:32
quotego where the opportunities are best for your whole life, not just for your name of your institution.↗
▶Ep 5 · 40:27
clinicalPonsky performed distal splenorenal shunts early in his career at University Hospitals with Jerry Walkoff's assistance, believing the operation was 'the greatest thing since sliced bread' based on Dean Warren's physiologic approach, but the procedure became obsolete when endoscopic variceal banding was introduced.↗
▶Ep 5 · 40:27
quoteI thought that a distal splenor renal shunt was a great operation when they first did it. I dare say you've not done those.↗
▶Ep 5 · 41:05
clinicalPonsky performed 180 vertical banded gastroplasty procedures in one year during the mid-1980s, believing it would be a great bariatric operation, but later surgeons had to reverse many of them.↗
▶Ep 5 · 41:34
opinionPonsky performed 1600 colonoscopies in his final year of practice, predicting that in 20 years colonoscopy for screening may be obsolete.↗
▶Ep 5 · 41:34
quoteI dare say in 20 years, you may say, I remember when we did colonoscopy for screening on all these patients↗
▶Ep 5 · 42:07
opinionERCP is Ponsky's favorite procedure, which he describes as 'like golf for some people'—he would come in day or night to perform it and considers it a sophisticated procedure requiring 'body English.'↗
▶Ep 5 · 42:10
quoteTo me, ERCP is like golf for some people. I love ERCP. I would have come in day or night to do ERCP. I just loved it.↗
▶Ep 5 · 43:40
clinicalPonsky learned ERCP largely self-taught by watching videos, then arranged a teaching exchange with George Brodmerkel in Pittsburgh: Ponsky taught Brodmerkel laparoscopy under local anesthesia for liver biopsy, and Brodmerkel taught Ponsky sphincterotomy.↗
▶Ep 5 · 44:19
quoteERCP is like a a a a golf game. Is it body English in it. There it's very sophisticated and I love it.↗
▶Ep 5 · 44:54
opinionPonsky obtained an executive MBA at the urging of hospital administrators who said he made decisions 'out of your gut' without understanding return on investment or financing; he describes the MBA as learning 'the language of business' and when to 'say bullshit at the right time' in business meetings.↗
▶Ep 5 · 45:36
quoteI hate business. I don't care about business.↗
▶Ep 5 · 46:18
quoteIt's the people you meet. Yeah, it's the way they think. It's the way they approach a problem.↗
▶Ep 5 · 47:50
opinionPonsky initially felt like a 'traitor' to ASGE when SAGES started because he was already on the ASGE governing board.↗
▶Ep 5 · 47:50
quoteI felt a little bit like a traitor to ASGE because here are these group of surgeons who decided they're gonna start their own society.↗
▶Ep 5 · 48:24
opinionAt early SAGES meetings, papers focused on surgical problem-solving with endoscopy (bowel obstruction evaluation, suture line assessment, volvulus management)—topics distinct from ASGE content—which convinced Ponsky of the society's unique value.↗
▶Ep 5 · 48:46
quoteThere is a reason for this society, intraoperative endoscopy, things that we would do.↗
▶Ep 5 · 50:02
quoteEndoscopy has been made a part of surgery now and general surgery. It is a requirement for general surgery.↗
▶Ep 5 · 50:09
clinicalPonsky advocated to the Residency Review Committee (when Joe Fisher was head) for a minimum endoscopy case requirement in general surgery training; the 50-case requirement was initially controversial but established endoscopy as a core surgical competency.↗
▶Ep 5 · 50:45
quoteThe endoscope is now. The vehicle, it's the car that gets us to our destination. It drives us to our destination, then we put it down, we have it fixed, and we start to operate endoscopically↗
▶Ep 5 · 51:38
quoteThere's no reason that you can't be empathetic and be interested in psychiatric disease and still be somebody interested in the technical sides.↗
▶Ep 5 · 51:55
opinionPonsky's philosophy is to 'always volunteer, never say no, get involved in everything'—he believes people will find the time, decisions don't need to be belabored, and residents can help with much of the work.↗
▶Ep 5 · 51:55
quoteAll I tell people is always volunteer, never say no, get involved in everything. And you know what, you'll find the time.↗
▶Ep 5 · 51:58
quoteI think that surgeons can be better psychiatrists than some of the psychiatrists now. They're more empathetic in some ways↗
▶Ep 5 · 52:57
quoteDon't be afraid to do everything. Don't say I'm too busy. You can do everything.↗
▶Ep 5 · 54:00
quoteI don't take myself too seriously, and you shouldn't, because there are really other people around who've done many more things than me↗
▶Ep 5 · 55:18
quoteif you don't have hobbies, you're cheating yourself.↗
▶Ep 5 · 55:24
clinicalPonsky's wife purchased him a Harley-Davidson trike (three-wheeled motorcycle) when he turned 70; she would not permit a two-wheel motorcycle. They have ridden to Sturgis, South Dakota.↗
▶Ep 5 · 56:04
quoteThe answer is no. I've never been tempted. Uh, to move because my family is here. It's all about your family.↗
▶Ep 5 · 56:12
clinicalPonsky lives on 8 acres with horses; his son Zach built a house on the adjacent 5-acre lot, his daughter bought a house two properties away with another 5 acres, son Todd lives within half a mile, and son Lee lives 'almost 2 miles' away—creating a family compound in Cleveland.↗
▶Ep 5 · 57:22
clinicalPonsky has a house in Florida and would travel there for long weekends during his working years, leaving Friday morning at 6 AM and returning Monday, using vacation days for Friday and Monday.↗
▶Ep 5 · 58:08
quoteMy family only wants to be near my wife. They can care less about me unless Jackie, unless something breaks. Then they call me, but they only want to be near my wife.↗
▶Ep 5 · 58:21
quoteShe's I'm gonna be very clear about that. She's pretty great, the glue that holds our family together↗
▶Ep 5 · 59:19
quoteMy favorite memories, my presidential addresses or highlights of my career. I love doing that.↗
▶Ep 5 · 59:45
quoteWe Are the Sages with the Japanese, because I go to tears when we do that every year, because 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.↗
The invention of the PEG tube with Dr. Jeffrey Ponsky
▶Ep 7 · 2:43
quoteI was told I couldn't do it because I was a surgical resident, and that piqued my interest↗
▶Ep 7 · 3:02
quoteI came back after that training and I was told I couldn't do endoscopy because I was a surgeon, couldn't touch the instruments↗
▶Ep 7 · 3:27
clinicalIn 1974-1975, there were no pediatric gastroenterologists, and Ponsky performed endoscopy on children, young adults, and neonates with GI problems using his personally owned scope.↗
▶Ep 7 · 4:33
clinicalDuring neonatal endoscopy, the room would light up because babies were so thin; when pediatric surgeon Michael Gower pushed on the transilluminated light with his finger, an indentation was visible endoscopically.↗
▶Ep 7 · 4:42
quoteMichael would push on the light with his finger, and I'd be scoping and I would see an indentation. And we realized we got together and said, you know, maybe we could do something with this.↗
▶Ep 7 · 4:59
clinicalThe first PEG tubes were constructed from OR gastrostomy tubes (small Pezzer catheters) with sutures threaded through the end and passed through an IV catheter (medicut) to create a dilator tip.↗
▶Ep 7 · 5:42
clinicalThe first five PEG procedures in May 1979 were performed in neonates with severe psychomotor retardation who were brain dead, fed by nasogastric tubes, had no chance of recovery, and were being sent for open gastrostomy before long-term nursing facility placement.↗
▶Ep 7 · 6:15
quotewe have to do a major laparotomy on these babies, uh, but we have an idea for performing this, uh, by a new technique. Uh, we don't have any idea if it'll work. We think it will, it's pretty simple, but if it doesn't, we will do the laparotomy right there and then and complete the gastrostomy↗
▶Ep 7 · 6:25
clinicalInformed consent for the first PEG cases consisted of telling mothers that if the new technique failed, immediate laparotomy and open gastrostomy would be performed.↗
clinicalThe first PEG procedures succeeded easily within a few minutes.↗
▶Ep 7 · 6:47
clinicalAfter the initial five neonatal cases, Ponsky moved to Mount Sinai Medical Center and began performing PEG in adult stroke patients with similar neurologic prognosis who needed feeding access.↗
▶Ep 7 · 7:13
clinicalLaboratory studies on PEG tract formation, tube dwell time before safe replacement, and leakage risk were conducted after clinical implementation—the reverse of typical research-then-clinical sequence.↗
▶Ep 7 · 7:28
clinicalJohn Mellinger, who later worked at the American Board of Surgery, conducted original research on PEG tract formation.↗
▶Ep 7 · 7:44
quoteit was sort of the reverse of what you would do now by going to the laboratory first and then And then to the operating room.↗
clinicalMultiple medical device companies refused to manufacture the PEG tube initially, believing nobody would use it.↗
▶Ep 7 · 8:54
clinicalA small company in Mentor, Ohio eventually manufactured the PEG tube exactly as designed by Ponsky and Gower.↗
▶Ep 7 · 9:06
opinionPonsky and Gower never patented the PEG tube; they were more interested in publication than patents and wanted to disseminate the technique.↗
▶Ep 7 · 9:06
quotewe never even thought about patenting the tube. It wasn't even on our mind.↗
▶Ep 7 · 9:18
quoteWe wanted to get papers out of it. We wanted to make a contribution to literature. We were more interested in publication than patents↗
▶Ep 7 · 9:39
clinicalPEG tube complications included rare colonic perforation when the tube traversed the colon en route to the stomach, which still occurs rarely today.↗
▶Ep 7 · 9:51
clinicalExit-site infection was a major early PEG complication.↗
▶Ep 7 · 10:24
clinicalPEG tubes evolved from multi-piece rubber construction to one-piece silicone, but have had very few modifications in the last few years and have become a commodity product purchased by hospitals at the lowest price.↗
▶Ep 7 · 10:50
clinicalThe PEG technique has remained very much the same as the original with only a few modifications.↗
▶Ep 7 · 11:19
clinicalPonsky and the manufacturing company conducted dozens of animal experiments to determine tube removal pressure, tip retention, and optimal tube size for FDA approval.↗
▶Ep 7 · 12:09
quoteI said, wow, look at this. What else can we do with this thing?↗
▶Ep 7 · 12:13
clinicalThe PEG tube was the first and only time any instrument or needle was thrust through the abdominal wall into the GI tract and left in place.↗
▶Ep 7 · 12:13
quotethe peg tube and was and still is the only time. Any instrument or needle was thrust through the abdominal wall into the GI tract.↗
▶Ep 7 · 12:55
clinicalIn 1975, Ponsky developed and published endoscopic tattooing using India ink injected alongside polypectomy sites to mark the location for potential surgical resection if cancer was found; the technique remains in use today.↗
▶Ep 7 · 13:38
quotethere was a lot of low hanging fruit then we could do things that seemed logical, and that's the fun of a new area.↗
▶Ep 7 · 13:56
quoteeverybody thinks that everybody's been, everything's been discovered already, that's not true.↗
▶Ep 7 · 15:31
clinicalIn the late 1970s, surgical residents were on call every other night (36 hours on, 12 hours off) for five years of training.↗
▶Ep 7 · 15:49
quoteI wanna have an elective that's a little bit easier.↗
▶Ep 7 · 15:58
quoteI said, wow, that would be a great way to blow up 3 months. I won't have to take night off. This will be easier. That was an accident.↗
▶Ep 7 · 17:07
quotewhen you see a new technology, whatever that technology is. Investigate it, see if it's something that offers you something that you can uh make it your own and become an expert in it.↗
▶Ep 7 · 17:35
clinicalIn the mid-1970s, the predominant American endoscope was the ACMI (American Cystoscope Makers Incorporated) with a joystick control, approximately 1 cm diameter, with image quality like looking through ground glass.↗
clinicalJapanese companies (Mashida and Olympus in the US) produced fiber-optic endoscopes with crystal-clear optics that were markedly superior to American models.↗
▶Ep 7 · 18:15
quoteIt was crystal clear. It was like you were just right there.↗
clinical1970s fiber-optic endoscopes transmitted light via fiber bundles to the lumen and returned images to the eyepiece; photography required clipping a camera to the eyepiece for film-strip images.↗
▶Ep 7 · 18:51
clinicalTeaching attachments for 1970s endoscopes consisted of a wire-connected second eyepiece that provided a dim image for trainees in darkened rooms.↗
▶Ep 7 · 19:06
clinicalAround 1980, video chip technology placed a camera at the endoscope tip instead of using fiber-optic image transmission, displaying images on large monitors—the technology used in current endoscopes.↗
▶Ep 7 · 19:36
clinicalIn the late 1970s, neonates could tolerate endoscopes approximately 9 millimeters wide, which was the limit for safe use.↗
▶Ep 7 · 19:57
clinicalThe original PEG procedure was performed with an adult endoscope.↗
▶Ep 7 · 20:07
quoteI would almost not let anyone touch it except me↗
▶Ep 7 · 20:56
clinicalIn the 1970s, endoscopes were cleaned between procedures using only green soap; high-level disinfection and sterilization protocols did not yet exist.↗
▶Ep 7 · 21:45
clinicalThe PEG tube received FDA 510(k) approval as a modification of existing gastrostomy tubes used for similar purposes, which is easier than approval for entirely novel devices.↗
▶Ep 7 · 22:17
clinicalPEG indications expanded beyond feeding to include gastric decompression in gastroparesis or obstruction (including carcinomatosis), delivery of unpalatable feedings, and treatment of gastric volvulus.↗
▶Ep 7 · 23:00
clinicalThe PEG technique was adapted for colonic applications including sigmoid volvulus fixation and Ogilvie syndrome decompression, with multiple PEGs used for sigmoid volvulus.↗
▶Ep 7 · 23:30
quoteI like to think that the endoscope is a tube, uh, it's a, it's a, a vehicle that gets us to where we need to be to perform an operation. That's what we think of as surgeons.↗
▶Ep 7 · 23:56
opinionMany endoscopic procedures developed by surgeons, including PEG, were extensions of surgical operations already performed via laparotomy.↗
▶Ep 7 · 25:32
clinicalGastroenterologists rapidly adopted PEG as a therapeutic procedure they could easily accomplish, driving widespread dissemination.↗
▶Ep 7 · 25:56
clinicalSurgeons were slower to adopt PEG initially because they were not performing as much therapeutic endoscopy at that time, but they did not offer significant resistance.↗
▶Ep 7 · 26:40
clinicalA properly performed PEG procedure takes under 5 minutes when done carefully by an experienced operator.↗
▶Ep 7 · 26:47
clinicalCurrent PEG procedures still require patient sedation or anesthesia and constitute an intervention.↗
▶Ep 7 · 26:58
quoteI want you to use your imagination that some day you will place a patient on a table. And have a machine that uses ultrasound or something, and has a gun that goes in and goes boom, and places that right into the stomach without anything, except maybe a little local↗
opinionRadiologists perform gastrostomy tube placement using ultrasound guidance, though Ponsky does not prefer the tubes they use.↗
▶Ep 7 · 32:57
quoteyou should always uh take a chance. Now, you shouldn't take a chance with patients' lives, but you should take a chance on developing new ideas and new procedures and new instruments.↗
Jeffrey Ponsky: Portrait of a SAGES Pioneer
▶Ep 18 · 0:13
quoteI was told not to go to college, uh, maybe trade school.↗
▶Ep 18 · 5:52
clinicalPonsky's mother-in-law purchased his first endoscope for $5,200 as a Christmas/Hanukkah gift after he was blocked from using the university gastroenterology department's equipment.↗
▶Ep 18 · 7:46
clinicalIn 1979, Ponsky and Michael Gauderer performed the first percutaneous endoscopic gastrostomy (PEG) procedures in five brain-damaged infants who were scheduled for open gastrostomy, after observing transillumination of the abdominal wall during upper endoscopy.↗
▶Ep 18 · 8:40
clinicalThe first PEG procedures in 1979 were performed without formal IRB review; consent was obtained by explaining to mothers that the team would attempt the endoscopic approach but would convert to open gastrostomy if unsuccessful.↗
▶Ep 18 · 10:18
guidelineThe American Board of Surgery mandated around 1980 that surgical residents must have experience in endoscopy, but most programs rotated residents to gastroenterology services where they only observed rather than performed procedures.↗
▶Ep 18 · 11:35
clinicalSAGES was founded around 1980 by Jerry Marks and other surgeons including John Coller, Ken Ford, John Van Sant, and Jim Lynn because ASGE did not want surgical papers on their programs frequently and excluded surgeons from leadership roles.↗
▶Ep 18 · 13:55
clinicalBarbara Saltzman (later Barbara Bercy after marrying George Bercy) served as SAGES administrator from the early years and was critical to establishing the organization's culture and managing its growth.↗
▶Ep 18 · 15:17
epidemiologicalDuring Ponsky's 18-month SAGES presidency (approximately 1989-1990), membership grew from 300 to 2000 members, driven by the introduction of laparoscopic cholecystectomy after Jacques Perrissat showed his video at a Louisville meeting in 1989.↗
▶Ep 18 · 16:43
opinionSAGES developed a flat organizational structure unlike hierarchical traditional surgical societies, encouraging young surgeons to participate equally on committees and at social events regardless of seniority.↗
▶Ep 18 · 18:05
clinicalSAGES changed its name from Society of Gastrointestinal Endoscopic Surgeons to Society of Gastrointestinal and Endoscopic Surgeons in the last decade, making both endoscopy and general GI surgery equal parts of the organization's mission.↗
▶Ep 18 · 18:35
epidemiologicalCurrent SAGES membership is close to 7,000 members.↗
▶Ep 18 · 22:17
clinicalJapanese surgeons, particularly through Choichi Segawa, Manabu Yamamoto, and others, were instrumental in teaching SAGES members advanced endoscopic techniques including POEM and endoscopic submucosal dissection.↗
▶Ep 18 · 31:14
clinicalThree of Ponsky's fellows became SAGES presidents: John Mellinger, Brian Duncan, and Jeff Marks.↗
▶Ep 18 · 35:59
opinionWalter Pore, in his mid-80s, continues to hold NIH grants and remains relevant in research and lecturing, demonstrating that surgeons can maintain professional relevance well into advanced age.↗
▶Ep 18 · 37:57
clinicalGeorge Bercy at age 96 continues to develop new surgical instruments and regularly contacts Ponsky to review new designs, including a smaller chip-camera choledochoscope and a VTO scope for cardiac surgeons to view valve anastomoses without loupes.↗
▶Ep 18 · 38:49
quoteHe doesn't look at the instrument for what it is today. He looks at the instrument for what it could be with improvement.↗
▶Ep 18 · 39:01
clinicalThe video camera was essential to the laparoscopic revolution because it allowed the entire surgical team to see what the surgeon was doing, unlike earlier laparoscopy where only the surgeon looking through the eyepiece could see the operative field.↗
▶Ep 18 · 39:49
clinicalEddie Joe Reddick and Doug Olson in Nashville, and Barry McKernan and Bill Saye in Marietta, Georgia (who did the first laparoscopic cholecystectomy in the United States) were the key early teachers of the procedure.↗
▶Ep 18 · 40:17
clinicalSAGES initially trained trainers (including John Hunter, Nat Soper, John Saker, George Bercy) in laparoscopic cholecystectomy before offering courses to the broader surgical community.↗
▶Ep 18 · 40:57
clinicalIn the early laparoscopic era, instrument shortages were severe; surgeons needed personal connections to manufacturers to obtain equipment and often used gynecologic instruments adapted for general surgery.↗
▶Ep 18 · 42:06
clinicalIn early laparoscopic common bile duct exploration, before mastering laparoscopic suturing, surgeons would twist the two suture ends together like a twist-tie and secure them with a clip rather than tying knots.↗
▶Ep 18 · 42:46
clinicalPonsky was the first SAGES member appointed to the American Board of Surgery and later served as chairman of the board.↗
▶Ep 18 · 45:32
quoteThe day that you resigned from your great position as chairman. And you expect them to sing your praises forever. What they're really talking about is who's the next in line for your office.↗
Special Lecture: Dr. Jeffrey Ponsky | St. George's University
▶Ep 21 · 6:36
quoteSo you think you're the first guys that wanted the truth?↗
▶Ep 21 · 9:12
quoteThe 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.↗
▶Ep 21 · 9:12
opinionMedical truth is based on what tools we have to perceive it with—when we have new tools to perceive truth, our idea of what the truth is changes.↗
▶Ep 21 · 10:51
clinical120 years ago at Johns Hopkins, medical education focused heavily on anatomy because physicians lacked knowledge of the Krebs cycle, cytochrome system, blood transfusion, blood typing, antibiotics, and pharmacology.↗
▶Ep 21 · 10:51
quoteSo ask yourself, 120 years ago, When William Halstead was at Hopkins and William Osler Was at Hopkins? What did they teach medical students for 4 years?↗
▶Ep 21 · 13:07
clinicalIn 1889, William Osler and William Halsted believed gastric acid caused peptic ulcer disease.↗
▶Ep 21 · 13:16
quoteWhat causes peptic ulcer disease today? Gastric acid was the truth then. Gastric acid was absolutely the truth.↗
▶Ep 21 · 13:32
clinicalH. pylori was discovered in 1990 as a cause of peptic ulcer disease; it blocks production of prostaglandin E3, destroying the mucosal barrier and allowing acid to cause ulcers.↗
▶Ep 21 · 13:34
quoteIn 1990, they discovered H. pylori. They said it was the greatest thing since the discovery of the cure for polio. I'm not sure that's true.↗
▶Ep 21 · 16:15
clinicalGastrojejunostomy was the first operation for peptic ulcer disease, designed to rapidly drain gastric acid from the stomach, but it failed with a 50% recurrence rate due to marginal ulcers developing in unbuffered small bowel.↗
▶Ep 21 · 18:32
clinicalSubtotal gastrectomy (removing 80% of the stomach) had a 99% success rate in preventing ulcers because it removed the parietal cells that produce acid.↗
▶Ep 21 · 19:01
clinicalSubtotal gastrectomy had high mortality due to lack of intensive care units, IV fluids, and antibiotics; survivors often suffered malnutrition (inanition) severe enough to cause death.↗
▶Ep 21 · 19:38
epidemiologicalApproximately 15% of patients after subtotal gastrectomy developed dumping syndrome with severe cramps, sweating, hypotension, and diarrhea.↗
▶Ep 21 · 19:52
clinicalEarly dumping syndrome (20 minutes to 2 hours post-meal) is caused by inappropriate release of vasoactive intestinal polypeptide (VIP) from the pancreas, not by hypertonic fluid dumping into the small bowel as originally thought.↗
▶Ep 21 · 21:05
clinicalLate dumping syndrome (2-4 hours post-meal) results from insulin-glucose imbalance: the intestine releases gastric inhibitory polypeptide (GIP) which stimulates pancreatic insulin release disproportionate to glucose absorption, causing insulin shock with hypoglycemia, hypotension, and tachycardia.↗
▶Ep 21 · 22:58
clinicalThe subtotal gastrectomy operation was later adapted as the basis for gastric bypass surgery in bariatric treatment of morbid obesity, born out of the observation that the operation caused significant weight loss.↗
▶Ep 21 · 24:00
clinicalPavlov discovered the phases of digestion; the cephalic phase occurs when sight or smell of food stimulates the vagus nerve via the area postrema of the fourth ventricle, causing salivation and gastric acid secretion.↗
▶Ep 21 · 25:34
clinicalThe gastric phase of digestion occurs when food distends the stomach, buffers acid (raising pH), and peptones stimulate G cells in the antrum to secrete gastrin, a heptadecapeptide (17 amino acids) that stimulates parietal cell H2 receptors to produce acid.↗
▶Ep 21 · 26:48
clinicalLester Dragstedt designed truncal vagotomy to ablate the cephalic phase of digestion by cutting both vagus nerves, but this caused the stomach to become atonic and unable to empty, requiring addition of a drainage procedure (gastrojejunostomy or pyloroplasty).↗
▶Ep 21 · 28:56
epidemiologicalTruncal vagotomy with drainage had a 15% recurrence rate for peptic ulcer disease.↗
▶Ep 21 · 29:13
clinicalComplications of truncal vagotomy included severe diarrhea from denervating the celiac plexus, gallstones from denervating the liver, and dumping syndrome (15% of patients) from bypassing or destroying the pylorus.↗
▶Ep 21 · 30:10
clinicalAntrectomy (removing the lower 40% of stomach containing G cells) combined with truncal vagotomy ablates both cephalic and gastric phases of digestion, achieving a 98% cure rate (2% recurrence) for peptic ulcer disease.↗
▶Ep 21 · 31:29
epidemiologicalAntrectomy with truncal vagotomy still caused dumping in 15% of patients and diarrhea in some patients.↗
▶Ep 21 · 32:38
clinicalSelective vagotomy preserves the celiac and hepatic vagal branches while denervating only the stomach, reducing complications of gallstones and diarrhea while maintaining a 15% recurrence rate.↗
▶Ep 21 · 34:01
clinicalThe nerve of Latarjet, described by a French anatomist 100 years ago, is the terminal vagal branch that provides motor function to the pylorus but does not stimulate acid production because it innervates the antrum, which lacks parietal cells.↗
▶Ep 21 · 35:17
clinicalHighly selective vagotomy denervates the acid-producing portion of the stomach while preserving the nerve of Latarjet, eliminating the cephalic phase of acid secretion while maintaining pyloric motor function, thus avoiding the need for drainage procedures and reducing dumping syndrome.↗
▶Ep 21 · 35:42
opinionHighly selective vagotomy represents a synthesis of old anatomic knowledge (histology of parietal cell distribution, nerve of Latarjet anatomy) with modern physiology and endocrinology.↗
▶Ep 21 · 36:12
quoteSo when you study in medical school and you say, well, I don't need to know that anymore, that's old stuff. What is important is anatomy important? You better learn it if you want to make a contribution.↗
▶Ep 21 · 37:07
opinionDiscovery favors the prepared mind—knowing old information (anatomy, physiology, endocrinology) enables physicians to design new approaches by recombining old and new knowledge.↗
▶Ep 21 · 37:07
quoteDiscovery favors the prepared mind. If you know where the parietal cells are and where they're not, and you know what that nerve does and where it is, you can design something new based on a lot of old information.↗
▶Ep 21 · 37:48
guidelineSurgery for peptic ulcer disease is now indicated only for complications: hemorrhage, obstruction, perforation, and intractability, the same indications as 120 years ago.↗
▶Ep 21 · 38:58
clinicalModern surgical practice for peptic ulcer obstruction involves pyloroplasty combined with H. pylori treatment and proton pump inhibitors rather than vagotomy, reflecting evolution of treatment approaches.↗
▶Ep 21 · 41:30
quoteDon't ask people to write you a letter of recommendation. They're gonna write you bad letters. I mean, hello, that's an intelligence test, and you'd be surprised how many people don't realize that.↗
▶Ep 21 · 44:04
opinionStudents who actively participate and risk being wrong during teaching sessions retain information better than passive observers because emotional investment (anxiety, satisfaction) enhances memory consolidation.↗
▶Ep 21 · 44:25
quoteBut 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. If you get it right, you'll remember it because you were happy about it. There was an investment there.↗
Innovations in Surgery: PEG Tube
▶Ep 26 · 2:53
quoteI was told I couldn't do it because I was a surgical resident, and that piqued my interest↗
▶Ep 26 · 2:53
quoteI was told I couldn't do it because I was a surgical resident, and that piqued my interest↗
▶Ep 26 · 3:02
clinicalPonsky purchased his own Olympus endoscope with financial help from his mother-in-law after being told surgeons could not use gastroenterology equipment.↗
▶Ep 26 · 3:02
quoteI was told I couldn't do endoscopy because I was a surgeon, couldn't touch the instruments↗
▶Ep 26 · 3:02
quoteI was told I couldn't do endoscopy because I was a surgeon, couldn't touch the instruments↗
▶Ep 26 · 3:02
clinicalPonsky purchased his own Olympus endoscope with financial help from his mother-in-law after being told surgeons could not use gastroenterology equipment.↗
▶Ep 26 · 3:27
clinicalNo pediatric gastroenterologists existed in Cleveland in the mid-1970s, creating an opportunity for Ponsky to perform pediatric endoscopy.↗
▶Ep 26 · 3:27
clinicalNo pediatric gastroenterologists existed in Cleveland in the mid-1970s, creating an opportunity for Ponsky to perform pediatric endoscopy.↗
▶Ep 26 · 4:33
clinicalTransillumination was observed in thin neonates during endoscopy, with the room lighting up and finger indentation visible on the scope when pressed against the abdominal wall.↗
▶Ep 26 · 4:33
clinicalTransillumination was observed in thin neonates during endoscopy, with the room lighting up and finger indentation visible on the scope when pressed against the abdominal wall.↗
▶Ep 26 · 4:47
quotemaybe we could do something with this. Maybe we could figure out a way to poke a tube through that abdominal wall and and make a feeding gastrostomy↗
▶Ep 26 · 4:47
quotemaybe we could do something with this. Maybe we could figure out a way to poke a tube through that abdominal wall and and make a feeding gastrostomy↗
▶Ep 26 · 4:59
clinicalThe initial PEG tube was constructed using a Foley catheter (depezar catheter), sutures, and an IV catheter called a medicut as a dilator.↗
▶Ep 26 · 4:59
clinicalThe initial PEG tube was constructed using a Foley catheter (depezar catheter), sutures, and an IV catheter called a medicut as a dilator.↗
▶Ep 26 · 5:45
clinicalThe first five PEG procedures were performed in neurologically impaired infants who were brain dead with severe psychomotor retardation, being fed by nasogastric tubes with no chance of recovery.↗
▶Ep 26 · 5:45
clinicalThe first five PEG procedures were performed in neurologically impaired infants who were brain dead with severe psychomotor retardation, being fed by nasogastric tubes with no chance of recovery.↗
▶Ep 26 · 6:15
quotewe have to do a major laparotomy on these babies, uh, but we have an idea for performing this, uh, by a new technique. Uh, we don't have any idea if it'll work. We think it will, it's pretty simple, but if it doesn't, we will do the laparotomy right there and then and complete the gastrostomy↗
▶Ep 26 · 6:15
quotewe have to do a major laparotomy on these babies, uh, but we have an idea for performing this, uh, by a new technique. Uh, we don't have any idea if it'll work. We think it will, it's pretty simple, but if it doesn't, we will do the laparotomy right there and then and complete the gastrostomy↗
▶Ep 26 · 6:25
clinicalInformed consent for the first PEG procedures involved telling mothers that if the new technique failed, an immediate laparotomy would be performed.↗
▶Ep 26 · 6:25
clinicalInformed consent for the first PEG procedures involved telling mothers that if the new technique failed, an immediate laparotomy would be performed.↗
▶Ep 26 · 6:42
clinicalThe PEG tube procedure was developed in May 1979 by Jeffrey Ponsky and Michael Gower at University Hospitals of Cleveland.↗
▶Ep 26 · 6:42
clinicalThe PEG tube procedure was developed in May 1979 by Jeffrey Ponsky and Michael Gower at University Hospitals of Cleveland.↗
▶Ep 26 · 7:13
quotewe went to the laboratory and started looking at uh what this meant in terms of tract formation, how long the tube had to be in before you could change it, and was there any chance of leakage↗
▶Ep 26 · 7:13
quotewe went to the laboratory and started looking at uh what this meant in terms of tract formation, how long the tube had to be in before you could change it, and was there any chance of leakage↗
▶Ep 26 · 7:13
clinicalLaboratory studies on PEG tract formation were conducted after the initial clinical cases, reversing the typical research sequence.↗
▶Ep 26 · 7:13
clinicalLaboratory studies on PEG tract formation were conducted after the initial clinical cases, reversing the typical research sequence.↗
▶Ep 26 · 7:35
quoteit was sort of the reverse of what you would do now by going to the laboratory first and then And then to the operating room↗
▶Ep 26 · 7:35
quoteit was sort of the reverse of what you would do now by going to the laboratory first and then And then to the operating room↗
▶Ep 26 · 8:32
quoteWe literally begged. Many companies to make this tube for us because when we presented it. The uh There was great excitement in the endoscopy of surgery world, but uh no company would make it. They thought nobody would use it↗
▶Ep 26 · 8:32
quoteWe literally begged. Many companies to make this tube for us because when we presented it. The uh There was great excitement in the endoscopy of surgery world, but uh no company would make it. They thought nobody would use it↗
▶Ep 26 · 8:39
clinicalMultiple medical device companies initially refused to manufacture the PEG tube, believing nobody would use it.↗
▶Ep 26 · 8:39
clinicalMultiple medical device companies initially refused to manufacture the PEG tube, believing nobody would use it.↗
▶Ep 26 · 8:54
clinicalA small company in Mentor, Ohio eventually manufactured the PEG tube exactly as designed, without patent protection being pursued.↗
▶Ep 26 · 8:54
clinicalA small company in Mentor, Ohio eventually manufactured the PEG tube exactly as designed, without patent protection being pursued.↗
▶Ep 26 · 9:06
quotewe never even thought about patenting the tube. It wasn't even on our mind↗
▶Ep 26 · 9:06
quotewe never even thought about patenting the tube. It wasn't even on our mind↗
▶Ep 26 · 9:16
quoteWe were more interested in publication than patents, and we were interested in getting the technique out there↗
▶Ep 26 · 9:16
quoteWe were more interested in publication than patents, and we were interested in getting the technique out there↗
▶Ep 26 · 9:39
clinicalColonic perforation can occur during PEG placement if the tube goes through the colon on the way to the stomach, though this is rare.↗
▶Ep 26 · 9:39
clinicalColonic perforation can occur during PEG placement if the tube goes through the colon on the way to the stomach, though this is rare.↗
▶Ep 26 · 9:51
clinicalExit-site infection was a major complication of PEG placement initially.↗
▶Ep 26 · 9:51
clinicalExit-site infection was a major complication of PEG placement initially.↗
▶Ep 26 · 10:24
clinicalPEG tubes evolved from multi-piece rubber construction to one-piece silicone, with few modifications after the first few years.↗
▶Ep 26 · 10:24
clinicalPEG tubes evolved from multi-piece rubber construction to one-piece silicone, with few modifications after the first few years.↗
▶Ep 26 · 12:13
clinicalThe PEG tube was the first time any instrument or needle was thrust through the abdominal wall into the GI tract and left there.↗
▶Ep 26 · 12:13
quotethe peg tube and was and still is the only time. Any instrument or needle was thrust through the abdominal wall into the GI tract↗
▶Ep 26 · 12:13
clinicalThe PEG tube was the first time any instrument or needle was thrust through the abdominal wall into the GI tract and left there.↗
▶Ep 26 · 12:13
quotethe peg tube and was and still is the only time. Any instrument or needle was thrust through the abdominal wall into the GI tract↗
▶Ep 26 · 13:00
clinicalEndoscopic tattooing with India ink was developed in 1975 to mark polypectomy sites, allowing surgeons to locate the resection area if cancer was found.↗
▶Ep 26 · 13:00
clinicalEndoscopic tattooing with India ink was developed in 1975 to mark polypectomy sites, allowing surgeons to locate the resection area if cancer was found.↗
▶Ep 26 · 13:38
quotethere was a lot of low hanging fruit then we could do things that seemed logical, and that's the fun of a new area↗
▶Ep 26 · 13:38
quotethere was a lot of low hanging fruit then we could do things that seemed logical, and that's the fun of a new area↗
▶Ep 26 · 13:56
quoteeverybody thinks that everybody's been, everything's been discovered already, that's not true↗
▶Ep 26 · 13:56
quoteeverybody thinks that everybody's been, everything's been discovered already, that's not true↗
▶Ep 26 · 15:53
quoteI said, wow, that would be a great way to blow up 3 months. I won't have to take night off. This will be easier. That was an accident↗
▶Ep 26 · 15:53
quoteI said, wow, that would be a great way to blow up 3 months. I won't have to take night off. This will be easier. That was an accident↗
▶Ep 26 · 16:13
clinicalPonsky was initially denied endoscopy training as a surgical resident in the mid-1970s because gastroenterologists claimed the field as their exclusive domain.↗
▶Ep 26 · 16:13
clinicalPonsky was initially denied endoscopy training as a surgical resident in the mid-1970s because gastroenterologists claimed the field as their exclusive domain.↗
▶Ep 26 · 17:07
quotewhen you see a new technology, whatever that technology is. Investigate it, see if it's something that offers you something that you can uh make it your own and become an expert in it↗
▶Ep 26 · 17:07
quotewhen you see a new technology, whatever that technology is. Investigate it, see if it's something that offers you something that you can uh make it your own and become an expert in it↗
▶Ep 26 · 17:35
clinicalAmerican Cystoscope Makers Incorporated (ACMI) produced early endoscopes with joystick controls and poor image quality compared to Japanese Olympus scopes.↗
▶Ep 26 · 17:35
clinicalAmerican Cystoscope Makers Incorporated (ACMI) produced early endoscopes with joystick controls and poor image quality compared to Japanese Olympus scopes.↗
▶Ep 26 · 18:26
clinicalEarly fiber-optic endoscopes required direct eye-to-lens visualization with images carried by fiber bundles, and photographs were taken on small film strips.↗
▶Ep 26 · 18:26
clinicalEarly fiber-optic endoscopes required direct eye-to-lens visualization with images carried by fiber bundles, and photographs were taken on small film strips.↗
▶Ep 26 · 19:06
clinicalVideo chip camera technology emerged around 1980, placing a camera at the scope tip and displaying images on monitors.↗
▶Ep 26 · 19:06
clinicalVideo chip camera technology emerged around 1980, placing a camera at the scope tip and displaying images on monitors.↗
▶Ep 26 · 19:36
clinicalPediatric patients could tolerate adult endoscopes approximately 9 millimeters wide in the late 1970s.↗
▶Ep 26 · 19:36
clinicalPediatric patients could tolerate adult endoscopes approximately 9 millimeters wide in the late 1970s.↗
▶Ep 26 · 20:56
clinicalEarly endoscope cleaning consisted only of washing with green soap between procedures, without high-level disinfection or sterilization.↗
▶Ep 26 · 20:56
clinicalEarly endoscope cleaning consisted only of washing with green soap between procedures, without high-level disinfection or sterilization.↗
▶Ep 26 · 21:45
guidelineThe PEG tube received FDA 510(k) approval as a device used for a similar purpose to existing gastrostomy tubes, though the insertion method was novel.↗
▶Ep 26 · 21:45
guidelineThe PEG tube received FDA 510(k) approval as a device used for a similar purpose to existing gastrostomy tubes, though the insertion method was novel.↗
▶Ep 26 · 22:17
clinicalPEG indications expanded beyond feeding to include gastric decompression for gastroparesis or obstruction in carcinomatosis patients, delivery of unpalatable feedings, and management of gastric volvulus.↗
▶Ep 26 · 22:17
clinicalPEG indications expanded beyond feeding to include gastric decompression for gastroparesis or obstruction in carcinomatosis patients, delivery of unpalatable feedings, and management of gastric volvulus.↗
▶Ep 26 · 23:00
clinicalThe PEG technique was adapted for colonic use in sigmoid volvulus and Ogilvie syndrome decompression.↗
▶Ep 26 · 23:00
clinicalThe PEG technique was adapted for colonic use in sigmoid volvulus and Ogilvie syndrome decompression.↗
▶Ep 26 · 23:30
quoteI like to think that the endoscope is a tube, uh, it's a, it's a, a vehicle that gets us to where we need to be to perform an operation↗
▶Ep 26 · 23:30
quoteI like to think that the endoscope is a tube, uh, it's a, it's a, a vehicle that gets us to where we need to be to perform an operation↗
▶Ep 26 · 24:38
opinionAt the 1980 Salt Lake City presentation to 1,500 attendees, a Mass General surgeon stated he could perform open gastrostomy in 30 minutes.↗
▶Ep 26 · 24:38
opinionAt the 1980 Salt Lake City presentation to 1,500 attendees, a Mass General surgeon stated he could perform open gastrostomy in 30 minutes.↗
▶Ep 26 · 25:16
opinionA prominent ERCP expert told Ponsky at the 1980 presentation that he wished he had thought of the PEG technique.↗
▶Ep 26 · 25:16
opinionA prominent ERCP expert told Ponsky at the 1980 presentation that he wished he had thought of the PEG technique.↗
▶Ep 26 · 25:37
clinicalGastroenterologists adopted the PEG procedure first as a therapeutic endoscopic technique, while surgeons were slower to adopt it due to less familiarity with endoscopy.↗
▶Ep 26 · 25:37
clinicalGastroenterologists adopted the PEG procedure first as a therapeutic endoscopic technique, while surgeons were slower to adopt it due to less familiarity with endoscopy.↗
▶Ep 26 · 26:40
clinicalPEG tube placement takes under 5 minutes when performed correctly and carefully.↗
▶Ep 26 · 26:40
clinicalPEG tube placement takes under 5 minutes when performed correctly and carefully.↗
▶Ep 26 · 26:58
quoteI want you to use your imagination that some day you will place a patient on a table. And have a machine that uses ultrasound or something, and has a gun that goes in and goes boom, and places that right into the stomach without anything, except maybe a little local↗
▶Ep 26 · 26:58
quoteI want you to use your imagination that some day you will place a patient on a table. And have a machine that uses ultrasound or something, and has a gun that goes in and goes boom, and places that right into the stomach without anything, except maybe a little local↗
opinionRadiologic PEG placement exists using ultrasound guidance, though Ponsky prefers the endoscopic tube design.↗
▶Ep 26 · 27:43
opinionRadiologic PEG placement exists using ultrasound guidance, though Ponsky prefers the endoscopic tube design.↗
▶Ep 26 · 28:18
quotelet's draw it out. Draw it. Don't just talk about it. Draw it out and write up your idea. Put it on paper↗
▶Ep 26 · 28:18
quotelet's draw it out. Draw it. Don't just talk about it. Draw it out and write up your idea. Put it on paper↗
▶Ep 26 · 29:32
quotewhen we're in the operating room, and if you have an idea for uh altering an existing procedure a little bit. You can do that Nothing wrong with that. It's called innovative therapy↗
▶Ep 26 · 29:32
quotewhen we're in the operating room, and if you have an idea for uh altering an existing procedure a little bit. You can do that Nothing wrong with that. It's called innovative therapy↗
▶Ep 26 · 30:28
quotethe endoscope is a wonderful tool, and it has to be used as a vehicle to deliver surgery at a distance↗
▶Ep 26 · 30:28
quotethe endoscope is a wonderful tool, and it has to be used as a vehicle to deliver surgery at a distance↗
▶Ep 26 · 31:36
quoteDon't think that everything's been thought of already. Otherwise we'd still be with radical mastectomy for breast cancer↗
▶Ep 26 · 31:36
quoteDon't think that everything's been thought of already. Otherwise we'd still be with radical mastectomy for breast cancer↗
▶Ep 26 · 31:46
quoteone day PEG tubes will be of the past, but right now it's a good marker for endoscopic surgery↗
▶Ep 26 · 31:46
quoteone day PEG tubes will be of the past, but right now it's a good marker for endoscopic surgery↗
▶Ep 26 · 32:02
quoteanyone who tells you that there's nothing more to be innovated, that there's no, nothing new coming along the pipe, that this is it. I, uh, somewhat to be avoided↗
▶Ep 26 · 32:02
quoteanyone who tells you that there's nothing more to be innovated, that there's no, nothing new coming along the pipe, that this is it. I, uh, somewhat to be avoided↗
▶Ep 26 · 32:38
quotethe best thing to do is to listen to people who don't know anything about the procedure. When your medical students come in and start asking you questions, uh, that's a good person to listen to because they don't have the barriers, uh, to their thought process that we do↗
▶Ep 26 · 32:38
quotethe best thing to do is to listen to people who don't know anything about the procedure. When your medical students come in and start asking you questions, uh, that's a good person to listen to because they don't have the barriers, uh, to their thought process that we do↗
Behind The Knife: The Surgery Podcast / Innovations in Surgery: PEG Tube
▶Ep 27 · 2:27
clinicalThe PEG tube procedure was developed in May 1979 by Jeffrey Ponsky and Michael Gower at University Hospitals of Cleveland.↗
▶Ep 27 · 2:43
clinicalIn the mid-1970s, surgical residents were prohibited from performing endoscopy by gastroenterologists who considered it their exclusive domain.↗
▶Ep 27 · 2:43
quoteI was told I couldn't do it because I was a surgical resident, and that piqued my interest↗
▶Ep 27 · 3:02
quoteI came back after that training and I was told I couldn't do endoscopy because I was a surgeon, couldn't touch the instruments↗
▶Ep 27 · 4:42
quoteMichael would push on the light with his finger, and I'd be scoping and I would see an indentation. And we realized we got together and said, you know, maybe we could do something with this.↗
▶Ep 27 · 4:59
clinicalThe original PEG tube was constructed using a Foley catheter (depezar catheter) and an IV catheter called a medicut, with sutures threaded through to create a dilator end.↗
▶Ep 27 · 5:42
clinicalThe initial PEG tube patients were neurologically impaired infants with severe psychomotor retardation who were being fed by nasogastric tubes and had no chance of recovery.↗
▶Ep 27 · 6:42
clinicalThe first five PEG procedures were performed in infants, followed by adult stroke patients with similar neurologic prognosis.↗
▶Ep 27 · 7:13
clinicalLaboratory studies on tract formation and tube safety were conducted after the initial clinical procedures, representing a reverse of modern innovation protocols.↗
clinicalMultiple medical device companies initially refused to manufacture the PEG tube because they believed nobody would use it.↗
▶Ep 27 · 9:06
quoteWe never even thought about patenting the tube. It wasn't even on our mind.↗
▶Ep 27 · 9:18
quoteWe were more interested in publication than patents, and we were interested in getting the technique out there.↗
▶Ep 27 · 9:37
clinicalComplications of PEG tube placement include rare instances of the tube passing through the colon en route to the stomach, bleeding (not a major problem), and infection at the skin exit site (initially a significant problem).↗
▶Ep 27 · 10:24
clinicalThe PEG tube technique has remained largely unchanged since the first few years after its introduction, with tubes becoming silicon one-piece designs.↗
▶Ep 27 · 12:09
quoteI said, wow, look at this. What else can we do with this thing?↗
▶Ep 27 · 12:13
clinicalThe PEG tube was the first and only procedure to thrust an instrument through the abdominal wall into the GI tract percutaneously.↗
▶Ep 27 · 12:13
quotethe peg tube and was and still is the only time. Any instrument or needle was thrust through the abdominal wall into the GI tract.↗
▶Ep 27 · 12:55
clinicalEndoscopic tattooing with India ink was developed in 1975 to mark polypectomy sites so surgeons could identify the location if cancer was found on pathology.↗
▶Ep 27 · 13:56
quoteeverybody thinks that everybody's been, everything's been discovered already, that's not true.↗
▶Ep 27 · 15:29
quoteyou wanna know the truth. The truth is that when I was a resident... I said, boy, I'm beat. I wanna have an elective that's a little bit easier.↗
▶Ep 27 · 17:07
quotewhen you see a new technology, whatever that technology is. Investigate it, see if it's something that offers you something that you can uh make it your own and become an expert in it.↗
▶Ep 27 · 17:30
clinicalOlympus fiber-optic endoscopes in the 1970s provided crystal-clear visualization compared to American-made ACMI scopes with joystick controls that were approximately 1 centimeter in diameter and had poor image quality.↗
clinicalFiber-optic endoscopes in the 1970s transmitted images through fiber bundles to the operator's eye, with photographs taken by clipping a camera to the eyepiece, producing small images on film strips.↗
▶Ep 27 · 19:06
clinicalVideo chip technology was introduced around 1980, placing a camera chip at the scope tip and displaying images on a monitor, replacing direct fiber-optic visualization.↗
▶Ep 27 · 19:36
clinicalPediatric patients in the late 1970s could accommodate adult endoscopes approximately 9 millimeters wide, which was the size limit for safe use in infants.↗
▶Ep 27 · 20:56
clinicalEarly endoscope cleaning protocols in the late 1970s used only green soap between procedures, before high-level disinfection or sterilization standards were established.↗
▶Ep 27 · 20:59
quoteAll we did was wash it with green soap in between procedures. We didn't know about high level of sterile disinfection or sterilization then.↗
▶Ep 27 · 21:45
guidelineThe PEG tube received FDA 510(k) approval as a modification of existing gastrostomy tubes used for similar purposes, rather than as an entirely novel device.↗
▶Ep 27 · 22:13
clinicalIndications for PEG tubes expanded beyond feeding to include gastric decompression for gastroparesis or obstruction in carcinomatosis patients, delivery of unpalatable feedings, treatment of gastric volvulus, colonic decompression for Ogilvie syndrome, and sigmoid volvulus fixation.↗
▶Ep 27 · 23:30
quoteI like to think that the endoscope is a tube, uh, it's a, it's a, a vehicle that gets us to where we need to be to perform an operation. That's what we think of as surgeons.↗
▶Ep 27 · 24:38
clinicalAt the 1980 presentation in Salt Lake City to 1,500 attendees, gastroenterologists immediately recognized the PEG tube as a therapeutic procedure they could perform, while surgeons were slower to adopt it due to less familiarity with endoscopy.↗
▶Ep 27 · 26:40
clinicalA properly performed PEG tube placement takes under 5 minutes when done correctly and carefully.↗
▶Ep 27 · 26:58
quoteI want you to use your imagination that some day you will place a patient on a table. And have a machine that uses ultrasound or something, and has a gun that goes in and goes boom, and places that right into the stomach without anything, except maybe a little local↗
▶Ep 27 · 27:19
quoteThe world of imagination and innovation does not end because you have a good procedure.↗
clinicalRadiologists have developed ultrasound-guided gastrostomy tube placement techniques, though Ponsky expresses reservations about the tubes they use.↗
▶Ep 27 · 29:32
guidelineInnovative therapy—minor modifications to existing procedures such as changing suture number or technique—can be performed in the operating room without IRB approval, but systematic study of new procedures requires IRB review.↗
▶Ep 27 · 29:45
quoteIt's called innovative therapy. You can try to alter that procedure. You put in 3 stitches instead of 2.↗
▶Ep 27 · 30:14
quoteIt was an innovation. It was an important innovation because it said to the world that surgical procedures can be accomplished endoscopically.↗
▶Ep 27 · 30:15
opinionThe PEG tube demonstrated that surgical procedures could be accomplished endoscopically and established the endoscope as a surgical instrument for delivering surgery at a distance.↗
▶Ep 27 · 31:19
quoteThe idea of standing back. Looking at the problem and saying, wow, can I approach this problem. In a different way, can I approach it from outside or inside or through the wall?↗
▶Ep 27 · 31:36
quoteDon't think that everything's been thought of already. Otherwise we'd still be with radical mastectomy for breast cancer.↗
▶Ep 27 · 31:44
quoteone day PEG tubes will be of the past, but right now it's a good marker for endoscopic surgery.↗
▶Ep 27 · 32:02
quoteanyone who tells you that there's nothing more to be innovated, that there's no, nothing new coming along the pipe, that this is it. I, uh, somewhat to be avoided.↗
▶Ep 27 · 32:38
quotethe best thing to do is to listen to people who don't know anything about the procedure. When your medical students come in and start asking you questions, uh, that's a good person to listen to because they don't have the barriers, uh, to their thought process that we do.↗
▶Ep 27 · 32:57
quoteyou shouldn't take a chance with patients' lives, but you should take a chance on developing new ideas and new procedures and new instruments.↗
All About Advanced Surgical Endoscopy
▶Ep 28 · 1:22
quoteyears 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.↗
▶Ep 28 · 1:22
clinicalEarly 20th century endoscopy used rigid tubes requiring patient contortion to align with the tubes for visualization of the esophagus and colon.↗
▶Ep 28 · 1:39
clinicalFiber optic technology developed mid-20th century allowed flexible endoscopes to assess diseases including esophagitis, esophageal cancer, gastric tumors, gastritis, colon cancer, and causes of colonic inflammation and diarrhea.↗
▶Ep 28 · 2:05
clinicalTherapeutic endoscopy began with pinch biopsies, then advanced to polypectomy using electrocautery snares to remove polyps that previously required surgical removal.↗
▶Ep 28 · 2:05
quotewe had the development of therapeutic options through these tubes. People first did little pinch biopsies to assess the activity of the disease and then found out that they could put an electric wire in and surround a polyp, for example, and actually take out a polyp that previously required surgical removal.↗
▶Ep 28 · 2:26
clinicalEndoscopic coagulation of bleeding ulcers prevented the need for surgery.↗
▶Ep 28 · 2:37
clinicalGallstones can be removed from the bile duct by opening the sphincter of Oddi endoscopically and extracting the stones.↗
▶Ep 28 · 3:23
clinicalBalloon-assisted enteroscopy uses inflating and deflating balloons on the outside of endoscopes to walk down the small intestine farther than normal scopes, allowing visualization and treatment of distant lesions.↗
▶Ep 28 · 4:05
clinicalVideo capsule endoscopy involves swallowing a capsule with a flashing light that takes frequent pictures, recording to a hip-worn monitor to assess the small intestine for occult bleeding sources not found on upper endoscopy or colonoscopy.↗
▶Ep 28 · 4:57
clinicalERCP allows access to the bile duct opening in the duodenum where dye injection can identify problems, sphincterotomy can be performed to extract stones, and stents (plastic or metal) can be placed for tumors.↗
▶Ep 28 · 5:12
quotewe can pass a little tube into the opening at the intestine, inject dye, see what the problem is, and very often take care of it. That's called ERCP. We can cut the opening at the bottom and pull stones out. If we see tumors, we can often define them by biopsying them or putting in a little plastic or metal stent↗
▶Ep 28 · 5:48
clinicalEndoscopic ultrasound allows visualization and biopsy of structures beyond the intestinal wall including the bile duct, pancreas, stomach wall, and adjacent vessels, identifying tumors not visible on standard endoscopy.↗
▶Ep 28 · 6:14
clinicalPeroral endoscopic myotomy (POEM) treats esophageal motility disorders by making a mucosal incision, tunneling through the esophageal wall, cutting the lower esophageal sphincter muscles, and closing the mucosal entry, allowing patients to go home without abdominal surgery.↗
▶Ep 28 · 6:16
quotewe've taken the endoscope and we've started to do real surgery through it, not just looking, not just biopsying, but really operating↗
▶Ep 28 · 7:27
clinicalEndoscopic mucosal resection (EMR) allows shaving out of tumors seen during endoscopy.↗
▶Ep 28 · 7:36
clinicalEndoscopic submucosal dissection (ESD) is used for flat, long, broad tumors by lifting tissue and shaving down to the next layer, providing better cancer or pre-cancer resection than EMR.↗
▶Ep 28 · 7:49
clinicalEMR and ESD have been proven safe and effective, avoiding the need for open surgery.↗
▶Ep 28 · 8:03
clinicalPercutaneous endoscopic gastrostomy (PEG) was developed 40 years ago by Michael Gauderer and Jeffrey Ponsky to place feeding tubes in patients unable to eat due to neurological or oral problems, replacing open abdominal surgery with endoscopically-guided needle puncture.↗
▶Ep 28 · 9:01
clinicalThe PEG technique was discovered when transillumination through the abdominal wall of brain-damaged infants during endoscopy revealed close contact between the endoscope and abdominal wall, suggesting needle puncture was feasible.↗
▶Ep 28 · 9:12
quoteThe 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.↗
▶Ep 28 · 9:54
clinicalEndoscopic surgical procedures carry risks of bleeding, perforation, and infection.↗
▶Ep 28 · 9:54
quotethis 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.↗
▶Ep 28 · 10:15
clinicalEndoscopic 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.↗
▶Ep 28 · 10:17
quotewe are able to open the bottom of the stomach called the pylorus and open that muscle in the same way we do with the poem in the intramural space inside the wall. We cut the thick muscle that won't open, clip it closed, and the patient goes home the same day and their stomach empties better.↗
▶Ep 28 · 10:39
clinicalEndoscopic pyloric myotomy requires 2 days of liquid diet before the procedure and 1 week of liquid diet afterward.↗
▶Ep 28 · 10:49
clinicalZenker's diverticulum, which previously required major neck surgery, can now be treated transorally by making a mucosal incision in the posterior pharynx, cutting the cricopharyngeus muscle, and clipping it closed, with same-day discharge.↗
▶Ep 28 · 11:09
clinicalZenker's diverticulotomy requires 2 days of liquid diet before and 1 week of liquid diet after the procedure.↗
▶Ep 28 · 11:15
clinicalAdvanced endoscopic procedures are increasingly performed as outpatient or overnight-stay procedures.↗
▶Ep 28 · 11:34
opinionAll current surgical procedures are being evaluated for less invasive, endoscopically-guided approaches.↗
▶Ep 28 · 11:34
quoteEverything that we do surgically today is being looked at in a less invasive, endoscopically guided fashion.↗
▶Ep 28 · 11:54
opinionFuture endoscopic surgery will incorporate robotics for more precise movements and better results, progressing to image-guided, robotically-assisted, and eventually robotically-controlled surgery.↗
▶Ep 28 · 12:15
quoteTechnology, innovation. And human thought will lead us to less invasive ways to do surgery. The way we do surgery today is not anything like we did 100 years ago, nor will it be in 100 more years.↗
▶Ep 28 · 13:49
quoteSurgical 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.↗
Jeffrey's statements about Gastroparesis162 statements
The invention of the PEG tube with Dr. Jeffrey Ponsky
▶Ep 6 · 2:43
quoteI was told I couldn't do it because I was a surgical resident, and that piqued my interest↗
▶Ep 6 · 3:02
quoteI came back after that training and I was told I couldn't do endoscopy because I was a surgeon, couldn't touch the instruments↗
▶Ep 6 · 3:27
clinicalIn 1974-1975, there were no pediatric gastroenterologists, and Ponsky performed endoscopy on children, young adults, and neonates with GI problems using his personally owned scope.↗
▶Ep 6 · 4:33
clinicalDuring neonatal endoscopy, the room would light up because babies were so thin; when pediatric surgeon Michael Gower pushed on the transilluminated light with his finger, an indentation was visible endoscopically.↗
▶Ep 6 · 4:42
quoteMichael would push on the light with his finger, and I'd be scoping and I would see an indentation. And we realized we got together and said, you know, maybe we could do something with this.↗
▶Ep 6 · 4:59
clinicalThe first PEG tubes were constructed from OR gastrostomy tubes (small Pezzer catheters) with sutures threaded through the end and passed through an IV catheter (medicut) to create a dilator tip.↗
▶Ep 6 · 5:42
clinicalThe first five PEG procedures in May 1979 were performed in neonates with severe psychomotor retardation who were brain dead, fed by nasogastric tubes, had no chance of recovery, and were being sent for open gastrostomy before long-term nursing facility placement.↗
▶Ep 6 · 6:15
quotewe have to do a major laparotomy on these babies, uh, but we have an idea for performing this, uh, by a new technique. Uh, we don't have any idea if it'll work. We think it will, it's pretty simple, but if it doesn't, we will do the laparotomy right there and then and complete the gastrostomy↗
▶Ep 6 · 6:25
clinicalInformed consent for the first PEG cases consisted of telling mothers that if the new technique failed, immediate laparotomy and open gastrostomy would be performed.↗
clinicalThe first PEG procedures succeeded easily within a few minutes.↗
▶Ep 6 · 6:47
clinicalAfter the initial five neonatal cases, Ponsky moved to Mount Sinai Medical Center and began performing PEG in adult stroke patients with similar neurologic prognosis who needed feeding access.↗
▶Ep 6 · 7:13
clinicalLaboratory studies on PEG tract formation, tube dwell time before safe replacement, and leakage risk were conducted after clinical implementation—the reverse of typical research-then-clinical sequence.↗
▶Ep 6 · 7:28
clinicalJohn Mellinger, who later worked at the American Board of Surgery, conducted original research on PEG tract formation.↗
▶Ep 6 · 7:44
quoteit was sort of the reverse of what you would do now by going to the laboratory first and then And then to the operating room.↗
clinicalMultiple medical device companies refused to manufacture the PEG tube initially, believing nobody would use it.↗
▶Ep 6 · 8:54
clinicalA small company in Mentor, Ohio eventually manufactured the PEG tube exactly as designed by Ponsky and Gower.↗
▶Ep 6 · 9:06
quotewe never even thought about patenting the tube. It wasn't even on our mind.↗
▶Ep 6 · 9:06
opinionPonsky and Gower never patented the PEG tube; they were more interested in publication than patents and wanted to disseminate the technique.↗
▶Ep 6 · 9:18
quoteWe wanted to get papers out of it. We wanted to make a contribution to literature. We were more interested in publication than patents↗
▶Ep 6 · 9:39
clinicalPEG tube complications included rare colonic perforation when the tube traversed the colon en route to the stomach, which still occurs rarely today.↗
▶Ep 6 · 9:51
clinicalExit-site infection was a major early PEG complication.↗
▶Ep 6 · 10:24
clinicalPEG tubes evolved from multi-piece rubber construction to one-piece silicone, but have had very few modifications in the last few years and have become a commodity product purchased by hospitals at the lowest price.↗
▶Ep 6 · 10:50
clinicalThe PEG technique has remained very much the same as the original with only a few modifications.↗
▶Ep 6 · 11:19
clinicalPonsky and the manufacturing company conducted dozens of animal experiments to determine tube removal pressure, tip retention, and optimal tube size for FDA approval.↗
▶Ep 6 · 12:09
quoteI said, wow, look at this. What else can we do with this thing?↗
▶Ep 6 · 12:13
quotethe peg tube and was and still is the only time. Any instrument or needle was thrust through the abdominal wall into the GI tract.↗
▶Ep 6 · 12:13
clinicalThe PEG tube was the first and only time any instrument or needle was thrust through the abdominal wall into the GI tract and left in place.↗
▶Ep 6 · 12:55
clinicalIn 1975, Ponsky developed and published endoscopic tattooing using India ink injected alongside polypectomy sites to mark the location for potential surgical resection if cancer was found; the technique remains in use today.↗
▶Ep 6 · 13:38
quotethere was a lot of low hanging fruit then we could do things that seemed logical, and that's the fun of a new area.↗
▶Ep 6 · 13:56
quoteeverybody thinks that everybody's been, everything's been discovered already, that's not true.↗
▶Ep 6 · 15:31
clinicalIn the late 1970s, surgical residents were on call every other night (36 hours on, 12 hours off) for five years of training.↗
▶Ep 6 · 15:49
quoteI wanna have an elective that's a little bit easier.↗
▶Ep 6 · 15:58
quoteI said, wow, that would be a great way to blow up 3 months. I won't have to take night off. This will be easier. That was an accident.↗
▶Ep 6 · 17:07
quotewhen you see a new technology, whatever that technology is. Investigate it, see if it's something that offers you something that you can uh make it your own and become an expert in it.↗
▶Ep 6 · 17:35
clinicalIn the mid-1970s, the predominant American endoscope was the ACMI (American Cystoscope Makers Incorporated) with a joystick control, approximately 1 cm diameter, with image quality like looking through ground glass.↗
clinicalJapanese companies (Mashida and Olympus in the US) produced fiber-optic endoscopes with crystal-clear optics that were markedly superior to American models.↗
▶Ep 6 · 18:15
quoteIt was crystal clear. It was like you were just right there.↗
clinical1970s fiber-optic endoscopes transmitted light via fiber bundles to the lumen and returned images to the eyepiece; photography required clipping a camera to the eyepiece for film-strip images.↗
▶Ep 6 · 18:51
clinicalTeaching attachments for 1970s endoscopes consisted of a wire-connected second eyepiece that provided a dim image for trainees in darkened rooms.↗
▶Ep 6 · 19:06
clinicalAround 1980, video chip technology placed a camera at the endoscope tip instead of using fiber-optic image transmission, displaying images on large monitors—the technology used in current endoscopes.↗
▶Ep 6 · 19:36
clinicalIn the late 1970s, neonates could tolerate endoscopes approximately 9 millimeters wide, which was the limit for safe use.↗
▶Ep 6 · 19:57
clinicalThe original PEG procedure was performed with an adult endoscope.↗
▶Ep 6 · 20:07
quoteI would almost not let anyone touch it except me↗
▶Ep 6 · 20:56
clinicalIn the 1970s, endoscopes were cleaned between procedures using only green soap; high-level disinfection and sterilization protocols did not yet exist.↗
▶Ep 6 · 21:45
clinicalThe PEG tube received FDA 510(k) approval as a modification of existing gastrostomy tubes used for similar purposes, which is easier than approval for entirely novel devices.↗
▶Ep 6 · 22:17
clinicalPEG indications expanded beyond feeding to include gastric decompression in gastroparesis or obstruction (including carcinomatosis), delivery of unpalatable feedings, and treatment of gastric volvulus.↗
▶Ep 6 · 23:00
clinicalThe PEG technique was adapted for colonic applications including sigmoid volvulus fixation and Ogilvie syndrome decompression, with multiple PEGs used for sigmoid volvulus.↗
▶Ep 6 · 23:30
quoteI like to think that the endoscope is a tube, uh, it's a, it's a, a vehicle that gets us to where we need to be to perform an operation. That's what we think of as surgeons.↗
▶Ep 6 · 23:56
opinionMany endoscopic procedures developed by surgeons, including PEG, were extensions of surgical operations already performed via laparotomy.↗
▶Ep 6 · 25:32
clinicalGastroenterologists rapidly adopted PEG as a therapeutic procedure they could easily accomplish, driving widespread dissemination.↗
▶Ep 6 · 25:56
clinicalSurgeons were slower to adopt PEG initially because they were not performing as much therapeutic endoscopy at that time, but they did not offer significant resistance.↗
▶Ep 6 · 26:40
clinicalA properly performed PEG procedure takes under 5 minutes when done carefully by an experienced operator.↗
▶Ep 6 · 26:47
clinicalCurrent PEG procedures still require patient sedation or anesthesia and constitute an intervention.↗
▶Ep 6 · 26:58
quoteI want you to use your imagination that some day you will place a patient on a table. And have a machine that uses ultrasound or something, and has a gun that goes in and goes boom, and places that right into the stomach without anything, except maybe a little local↗
opinionRadiologists perform gastrostomy tube placement using ultrasound guidance, though Ponsky does not prefer the tubes they use.↗
▶Ep 6 · 32:57
quoteyou should always uh take a chance. Now, you shouldn't take a chance with patients' lives, but you should take a chance on developing new ideas and new procedures and new instruments.↗
Innovations in Surgery: PEG Tube
▶Ep 7 · 2:53
quoteI was told I couldn't do it because I was a surgical resident, and that piqued my interest↗
▶Ep 7 · 3:02
clinicalPonsky purchased his own Olympus endoscope with financial help from his mother-in-law after being told surgeons could not use gastroenterology equipment.↗
▶Ep 7 · 3:02
quoteI was told I couldn't do endoscopy because I was a surgeon, couldn't touch the instruments↗
▶Ep 7 · 3:27
clinicalNo pediatric gastroenterologists existed in Cleveland in the mid-1970s, creating an opportunity for Ponsky to perform pediatric endoscopy.↗
▶Ep 7 · 4:33
clinicalTransillumination was observed in thin neonates during endoscopy, with the room lighting up and finger indentation visible on the scope when pressed against the abdominal wall.↗
▶Ep 7 · 4:47
quotemaybe we could do something with this. Maybe we could figure out a way to poke a tube through that abdominal wall and and make a feeding gastrostomy↗
▶Ep 7 · 4:59
clinicalThe initial PEG tube was constructed using a Foley catheter (depezar catheter), sutures, and an IV catheter called a medicut as a dilator.↗
▶Ep 7 · 5:45
clinicalThe first five PEG procedures were performed in neurologically impaired infants who were brain dead with severe psychomotor retardation, being fed by nasogastric tubes with no chance of recovery.↗
▶Ep 7 · 6:15
quotewe have to do a major laparotomy on these babies, uh, but we have an idea for performing this, uh, by a new technique. Uh, we don't have any idea if it'll work. We think it will, it's pretty simple, but if it doesn't, we will do the laparotomy right there and then and complete the gastrostomy↗
▶Ep 7 · 6:25
clinicalInformed consent for the first PEG procedures involved telling mothers that if the new technique failed, an immediate laparotomy would be performed.↗
▶Ep 7 · 6:42
clinicalThe PEG tube procedure was developed in May 1979 by Jeffrey Ponsky and Michael Gower at University Hospitals of Cleveland.↗
▶Ep 7 · 7:13
quotewe went to the laboratory and started looking at uh what this meant in terms of tract formation, how long the tube had to be in before you could change it, and was there any chance of leakage↗
▶Ep 7 · 7:13
clinicalLaboratory studies on PEG tract formation were conducted after the initial clinical cases, reversing the typical research sequence.↗
▶Ep 7 · 7:35
quoteit was sort of the reverse of what you would do now by going to the laboratory first and then And then to the operating room↗
▶Ep 7 · 8:32
quoteWe literally begged. Many companies to make this tube for us because when we presented it. The uh There was great excitement in the endoscopy of surgery world, but uh no company would make it. They thought nobody would use it↗
▶Ep 7 · 8:39
clinicalMultiple medical device companies initially refused to manufacture the PEG tube, believing nobody would use it.↗
▶Ep 7 · 8:54
clinicalA small company in Mentor, Ohio eventually manufactured the PEG tube exactly as designed, without patent protection being pursued.↗
▶Ep 7 · 9:06
quotewe never even thought about patenting the tube. It wasn't even on our mind↗
▶Ep 7 · 9:16
quoteWe were more interested in publication than patents, and we were interested in getting the technique out there↗
▶Ep 7 · 9:39
clinicalColonic perforation can occur during PEG placement if the tube goes through the colon on the way to the stomach, though this is rare.↗
▶Ep 7 · 9:51
clinicalExit-site infection was a major complication of PEG placement initially.↗
▶Ep 7 · 10:24
clinicalPEG tubes evolved from multi-piece rubber construction to one-piece silicone, with few modifications after the first few years.↗
▶Ep 7 · 12:13
clinicalThe PEG tube was the first time any instrument or needle was thrust through the abdominal wall into the GI tract and left there.↗
▶Ep 7 · 12:13
quotethe peg tube and was and still is the only time. Any instrument or needle was thrust through the abdominal wall into the GI tract↗
▶Ep 7 · 13:00
clinicalEndoscopic tattooing with India ink was developed in 1975 to mark polypectomy sites, allowing surgeons to locate the resection area if cancer was found.↗
▶Ep 7 · 13:38
quotethere was a lot of low hanging fruit then we could do things that seemed logical, and that's the fun of a new area↗
▶Ep 7 · 13:56
quoteeverybody thinks that everybody's been, everything's been discovered already, that's not true↗
▶Ep 7 · 15:53
quoteI said, wow, that would be a great way to blow up 3 months. I won't have to take night off. This will be easier. That was an accident↗
▶Ep 7 · 16:13
clinicalPonsky was initially denied endoscopy training as a surgical resident in the mid-1970s because gastroenterologists claimed the field as their exclusive domain.↗
▶Ep 7 · 17:07
quotewhen you see a new technology, whatever that technology is. Investigate it, see if it's something that offers you something that you can uh make it your own and become an expert in it↗
▶Ep 7 · 17:35
clinicalAmerican Cystoscope Makers Incorporated (ACMI) produced early endoscopes with joystick controls and poor image quality compared to Japanese Olympus scopes.↗
▶Ep 7 · 18:26
clinicalEarly fiber-optic endoscopes required direct eye-to-lens visualization with images carried by fiber bundles, and photographs were taken on small film strips.↗
▶Ep 7 · 19:06
clinicalVideo chip camera technology emerged around 1980, placing a camera at the scope tip and displaying images on monitors.↗
▶Ep 7 · 19:36
clinicalPediatric patients could tolerate adult endoscopes approximately 9 millimeters wide in the late 1970s.↗
▶Ep 7 · 20:56
clinicalEarly endoscope cleaning consisted only of washing with green soap between procedures, without high-level disinfection or sterilization.↗
▶Ep 7 · 21:45
guidelineThe PEG tube received FDA 510(k) approval as a device used for a similar purpose to existing gastrostomy tubes, though the insertion method was novel.↗
▶Ep 7 · 22:17
clinicalPEG indications expanded beyond feeding to include gastric decompression for gastroparesis or obstruction in carcinomatosis patients, delivery of unpalatable feedings, and management of gastric volvulus.↗
▶Ep 7 · 23:00
clinicalThe PEG technique was adapted for colonic use in sigmoid volvulus and Ogilvie syndrome decompression.↗
▶Ep 7 · 23:30
quoteI like to think that the endoscope is a tube, uh, it's a, it's a, a vehicle that gets us to where we need to be to perform an operation↗
▶Ep 7 · 24:38
opinionAt the 1980 Salt Lake City presentation to 1,500 attendees, a Mass General surgeon stated he could perform open gastrostomy in 30 minutes.↗
▶Ep 7 · 25:16
opinionA prominent ERCP expert told Ponsky at the 1980 presentation that he wished he had thought of the PEG technique.↗
▶Ep 7 · 25:37
clinicalGastroenterologists adopted the PEG procedure first as a therapeutic endoscopic technique, while surgeons were slower to adopt it due to less familiarity with endoscopy.↗
▶Ep 7 · 26:40
clinicalPEG tube placement takes under 5 minutes when performed correctly and carefully.↗
▶Ep 7 · 26:58
quoteI want you to use your imagination that some day you will place a patient on a table. And have a machine that uses ultrasound or something, and has a gun that goes in and goes boom, and places that right into the stomach without anything, except maybe a little local↗
opinionRadiologic PEG placement exists using ultrasound guidance, though Ponsky prefers the endoscopic tube design.↗
▶Ep 7 · 28:18
quotelet's draw it out. Draw it. Don't just talk about it. Draw it out and write up your idea. Put it on paper↗
▶Ep 7 · 29:32
quotewhen we're in the operating room, and if you have an idea for uh altering an existing procedure a little bit. You can do that Nothing wrong with that. It's called innovative therapy↗
▶Ep 7 · 30:28
quotethe endoscope is a wonderful tool, and it has to be used as a vehicle to deliver surgery at a distance↗
▶Ep 7 · 31:36
quoteDon't think that everything's been thought of already. Otherwise we'd still be with radical mastectomy for breast cancer↗
▶Ep 7 · 31:46
quoteone day PEG tubes will be of the past, but right now it's a good marker for endoscopic surgery↗
▶Ep 7 · 32:02
quoteanyone who tells you that there's nothing more to be innovated, that there's no, nothing new coming along the pipe, that this is it. I, uh, somewhat to be avoided↗
▶Ep 7 · 32:38
quotethe best thing to do is to listen to people who don't know anything about the procedure. When your medical students come in and start asking you questions, uh, that's a good person to listen to because they don't have the barriers, uh, to their thought process that we do↗
Behind The Knife: The Surgery Podcast / Innovations in Surgery: PEG Tube
▶Ep 8 · 2:27
clinicalThe PEG tube procedure was developed in May 1979 by Jeffrey Ponsky and Michael Gower at University Hospitals of Cleveland.↗
▶Ep 8 · 2:43
clinicalIn the mid-1970s, surgical residents were prohibited from performing endoscopy by gastroenterologists who considered it their exclusive domain.↗
▶Ep 8 · 2:43
quoteI was told I couldn't do it because I was a surgical resident, and that piqued my interest↗
▶Ep 8 · 3:02
quoteI came back after that training and I was told I couldn't do endoscopy because I was a surgeon, couldn't touch the instruments↗
▶Ep 8 · 4:42
quoteMichael would push on the light with his finger, and I'd be scoping and I would see an indentation. And we realized we got together and said, you know, maybe we could do something with this.↗
▶Ep 8 · 4:59
clinicalThe original PEG tube was constructed using a Foley catheter (depezar catheter) and an IV catheter called a medicut, with sutures threaded through to create a dilator end.↗
▶Ep 8 · 5:42
clinicalThe initial PEG tube patients were neurologically impaired infants with severe psychomotor retardation who were being fed by nasogastric tubes and had no chance of recovery.↗
▶Ep 8 · 6:42
clinicalThe first five PEG procedures were performed in infants, followed by adult stroke patients with similar neurologic prognosis.↗
▶Ep 8 · 7:13
clinicalLaboratory studies on tract formation and tube safety were conducted after the initial clinical procedures, representing a reverse of modern innovation protocols.↗
clinicalMultiple medical device companies initially refused to manufacture the PEG tube because they believed nobody would use it.↗
▶Ep 8 · 9:06
quoteWe never even thought about patenting the tube. It wasn't even on our mind.↗
▶Ep 8 · 9:18
quoteWe were more interested in publication than patents, and we were interested in getting the technique out there.↗
▶Ep 8 · 9:37
clinicalComplications of PEG tube placement include rare instances of the tube passing through the colon en route to the stomach, bleeding (not a major problem), and infection at the skin exit site (initially a significant problem).↗
▶Ep 8 · 10:24
clinicalThe PEG tube technique has remained largely unchanged since the first few years after its introduction, with tubes becoming silicon one-piece designs.↗
▶Ep 8 · 12:09
quoteI said, wow, look at this. What else can we do with this thing?↗
▶Ep 8 · 12:13
quotethe peg tube and was and still is the only time. Any instrument or needle was thrust through the abdominal wall into the GI tract.↗
▶Ep 8 · 12:13
clinicalThe PEG tube was the first and only procedure to thrust an instrument through the abdominal wall into the GI tract percutaneously.↗
▶Ep 8 · 12:55
clinicalEndoscopic tattooing with India ink was developed in 1975 to mark polypectomy sites so surgeons could identify the location if cancer was found on pathology.↗
▶Ep 8 · 13:56
quoteeverybody thinks that everybody's been, everything's been discovered already, that's not true.↗
▶Ep 8 · 15:29
quoteyou wanna know the truth. The truth is that when I was a resident... I said, boy, I'm beat. I wanna have an elective that's a little bit easier.↗
▶Ep 8 · 17:07
quotewhen you see a new technology, whatever that technology is. Investigate it, see if it's something that offers you something that you can uh make it your own and become an expert in it.↗
▶Ep 8 · 17:30
clinicalOlympus fiber-optic endoscopes in the 1970s provided crystal-clear visualization compared to American-made ACMI scopes with joystick controls that were approximately 1 centimeter in diameter and had poor image quality.↗
clinicalFiber-optic endoscopes in the 1970s transmitted images through fiber bundles to the operator's eye, with photographs taken by clipping a camera to the eyepiece, producing small images on film strips.↗
▶Ep 8 · 19:06
clinicalVideo chip technology was introduced around 1980, placing a camera chip at the scope tip and displaying images on a monitor, replacing direct fiber-optic visualization.↗
▶Ep 8 · 19:36
clinicalPediatric patients in the late 1970s could accommodate adult endoscopes approximately 9 millimeters wide, which was the size limit for safe use in infants.↗
▶Ep 8 · 20:56
clinicalEarly endoscope cleaning protocols in the late 1970s used only green soap between procedures, before high-level disinfection or sterilization standards were established.↗
▶Ep 8 · 20:59
quoteAll we did was wash it with green soap in between procedures. We didn't know about high level of sterile disinfection or sterilization then.↗
▶Ep 8 · 21:45
guidelineThe PEG tube received FDA 510(k) approval as a modification of existing gastrostomy tubes used for similar purposes, rather than as an entirely novel device.↗
▶Ep 8 · 22:13
clinicalIndications for PEG tubes expanded beyond feeding to include gastric decompression for gastroparesis or obstruction in carcinomatosis patients, delivery of unpalatable feedings, treatment of gastric volvulus, colonic decompression for Ogilvie syndrome, and sigmoid volvulus fixation.↗
▶Ep 8 · 23:30
quoteI like to think that the endoscope is a tube, uh, it's a, it's a, a vehicle that gets us to where we need to be to perform an operation. That's what we think of as surgeons.↗
▶Ep 8 · 24:38
clinicalAt the 1980 presentation in Salt Lake City to 1,500 attendees, gastroenterologists immediately recognized the PEG tube as a therapeutic procedure they could perform, while surgeons were slower to adopt it due to less familiarity with endoscopy.↗
▶Ep 8 · 26:40
clinicalA properly performed PEG tube placement takes under 5 minutes when done correctly and carefully.↗
▶Ep 8 · 26:58
quoteI want you to use your imagination that some day you will place a patient on a table. And have a machine that uses ultrasound or something, and has a gun that goes in and goes boom, and places that right into the stomach without anything, except maybe a little local↗
▶Ep 8 · 27:19
quoteThe world of imagination and innovation does not end because you have a good procedure.↗
clinicalRadiologists have developed ultrasound-guided gastrostomy tube placement techniques, though Ponsky expresses reservations about the tubes they use.↗
▶Ep 8 · 29:32
guidelineInnovative therapy—minor modifications to existing procedures such as changing suture number or technique—can be performed in the operating room without IRB approval, but systematic study of new procedures requires IRB review.↗
▶Ep 8 · 29:45
quoteIt's called innovative therapy. You can try to alter that procedure. You put in 3 stitches instead of 2.↗
▶Ep 8 · 30:14
quoteIt was an innovation. It was an important innovation because it said to the world that surgical procedures can be accomplished endoscopically.↗
▶Ep 8 · 30:15
opinionThe PEG tube demonstrated that surgical procedures could be accomplished endoscopically and established the endoscope as a surgical instrument for delivering surgery at a distance.↗
▶Ep 8 · 31:19
quoteThe idea of standing back. Looking at the problem and saying, wow, can I approach this problem. In a different way, can I approach it from outside or inside or through the wall?↗
▶Ep 8 · 31:36
quoteDon't think that everything's been thought of already. Otherwise we'd still be with radical mastectomy for breast cancer.↗
▶Ep 8 · 31:44
quoteone day PEG tubes will be of the past, but right now it's a good marker for endoscopic surgery.↗
▶Ep 8 · 32:02
quoteanyone who tells you that there's nothing more to be innovated, that there's no, nothing new coming along the pipe, that this is it. I, uh, somewhat to be avoided.↗
▶Ep 8 · 32:38
quotethe best thing to do is to listen to people who don't know anything about the procedure. When your medical students come in and start asking you questions, uh, that's a good person to listen to because they don't have the barriers, uh, to their thought process that we do.↗
▶Ep 8 · 32:57
quoteyou shouldn't take a chance with patients' lives, but you should take a chance on developing new ideas and new procedures and new instruments.↗
Jeffrey's statements about Inguinal Hernia1 statement
quoteI 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.↗
Jeffrey's statements about Low Cardiac Output1 statement
quoteI 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.↗
epidemiologicalNumbers from 2017 show approximately 14.5 million children in the United States are struggling with obesity.↗
▶Ep 15 · 1:18
epidemiologicalBig increases in pediatric obesity have been seen with COVID.↗
▶Ep 15 · 2:15
clinicalEpigenetic changes are thought to be causing higher levels of obesity.↗
▶Ep 15 · 2:15
clinicalObesity is a disease, and once weight is gained, the body fights to keep it on.↗
▶Ep 15 · 2:15
quoteif it was just calories in and calories out, I wouldn't have a job. And it wouldn't be a multi-billion dollar industry as well, right? It's just not that simple.↗
▶Ep 15 · 3:06
quoteThe more you talk about weight with your kids, the more likely they are to develop more issues and actually eating disorders in the future.↗
▶Ep 15 · 3:06
clinicalTalking about weight with children increases the likelihood they will develop eating disorders in the future.↗
▶Ep 15 · 3:25
clinicalStopping sugar drinks and sodas is recommended because these are easy calories to eliminate and are harmful to the body and liver.↗
▶Ep 15 · 3:25
epidemiologicalThere has been a tremendous decrease in physical activity among children.↗
▶Ep 15 · 3:25
clinicalManagement should focus on health and the whole family doing healthy habits together rather than discussing weight.↗
▶Ep 15 · 4:46
clinicalBariatric surgery works well across races and cultures, being equally effective for Black, White, and Asian patients.↗
▶Ep 15 · 4:46
opinionBariatric surgery is not a last resort but a viable treatment option that should be offered to children.↗
▶Ep 15 · 4:46
clinicalEverybody gets lifestyle changes regardless of treatment path.↗
▶Ep 15 · 4:46
clinicalThere is an increase in the use of medications for pediatric obesity, with off-label use until age 18 supported by research.↗
▶Ep 15 · 4:46
quotebariatric surgery is not a last resort. It's not that it's it's something we need to offer our kids because it's a viable option.↗
▶Ep 15 · 4:46
quotebariatric surgery is just as good if you're black or if you're white or if you're Asian.↗
▶Ep 15 · 5:40
clinicalSome GLP-1 inhibitors have been approved for ages 12 to 18.↗
▶Ep 15 · 5:40
clinicalMedications used for pediatric obesity include GLP-1 inhibitors, phentermine, Wellbutrin, and Topamax, all used off-label.↗
▶Ep 15 · 6:31
clinicalWellbutrin has a black box warning because it is an antidepressant, but it can help as an activator giving patients a boost.↗
▶Ep 15 · 8:07
epidemiologicalAdult bariatric surgery patients typically have BMIs in the low 40s at the time of surgery.↗
▶Ep 15 · 8:07
clinicalBariatric surgery in pediatrics is offered late, and starting at BMIs of 50 or 60 limits how far patients can expect to go with surgery.↗
▶Ep 15 · 8:07
epidemiologicalPediatric bariatric surgery patients typically have BMIs closer to 50 at the time of surgery.↗
▶Ep 15 · 8:07
clinicalBariatric surgery produces approximately a 25 to 35% decrease in BMI.↗
▶Ep 15 · 8:52
quotethese are kids and the their frontal lobe isn't developed. So therefore their ability to plan is really not there.↗
▶Ep 15 · 8:52
clinicalChildren's frontal lobes are not fully developed, limiting their ability to plan, which requires working with their developmental level to build skills for post-operative success.↗
▶Ep 15 · 10:10
quotemy favorite visit is that first post-op visit where they're wearing new clothes or they're putting on makeup or they just have that new zest for for life.↗
▶Ep 15 · 10:10
clinicalMost pediatric bariatric surgery patients have not been disappointed in their weight loss, with any weight loss making them feel good, stronger, and happier.↗
▶Ep 15 · 11:32
clinicalThe sleeve gastrectomy decreases hunger after surgery because many ghrelin cells are removed.↗
▶Ep 15 · 12:51
epidemiologicalAlmost all adolescent bariatric surgeries are sleeve gastrectomies.↗
▶Ep 15 · 12:51
clinicalAfter gastric bypass, the duodenum and gastric remnant cannot be visualized, which is a concern in young people with long life expectancy.↗
▶Ep 15 · 12:51
clinicalIf sleeve gastrectomy does not work, it can be converted to a gastric bypass.↗
▶Ep 15 · 15:16
clinicalCurrently, zero pediatric sleeve gastrectomy patients have required conversion to Roux-en-Y gastric bypass, though this may be seen by adult surgeons since the average patient age is 17.↗
Jeffrey's statements about Pancreatitis93 statements
clinicalBiliary dyskinesia is diagnosed with a HIDA scan showing ejection fraction less than 35% after CCK administration, when all other tests are negative.↗
▶Ep 11 · 1:53
clinicalBiliary dyskinesia is diagnosed with a HIDA scan showing ejection fraction less than 35% after CCK administration, when all other tests are negative.↗
▶Ep 11 · 5:00
clinicalModern practice favors early cholecystectomy within the first week for acute cholecystitis, rather than the older approach of cooling down for six weeks.↗
▶Ep 11 · 5:00
clinicalModern practice favors early cholecystectomy within the first week for acute cholecystitis, rather than the older approach of cooling down for six weeks.↗
▶Ep 11 · 5:40
clinicalFor 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.↗
▶Ep 11 · 5:40
clinicalFor 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.↗
▶Ep 11 · 6:10
clinicalThere is no evidence that prophylactic antibiotics help in acute cholecystitis management.↗
▶Ep 11 · 6:10
clinicalThere is no evidence that prophylactic antibiotics help in acute cholecystitis management.↗
▶Ep 11 · 12:12
clinicalThe sucker is a great tool for blunt dissection during difficult cholecystectomy; hydrodissection (injecting water between tissue planes) helps in tough areas.↗
▶Ep 11 · 12:12
clinicalThe sucker is a great tool for blunt dissection during difficult cholecystectomy; hydrodissection (injecting water between tissue planes) helps in tough areas.↗
▶Ep 11 · 12:40
clinicalAfter 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.↗
▶Ep 11 · 12:40
clinicalAfter 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.↗
▶Ep 11 · 13:02
opinionEasy gallbladders are dangerous because surgeons become complacent; accessory cystic ducts and vascular variants can be missed.↗
▶Ep 11 · 13:02
quoteEasy 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.↗
▶Ep 11 · 13:02
quoteEasy 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.↗
▶Ep 11 · 13:02
opinionEasy gallbladders are dangerous because surgeons become complacent; accessory cystic ducts and vascular variants can be missed.↗
▶Ep 11 · 14:50
clinicalRoutine 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.↗
▶Ep 11 · 14:50
clinicalRoutine 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.↗
▶Ep 11 · 18:33
clinicalWhen 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).↗
▶Ep 11 · 18:33
clinicalWhen 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).↗
▶Ep 11 · 19:00
clinicalIntraoperative administration of 30mg Toradol (age-adjusted in children) before the patient wakes facilitates same-day discharge after cholecystectomy.↗
▶Ep 11 · 19:00
clinicalIntraoperative administration of 30mg Toradol (age-adjusted in children) before the patient wakes facilitates same-day discharge after cholecystectomy.↗
▶Ep 11 · 20:30
quoteIf 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.↗
▶Ep 11 · 20:30
clinicalAny 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.↗
▶Ep 11 · 20:30
quoteIf 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.↗
▶Ep 11 · 20:30
clinicalAny 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.↗
▶Ep 11 · 21:11
clinicalFor suspected postoperative bile leak, obtain CT or ultrasound to identify fluid collections; if present, aspirate immediately—if bile is present, proceed to ERCP.↗
▶Ep 11 · 21:11
clinicalFor suspected postoperative bile leak, obtain CT or ultrasound to identify fluid collections; if present, aspirate immediately—if bile is present, proceed to ERCP.↗
▶Ep 11 · 21:32
opinionHIDA 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.↗
▶Ep 11 · 21:32
opinionHIDA 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.↗
▶Ep 11 · 22:37
clinicalFor 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.↗
▶Ep 11 · 22:37
clinicalFor 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.↗
▶Ep 11 · 23:41
clinicalBiliary dyskinesia with ejection fraction less than 35% is an indication for cholecystectomy when all other GI workup is negative.↗
▶Ep 11 · 23:41
clinicalBiliary dyskinesia with ejection fraction less than 35% is an indication for cholecystectomy when all other GI workup is negative.↗
▶Ep 11 · 24:11
clinicalGallstone pancreatitis is caused by small stones creating transient obstruction of both bile and pancreatic ducts while passing through the papilla.↗
▶Ep 11 · 24:11
clinicalGallstone pancreatitis is caused by small stones creating transient obstruction of both bile and pancreatic ducts while passing through the papilla.↗
▶Ep 11 · 24:40
quoteThe 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.↗
▶Ep 11 · 24:40
clinicalIn the old practice, all patients with gallstone pancreatitis received ERCP on presentation, but two-thirds had normal ERCPs because the stone had already passed.↗
▶Ep 11 · 24:40
quoteThe 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.↗
▶Ep 11 · 24:40
clinicalIn the old practice, all patients with gallstone pancreatitis received ERCP on presentation, but two-thirds had normal ERCPs because the stone had already passed.↗
▶Ep 11 · 25:10
clinicalCurrent 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.↗
▶Ep 11 · 25:10
clinicalCurrent 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.↗
▶Ep 11 · 26:27
opinionThe 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.↗
▶Ep 11 · 26:27
opinionThe 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.↗
▶Ep 11 · 28:33
clinicalSome 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.↗
▶Ep 11 · 30:14
clinicalFor 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.↗
▶Ep 11 · 30:14
clinicalFor 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.↗
▶Ep 11 · 30:56
clinicalIf 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.↗
▶Ep 11 · 30:56
clinicalIf 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.↗
▶Ep 11 · 31:35
clinicalA 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.↗
▶Ep 11 · 31:35
clinicalA 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.↗
▶Ep 11 · 32:44
clinicalModern 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.↗
▶Ep 11 · 32:44
clinicalModern 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.↗
▶Ep 11 · 33:27
clinicalAfter transcystic common duct exploration, place endoloops on the cystic duct stump because prolonged obstruction can blow off simple ties.↗
▶Ep 11 · 33:27
clinicalAfter transcystic common duct exploration, place endoloops on the cystic duct stump because prolonged obstruction can blow off simple ties.↗
▶Ep 11 · 34:56
clinicalLaparoscopic 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.↗
▶Ep 11 · 34:56
clinicalLaparoscopic 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.↗
▶Ep 11 · 35:30
clinicalFor laparoscopic choledocotomy, do not divide the cystic duct—use the gallbladder for lateral retraction while dissecting down to expose the anterior common duct surface.↗
▶Ep 11 · 35:30
clinicalFor laparoscopic choledocotomy, do not divide the cystic duct—use the gallbladder for lateral retraction while dissecting down to expose the anterior common duct surface.↗
▶Ep 11 · 37:40
clinicalT-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.↗
▶Ep 11 · 37:40
clinicalT-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.↗
▶Ep 11 · 38:50
clinicalT-tube cholangiogram is performed at 10 days post-choledocotomy; if clear, the T-tube is removed at 2 weeks.↗
▶Ep 11 · 38:50
clinicalT-tube cholangiogram is performed at 10 days post-choledocotomy; if clear, the T-tube is removed at 2 weeks.↗
▶Ep 11 · 39:27
clinicalFor severe pancreatitis with large phlegmon in the pancreatic head, obtain CT and consider waiting 6 weeks before cholecystectomy to allow inflammation to resolve.↗
▶Ep 11 · 39:27
clinicalFor severe pancreatitis with large phlegmon in the pancreatic head, obtain CT and consider waiting 6 weeks before cholecystectomy to allow inflammation to resolve.↗
▶Ep 11 · 40:00
clinicalFor 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.↗
▶Ep 11 · 40:00
clinicalFor 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.↗
▶Ep 11 · 41:04
clinicalPercutaneous 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.↗
▶Ep 11 · 41:04
clinicalPercutaneous 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.↗
▶Ep 11 · 41:47
clinicalIn 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.↗
▶Ep 11 · 41:47
clinicalIn 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.↗
▶Ep 11 · 42:29
clinicalCommon bile duct injuries typically occur during 'easy' cases when surgeons become complacent and fail to maintain vigilance.↗
▶Ep 11 · 42:29
clinicalCommon bile duct injuries typically occur during 'easy' cases when surgeons become complacent and fail to maintain vigilance.↗
▶Ep 11 · 43:00
clinicalThe 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.'↗
▶Ep 11 · 43:00
clinicalThe 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.'↗
▶Ep 11 · 43:29
clinicalBeing 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.↗
▶Ep 11 · 43:29
clinicalBeing 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.↗
▶Ep 11 · 44:00
quoteIf 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.↗
▶Ep 11 · 44:00
clinicalIf common bile duct injury is recognized intraoperatively: STOP immediately, call for help, and assess. If shaken or inexperienced with hepaticojejunostomy, do not attempt repair.↗
▶Ep 11 · 44:00
quoteIf 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.↗
▶Ep 11 · 44:00
clinicalIf common bile duct injury is recognized intraoperatively: STOP immediately, call for help, and assess. If shaken or inexperienced with hepaticojejunostomy, do not attempt repair.↗
▶Ep 11 · 44:20
quoteWhat happens in most of these cases is the primary injury is compounded by the attempted repair.↗
▶Ep 11 · 44:20
quoteWhat happens in most of these cases is the primary injury is compounded by the attempted repair.↗
▶Ep 11 · 44:20
clinicalIn most bile duct injury cases, the primary injury is compounded by the attempted repair.↗
▶Ep 11 · 44:20
clinicalIn most bile duct injury cases, the primary injury is compounded by the attempted repair.↗
▶Ep 11 · 44:37
quoteA 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.↗
▶Ep 11 · 44:37
clinicalPrimary 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.↗
▶Ep 11 · 44:37
clinicalPrimary 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.↗
▶Ep 11 · 44:37
quoteA 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.↗
▶Ep 11 · 44:56
clinicalFor small lateral common duct injuries, place a small T-tube rather than primary suture closure, as suture alone will leak.↗
▶Ep 11 · 44:56
clinicalFor small lateral common duct injuries, place a small T-tube rather than primary suture closure, as suture alone will leak.↗
▶Ep 11 · 45:37
clinicalFor 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.↗
▶Ep 11 · 45:37
clinicalFor 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.↗
Jeffrey's statements about Pediatric Obesity32 statements
epidemiologicalNumbers from 2017 show approximately 14.5 million children in the United States are struggling with obesity.↗
▶Ep 9 · 1:18
epidemiologicalBig increases in pediatric obesity have been seen with COVID.↗
▶Ep 9 · 2:15
clinicalObesity is a disease, and once weight is gained, the body fights to keep it on.↗
▶Ep 9 · 2:15
clinicalEpigenetic changes are thought to be causing higher levels of obesity.↗
▶Ep 9 · 2:15
quoteif it was just calories in and calories out, I wouldn't have a job. And it wouldn't be a multi-billion dollar industry as well, right? It's just not that simple.↗
▶Ep 9 · 3:06
quoteThe more you talk about weight with your kids, the more likely they are to develop more issues and actually eating disorders in the future.↗
▶Ep 9 · 3:06
clinicalTalking about weight with children increases the likelihood they will develop eating disorders in the future.↗
▶Ep 9 · 3:25
clinicalStopping sugar drinks and sodas is recommended because these are easy calories to eliminate and are harmful to the body and liver.↗
▶Ep 9 · 3:25
clinicalManagement should focus on health and the whole family doing healthy habits together rather than discussing weight.↗
▶Ep 9 · 3:25
epidemiologicalThere has been a tremendous decrease in physical activity among children.↗
▶Ep 9 · 4:46
clinicalBariatric surgery works well across races and cultures, being equally effective for Black, White, and Asian patients.↗
▶Ep 9 · 4:46
clinicalEverybody gets lifestyle changes regardless of treatment path.↗
▶Ep 9 · 4:46
clinicalThere is an increase in the use of medications for pediatric obesity, with off-label use until age 18 supported by research.↗
▶Ep 9 · 4:46
opinionBariatric surgery is not a last resort but a viable treatment option that should be offered to children.↗
▶Ep 9 · 4:46
quotebariatric surgery is just as good if you're black or if you're white or if you're Asian.↗
▶Ep 9 · 4:46
quotebariatric surgery is not a last resort. It's not that it's it's something we need to offer our kids because it's a viable option.↗
▶Ep 9 · 5:40
clinicalSome GLP-1 inhibitors have been approved for ages 12 to 18.↗
▶Ep 9 · 5:40
clinicalMedications used for pediatric obesity include GLP-1 inhibitors, phentermine, Wellbutrin, and Topamax, all used off-label.↗
▶Ep 9 · 6:31
clinicalWellbutrin has a black box warning because it is an antidepressant, but it can help as an activator giving patients a boost.↗
▶Ep 9 · 8:07
clinicalBariatric surgery in pediatrics is offered late, and starting at BMIs of 50 or 60 limits how far patients can expect to go with surgery.↗
▶Ep 9 · 8:07
epidemiologicalPediatric bariatric surgery patients typically have BMIs closer to 50 at the time of surgery.↗
▶Ep 9 · 8:07
epidemiologicalAdult bariatric surgery patients typically have BMIs in the low 40s at the time of surgery.↗
▶Ep 9 · 8:07
clinicalBariatric surgery produces approximately a 25 to 35% decrease in BMI.↗
▶Ep 9 · 8:52
clinicalChildren's frontal lobes are not fully developed, limiting their ability to plan, which requires working with their developmental level to build skills for post-operative success.↗
▶Ep 9 · 8:52
quotethese are kids and the their frontal lobe isn't developed. So therefore their ability to plan is really not there.↗
▶Ep 9 · 10:10
quotemy favorite visit is that first post-op visit where they're wearing new clothes or they're putting on makeup or they just have that new zest for for life.↗
▶Ep 9 · 10:10
clinicalMost pediatric bariatric surgery patients have not been disappointed in their weight loss, with any weight loss making them feel good, stronger, and happier.↗
▶Ep 9 · 11:32
clinicalThe sleeve gastrectomy decreases hunger after surgery because many ghrelin cells are removed.↗
▶Ep 9 · 12:51
clinicalIf sleeve gastrectomy does not work, it can be converted to a gastric bypass.↗
▶Ep 9 · 12:51
clinicalAfter gastric bypass, the duodenum and gastric remnant cannot be visualized, which is a concern in young people with long life expectancy.↗
▶Ep 9 · 12:51
epidemiologicalAlmost all adolescent bariatric surgeries are sleeve gastrectomies.↗
▶Ep 9 · 15:16
clinicalCurrently, zero pediatric sleeve gastrectomy patients have required conversion to Roux-en-Y gastric bypass, though this may be seen by adult surgeons since the average patient age is 17.↗
Jeffrey's statements about Psychomotor Retardation209 statements
clinicalPonsky had a 2.027 GPA graduating from Cleveland Heights High School and his college counselor recommended trade school instead of college.↗
▶Ep 1 · 9:01
quoteLook, 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.↗
▶Ep 1 · 9:17
opinionPonsky's transformation in college came from memorizing everything and studying constantly, discovering he had an exceptional memory that allowed him to 'eat the book and spit it out.'↗
▶Ep 1 · 21:12
clinicalWalter Pore taught pinch grafting technique at Metro Hospital, where students would inject local anesthesia, harvest small 'postage stamp' skin grafts from the thigh, and apply them to debrided bedsores. Pore emphasized giving patients zinc supplementation.↗
▶Ep 1 · 25:21
clinicalGastroenterologists at University Hospitals refused to train surgeons in endoscopy, telling Ponsky 'we're not training any surgeons.'↗
▶Ep 1 · 25:47
clinicalPonsky trained in endoscopy with Jim King in Canton, Ohio, performing approximately 500 cases over 5-6 months during an extended elective.↗
▶Ep 1 · 26:57
clinicalEarly endoscopes were cleaned with green soap and stored in the back of cars, without high-level disinfection protocols. Operators did not wear gloves during procedures.↗
▶Ep 1 · 28:30
clinicalWhen SAGES started, it had approximately 300 members. When Ponsky became president in 1990, the society was giving courses on surgical endoscopy and its relationship to surgical problem-solving.↗
▶Ep 1 · 28:48
clinicalJacques Perissat showed the video of laparoscopic cholecystectomy in the exhibit hall at the SAGES meeting in Louisville, Kentucky, marking a pivotal moment when Ponsky was SAGES president.↗
▶Ep 1 · 29:04
clinicalWhen laparoscopic cholecystectomy was introduced, instruments could not be purchased and surgeons had to use gynecologic instruments initially.↗
▶Ep 1 · 29:10
clinicalPonsky took one of the first laparoscopic cholecystectomy courses taught by Nat Soper, George Bercy, John Hunter, and John Sackier in Salt Lake City.↗
▶Ep 1 · 29:27
clinicalPonsky's first two laparoscopic cholecystectomies at Mount Sinai were proctored by David Dupper, who had performed only 8 cases himself at that time. The first patient was a member of the hospital's board of trustees.↗
▶Ep 1 · 30:31
clinicalPonsky became director of surgical endoscopy at University Hospitals at age 29 as a new attending.↗
▶Ep 1 · 31:23
clinicalThe PEG (percutaneous endoscopic gastrostomy) was developed in May 1979 by Ponsky and pediatric gastroenterologist Mike Gower, with the first five cases performed on babies with birth asphyxia and psychomotor retardation.↗
▶Ep 1 · 31:31
clinicalThe PEG procedure was developed without IRB approval, only discussing the approach with patients' families.↗
▶Ep 1 · 31:50
clinicalPonsky became chief of surgery at Mount Sinai Hospital at age 32 in 1979.↗
▶Ep 1 · 32:54
clinicalMount Sinai Hospital had an animal laboratory that was larger than Cleveland Clinic's laboratory, providing Ponsky freedom to conduct courses and train fellows.↗
▶Ep 1 · 40:27
clinicalThe distal splenorenal shunt, once considered a great operation based on physiology to reduce variceal pressure without decreasing portal flow, became obsolete when endoscopic variceal banding was introduced.↗
▶Ep 1 · 41:05
clinicalPonsky performed 180 vertical banded gastroplasties in one year in the mid-1980s, an operation that later required reversal in many patients.↗
▶Ep 1 · 41:34
clinicalPonsky performed 1,600 colonoscopies in a single year during his practice.↗
▶Ep 1 · 43:09
clinicalERCP was developed primarily in Japan by Itaru Oi and colleagues, with contributions from German physicians and Peter Cotton's group in London.↗
▶Ep 1 · 43:40
clinicalPonsky learned ERCP primarily through watching videos and self-teaching, then traded training with George Brodmerkel in Pittsburgh—teaching him laparoscopy under local anesthesia in exchange for learning sphincterotomy.↗
▶Ep 1 · 48:24
clinicalEarly SAGES meetings focused on surgical problem-solving with endoscopy, addressing topics like managing bowel obstruction, evaluating suture lines, and treating intestinal volvulus endoscopically—distinct from ASGE's focus.↗
▶Ep 1 · 50:09
clinicalPonsky advocated to the Residency Review Committee (when Joe Fisher was head) for a minimum endoscopy requirement in general surgery training. The initial requirement of 50 cases was controversial but established endoscopy as a required component of general surgery.↗
▶Ep 1 · 51:55
quoteAlways volunteer, never say no, get involved in everything. And you know what, you'll find the time. You don't have to belabor decisions. Make a decision and move on.↗
SAGES Stories: Dr. Jeffrey Ponsky on surgical endoscopy and the PEG tube legacy
clinicalPonsky graduated Cleveland Heights High School with a 2.027 GPA and was advised by his counselor to consider trade school instead of college.↗
▶Ep 2 · 7:03
quoteI had a 2.027 with my with my acu graduating from high school↗
▶Ep 2 · 9:01
quotelook, 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↗
opinionPonsky's transformation in college came from memorizing everything and studying constantly, discovering he had an 'unbelievable' memory that allowed him to 'eat the book and spit it out.'↗
clinicalWorking as an orderly at Mount Sinai Hospital, Ponsky gave bed baths, changed bedpans, and cared for a high school classmate who became paraplegic after an auto accident, which deepened his commitment to medicine.↗
▶Ep 2 · 12:15
clinicalPonsky was promoted to scrub tech and surgeons allowed him to close fascia, despite the head nurse objecting that he wasn't permitted to do so.↗
▶Ep 2 · 12:43
clinicalPonsky never took calculus, using logarithms to work around it in physics, and the Case Western dean of admissions accepted him despite this after he stated he had already been admitted to two other medical schools.↗
▶Ep 2 · 14:14
clinicalPonsky chose Case Western Reserve (then Western Reserve) over Northwestern and Cincinnati primarily because his family lacked money and he needed to live at home rather than pay rent elsewhere.↗
▶Ep 2 · 19:43
opinionBill Holden, chairman of surgery at Case, was an 'elegant' teacher who used the Socratic method and prioritized teaching over technical skill.↗
▶Ep 2 · 20:20
clinicalWalter Parry taught using theatrical methods, including having students smell a room to perceive 'the smell of death' (though there was no actual smell) and performing bedside pinch grafts on bedsores at Metro Hospital.↗
clinicalParry made Ponsky rewrite his first paper—a letter to the New England Journal about paradoxical air embolism—six times and read German poetry to him to encourage more poetic medical writing.↗
▶Ep 2 · 25:08
clinicalWhen Ponsky requested an endoscopy elective as a resident, the head of GI at University Hospitals refused, stating 'we're not training any surgeons.'↗
▶Ep 2 · 25:47
clinicalCharles Hube arranged for Ponsky to train with Jim King in Canton, Ohio, where Ponsky performed approximately 500 colonoscopy cases over 5-6 months using a mid-length scope not designed to reach the cecum.↗
▶Ep 2 · 26:19
clinicalAfter returning from Canton, the head of gastroenterology told Ponsky 'you're not gonna touch this scope,' so he used the VA's Olympus colonoscope instead.↗
▶Ep 2 · 26:51
clinicalPonsky's mother-in-law purchased his first colonoscope after hearing at a family dinner that he couldn't get access to equipment; in that era, scopes were washed with green soap and stored in car trunks.↗
▶Ep 2 · 27:13
clinicalAs a senior resident, Ponsky performed emergency endoscopy cases day and night with Bob Zollinger Junior signing the paperwork, eventually doing all cases while GI physicians stopped performing them.↗
▶Ep 2 · 28:30
clinicalWhen SAGES started, it had approximately 300 members; when Ponsky became president in 1990, the society was giving courses on surgical endoscopy and its relationship to surgical problem-solving.↗
▶Ep 2 · 28:48
clinicalAt the 1990 SAGES meeting in Louisville, Kentucky, Jacques Perissat showed video of laparoscopic cholecystectomy in the exhibit hall; Ponsky was SAGES president at the time and 'right in on the ground floor.'↗
▶Ep 2 · 29:06
clinicalEarly laparoscopic instruments were unavailable for purchase, so surgeons used gynecology instruments. Ponsky took one of the first training courses taught by Nat Soper, George Berci, John Hunter, and John Sackier in Salt Lake City.↗
▶Ep 2 · 29:27
clinicalPonsky's first two laparoscopic cholecystectomy cases at Mount Sinai were performed on a board of trustees member, proctored by David Dupper who had completed only eight cases himself.↗
▶Ep 2 · 31:11
clinicalThe PEG tube was invented in May 1979 when Ponsky and pediatric surgeon Michael Gower used transillumination (seeing light shine through the abdominal wall during endoscopy in neonates) to develop a minimally invasive gastrostomy technique, performing it on five babies with birth asphyxia and psychomotor retardation.↗
▶Ep 2 · 31:31
clinicalThe PEG tube procedure was performed without IRB approval; Ponsky and Gower only spoke with the patients' families before proceeding.↗
▶Ep 2 · 31:50
clinicalPonsky became chief of surgery at Mount Sinai Hospital at age 32, shortly after inventing the PEG tube.↗
▶Ep 2 · 32:44
opinionMount Sinai was Ponsky's 'favorite place I ever worked in my life'—a small hospital where every staff member knew each other, with an animal research laboratory larger than Cleveland Clinic's.↗
▶Ep 2 · 32:44
quotethe favorite place I ever worked in my life was Mount Sinai.↗
▶Ep 2 · 33:36
opinionPonsky left Mount Sinai in 1997 after 18 years when the hospital was sold to a for-profit company whose leadership 'could care less about quality.'↗
▶Ep 2 · 33:36
quoteThey were for-profit guys who could care less about quality.↗
▶Ep 2 · 34:21
clinicalPonsky had all but one of his children before finishing residency; his last son was born during his final year of residency, and his daughter was born three years later after he joined Mount Sinai.↗
▶Ep 2 · 34:43
opinionPonsky's wife had no partners helping her while he was on call every other night, but he credits his family—wife, children, and in-laws—as essential to his success, stating 'our success was a joint success, not just my success.'↗
▶Ep 2 · 34:49
quoteYou know, here's the important part. You, you gotta have a good partner. To have all the success doesn't come down cause you're a genius. You have to either destroy your family as many people did in the past, or use that to bolster your success↗
▶Ep 2 · 35:09
quoteour success was a joint success, not just my success.↗
▶Ep 2 · 35:30
quoteWho's watching our patients when we go? We all have a partner who's making rounds and taking our patients back when we have Complications↗
▶Ep 2 · 36:32
opinionPonsky's greatest academic achievement was becoming chairman of the Department of Surgery at Case Western Reserve, though his parents were most proud of his role as chief of surgery at Mount Sinai because it was meaningful within the Jewish community they knew.↗
▶Ep 2 · 36:39
quoteI think that, uh, I was chair of the board of the board of surgery. They wouldn't have understood that. That to them didn't mean anything. They saw it as the chief of surgery at Mount Sinai, that's enough.↗
▶Ep 2 · 38:47
opinionPonsky has counseled fellows away from positions at his own institutions when he believed better opportunities existed elsewhere, considering factors like family proximity, academic opportunity, and institutional need rather than institutional prestige.↗
▶Ep 2 · 38:58
quotethat is not the best opportunity for you. There is a great opportunity here because they need you more, because this is a better academic opportunity, because the people you'll be working with are more uh akin to what you need, or your family is in that city, your husband or wife's family is in that city.↗
▶Ep 2 · 39:32
quotego where the opportunities are best for your whole life, not just for your name of your institution.↗
▶Ep 2 · 40:27
quoteI thought that a distal splenor renal shunt was a great operation when they first did it. I dare say you've not done those.↗
▶Ep 2 · 40:27
clinicalPonsky performed distal splenorenal shunts early in his career at University Hospitals with Jerry Walkoff's assistance, believing the operation was 'the greatest thing since sliced bread' based on Dean Warren's physiologic approach, but the procedure became obsolete when endoscopic variceal banding was introduced.↗
▶Ep 2 · 41:05
clinicalPonsky performed 180 vertical banded gastroplasty procedures in one year during the mid-1980s, believing it would be a great bariatric operation, but later surgeons had to reverse many of them.↗
▶Ep 2 · 41:34
quoteI dare say in 20 years, you may say, I remember when we did colonoscopy for screening on all these patients↗
▶Ep 2 · 41:34
opinionPonsky performed 1600 colonoscopies in his final year of practice, predicting that in 20 years colonoscopy for screening may be obsolete.↗
▶Ep 2 · 42:07
opinionERCP is Ponsky's favorite procedure, which he describes as 'like golf for some people'—he would come in day or night to perform it and considers it a sophisticated procedure requiring 'body English.'↗
▶Ep 2 · 42:10
quoteTo me, ERCP is like golf for some people. I love ERCP. I would have come in day or night to do ERCP. I just loved it.↗
▶Ep 2 · 43:40
clinicalPonsky learned ERCP largely self-taught by watching videos, then arranged a teaching exchange with George Brodmerkel in Pittsburgh: Ponsky taught Brodmerkel laparoscopy under local anesthesia for liver biopsy, and Brodmerkel taught Ponsky sphincterotomy.↗
▶Ep 2 · 44:19
quoteERCP is like a a a a golf game. Is it body English in it. There it's very sophisticated and I love it.↗
▶Ep 2 · 44:54
opinionPonsky obtained an executive MBA at the urging of hospital administrators who said he made decisions 'out of your gut' without understanding return on investment or financing; he describes the MBA as learning 'the language of business' and when to 'say bullshit at the right time' in business meetings.↗
▶Ep 2 · 45:36
quoteI hate business. I don't care about business.↗
▶Ep 2 · 46:18
quoteIt's the people you meet. Yeah, it's the way they think. It's the way they approach a problem.↗
▶Ep 2 · 47:50
quoteI felt a little bit like a traitor to ASGE because here are these group of surgeons who decided they're gonna start their own society.↗
▶Ep 2 · 47:50
opinionPonsky initially felt like a 'traitor' to ASGE when SAGES started because he was already on the ASGE governing board.↗
▶Ep 2 · 48:24
opinionAt early SAGES meetings, papers focused on surgical problem-solving with endoscopy (bowel obstruction evaluation, suture line assessment, volvulus management)—topics distinct from ASGE content—which convinced Ponsky of the society's unique value.↗
▶Ep 2 · 48:46
quoteThere is a reason for this society, intraoperative endoscopy, things that we would do.↗
▶Ep 2 · 50:02
quoteEndoscopy has been made a part of surgery now and general surgery. It is a requirement for general surgery.↗
▶Ep 2 · 50:09
clinicalPonsky advocated to the Residency Review Committee (when Joe Fisher was head) for a minimum endoscopy case requirement in general surgery training; the 50-case requirement was initially controversial but established endoscopy as a core surgical competency.↗
▶Ep 2 · 50:45
quoteThe endoscope is now. The vehicle, it's the car that gets us to our destination. It drives us to our destination, then we put it down, we have it fixed, and we start to operate endoscopically↗
▶Ep 2 · 51:38
quoteThere's no reason that you can't be empathetic and be interested in psychiatric disease and still be somebody interested in the technical sides.↗
▶Ep 2 · 51:55
quoteAll I tell people is always volunteer, never say no, get involved in everything. And you know what, you'll find the time.↗
▶Ep 2 · 51:55
opinionPonsky's philosophy is to 'always volunteer, never say no, get involved in everything'—he believes people will find the time, decisions don't need to be belabored, and residents can help with much of the work.↗
▶Ep 2 · 51:58
quoteI think that surgeons can be better psychiatrists than some of the psychiatrists now. They're more empathetic in some ways↗
▶Ep 2 · 52:57
quoteDon't be afraid to do everything. Don't say I'm too busy. You can do everything.↗
▶Ep 2 · 54:00
quoteI don't take myself too seriously, and you shouldn't, because there are really other people around who've done many more things than me↗
▶Ep 2 · 55:18
quoteif you don't have hobbies, you're cheating yourself.↗
▶Ep 2 · 55:24
clinicalPonsky's wife purchased him a Harley-Davidson trike (three-wheeled motorcycle) when he turned 70; she would not permit a two-wheel motorcycle. They have ridden to Sturgis, South Dakota.↗
▶Ep 2 · 56:04
quoteThe answer is no. I've never been tempted. Uh, to move because my family is here. It's all about your family.↗
▶Ep 2 · 56:12
clinicalPonsky lives on 8 acres with horses; his son Zach built a house on the adjacent 5-acre lot, his daughter bought a house two properties away with another 5 acres, son Todd lives within half a mile, and son Lee lives 'almost 2 miles' away—creating a family compound in Cleveland.↗
▶Ep 2 · 57:22
clinicalPonsky has a house in Florida and would travel there for long weekends during his working years, leaving Friday morning at 6 AM and returning Monday, using vacation days for Friday and Monday.↗
▶Ep 2 · 58:08
quoteMy family only wants to be near my wife. They can care less about me unless Jackie, unless something breaks. Then they call me, but they only want to be near my wife.↗
▶Ep 2 · 58:21
quoteShe's I'm gonna be very clear about that. She's pretty great, the glue that holds our family together↗
▶Ep 2 · 59:19
quoteMy favorite memories, my presidential addresses or highlights of my career. I love doing that.↗
▶Ep 2 · 59:45
quoteWe Are the Sages with the Japanese, because I go to tears when we do that every year, because 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.↗
The invention of the PEG tube with Dr. Jeffrey Ponsky
▶Ep 3 · 2:43
quoteI was told I couldn't do it because I was a surgical resident, and that piqued my interest↗
▶Ep 3 · 3:02
quoteI came back after that training and I was told I couldn't do endoscopy because I was a surgeon, couldn't touch the instruments↗
▶Ep 3 · 3:27
clinicalIn 1974-1975, there were no pediatric gastroenterologists, and Ponsky performed endoscopy on children, young adults, and neonates with GI problems using his personally owned scope.↗
▶Ep 3 · 4:33
clinicalDuring neonatal endoscopy, the room would light up because babies were so thin; when pediatric surgeon Michael Gower pushed on the transilluminated light with his finger, an indentation was visible endoscopically.↗
▶Ep 3 · 4:42
quoteMichael would push on the light with his finger, and I'd be scoping and I would see an indentation. And we realized we got together and said, you know, maybe we could do something with this.↗
▶Ep 3 · 4:59
clinicalThe first PEG tubes were constructed from OR gastrostomy tubes (small Pezzer catheters) with sutures threaded through the end and passed through an IV catheter (medicut) to create a dilator tip.↗
▶Ep 3 · 5:42
clinicalThe first five PEG procedures in May 1979 were performed in neonates with severe psychomotor retardation who were brain dead, fed by nasogastric tubes, had no chance of recovery, and were being sent for open gastrostomy before long-term nursing facility placement.↗
▶Ep 3 · 6:15
quotewe have to do a major laparotomy on these babies, uh, but we have an idea for performing this, uh, by a new technique. Uh, we don't have any idea if it'll work. We think it will, it's pretty simple, but if it doesn't, we will do the laparotomy right there and then and complete the gastrostomy↗
▶Ep 3 · 6:25
clinicalInformed consent for the first PEG cases consisted of telling mothers that if the new technique failed, immediate laparotomy and open gastrostomy would be performed.↗
clinicalThe first PEG procedures succeeded easily within a few minutes.↗
▶Ep 3 · 6:47
clinicalAfter the initial five neonatal cases, Ponsky moved to Mount Sinai Medical Center and began performing PEG in adult stroke patients with similar neurologic prognosis who needed feeding access.↗
▶Ep 3 · 7:13
clinicalLaboratory studies on PEG tract formation, tube dwell time before safe replacement, and leakage risk were conducted after clinical implementation—the reverse of typical research-then-clinical sequence.↗
▶Ep 3 · 7:28
clinicalJohn Mellinger, who later worked at the American Board of Surgery, conducted original research on PEG tract formation.↗
▶Ep 3 · 7:44
quoteit was sort of the reverse of what you would do now by going to the laboratory first and then And then to the operating room.↗
clinicalMultiple medical device companies refused to manufacture the PEG tube initially, believing nobody would use it.↗
▶Ep 3 · 8:54
clinicalA small company in Mentor, Ohio eventually manufactured the PEG tube exactly as designed by Ponsky and Gower.↗
▶Ep 3 · 9:06
opinionPonsky and Gower never patented the PEG tube; they were more interested in publication than patents and wanted to disseminate the technique.↗
▶Ep 3 · 9:06
quotewe never even thought about patenting the tube. It wasn't even on our mind.↗
▶Ep 3 · 9:18
quoteWe wanted to get papers out of it. We wanted to make a contribution to literature. We were more interested in publication than patents↗
▶Ep 3 · 9:39
clinicalPEG tube complications included rare colonic perforation when the tube traversed the colon en route to the stomach, which still occurs rarely today.↗
▶Ep 3 · 9:51
clinicalExit-site infection was a major early PEG complication.↗
▶Ep 3 · 10:24
clinicalPEG tubes evolved from multi-piece rubber construction to one-piece silicone, but have had very few modifications in the last few years and have become a commodity product purchased by hospitals at the lowest price.↗
▶Ep 3 · 10:50
clinicalThe PEG technique has remained very much the same as the original with only a few modifications.↗
▶Ep 3 · 11:19
clinicalPonsky and the manufacturing company conducted dozens of animal experiments to determine tube removal pressure, tip retention, and optimal tube size for FDA approval.↗
▶Ep 3 · 12:09
quoteI said, wow, look at this. What else can we do with this thing?↗
▶Ep 3 · 12:13
clinicalThe PEG tube was the first and only time any instrument or needle was thrust through the abdominal wall into the GI tract and left in place.↗
▶Ep 3 · 12:13
quotethe peg tube and was and still is the only time. Any instrument or needle was thrust through the abdominal wall into the GI tract.↗
▶Ep 3 · 12:55
clinicalIn 1975, Ponsky developed and published endoscopic tattooing using India ink injected alongside polypectomy sites to mark the location for potential surgical resection if cancer was found; the technique remains in use today.↗
▶Ep 3 · 13:38
quotethere was a lot of low hanging fruit then we could do things that seemed logical, and that's the fun of a new area.↗
▶Ep 3 · 13:56
quoteeverybody thinks that everybody's been, everything's been discovered already, that's not true.↗
▶Ep 3 · 15:31
clinicalIn the late 1970s, surgical residents were on call every other night (36 hours on, 12 hours off) for five years of training.↗
▶Ep 3 · 15:49
quoteI wanna have an elective that's a little bit easier.↗
▶Ep 3 · 15:58
quoteI said, wow, that would be a great way to blow up 3 months. I won't have to take night off. This will be easier. That was an accident.↗
▶Ep 3 · 17:07
quotewhen you see a new technology, whatever that technology is. Investigate it, see if it's something that offers you something that you can uh make it your own and become an expert in it.↗
▶Ep 3 · 17:35
clinicalIn the mid-1970s, the predominant American endoscope was the ACMI (American Cystoscope Makers Incorporated) with a joystick control, approximately 1 cm diameter, with image quality like looking through ground glass.↗
clinicalJapanese companies (Mashida and Olympus in the US) produced fiber-optic endoscopes with crystal-clear optics that were markedly superior to American models.↗
▶Ep 3 · 18:15
quoteIt was crystal clear. It was like you were just right there.↗
clinical1970s fiber-optic endoscopes transmitted light via fiber bundles to the lumen and returned images to the eyepiece; photography required clipping a camera to the eyepiece for film-strip images.↗
▶Ep 3 · 18:51
clinicalTeaching attachments for 1970s endoscopes consisted of a wire-connected second eyepiece that provided a dim image for trainees in darkened rooms.↗
▶Ep 3 · 19:06
clinicalAround 1980, video chip technology placed a camera at the endoscope tip instead of using fiber-optic image transmission, displaying images on large monitors—the technology used in current endoscopes.↗
▶Ep 3 · 19:36
clinicalIn the late 1970s, neonates could tolerate endoscopes approximately 9 millimeters wide, which was the limit for safe use.↗
▶Ep 3 · 19:57
clinicalThe original PEG procedure was performed with an adult endoscope.↗
▶Ep 3 · 20:07
quoteI would almost not let anyone touch it except me↗
▶Ep 3 · 20:56
clinicalIn the 1970s, endoscopes were cleaned between procedures using only green soap; high-level disinfection and sterilization protocols did not yet exist.↗
▶Ep 3 · 21:45
clinicalThe PEG tube received FDA 510(k) approval as a modification of existing gastrostomy tubes used for similar purposes, which is easier than approval for entirely novel devices.↗
▶Ep 3 · 22:17
clinicalPEG indications expanded beyond feeding to include gastric decompression in gastroparesis or obstruction (including carcinomatosis), delivery of unpalatable feedings, and treatment of gastric volvulus.↗
▶Ep 3 · 23:00
clinicalThe PEG technique was adapted for colonic applications including sigmoid volvulus fixation and Ogilvie syndrome decompression, with multiple PEGs used for sigmoid volvulus.↗
▶Ep 3 · 23:30
quoteI like to think that the endoscope is a tube, uh, it's a, it's a, a vehicle that gets us to where we need to be to perform an operation. That's what we think of as surgeons.↗
▶Ep 3 · 23:56
opinionMany endoscopic procedures developed by surgeons, including PEG, were extensions of surgical operations already performed via laparotomy.↗
▶Ep 3 · 25:32
clinicalGastroenterologists rapidly adopted PEG as a therapeutic procedure they could easily accomplish, driving widespread dissemination.↗
▶Ep 3 · 25:56
clinicalSurgeons were slower to adopt PEG initially because they were not performing as much therapeutic endoscopy at that time, but they did not offer significant resistance.↗
▶Ep 3 · 26:40
clinicalA properly performed PEG procedure takes under 5 minutes when done carefully by an experienced operator.↗
▶Ep 3 · 26:47
clinicalCurrent PEG procedures still require patient sedation or anesthesia and constitute an intervention.↗
▶Ep 3 · 26:58
quoteI want you to use your imagination that some day you will place a patient on a table. And have a machine that uses ultrasound or something, and has a gun that goes in and goes boom, and places that right into the stomach without anything, except maybe a little local↗
opinionRadiologists perform gastrostomy tube placement using ultrasound guidance, though Ponsky does not prefer the tubes they use.↗
▶Ep 3 · 32:57
quoteyou should always uh take a chance. Now, you shouldn't take a chance with patients' lives, but you should take a chance on developing new ideas and new procedures and new instruments.↗
Behind The Knife: The Surgery Podcast / Innovations in Surgery: PEG Tube
▶Ep 4 · 2:27
clinicalThe PEG tube procedure was developed in May 1979 by Jeffrey Ponsky and Michael Gower at University Hospitals of Cleveland.↗
▶Ep 4 · 2:43
clinicalIn the mid-1970s, surgical residents were prohibited from performing endoscopy by gastroenterologists who considered it their exclusive domain.↗
▶Ep 4 · 2:43
quoteI was told I couldn't do it because I was a surgical resident, and that piqued my interest↗
▶Ep 4 · 3:02
quoteI came back after that training and I was told I couldn't do endoscopy because I was a surgeon, couldn't touch the instruments↗
▶Ep 4 · 4:42
quoteMichael would push on the light with his finger, and I'd be scoping and I would see an indentation. And we realized we got together and said, you know, maybe we could do something with this.↗
▶Ep 4 · 4:59
clinicalThe original PEG tube was constructed using a Foley catheter (depezar catheter) and an IV catheter called a medicut, with sutures threaded through to create a dilator end.↗
▶Ep 4 · 5:42
clinicalThe initial PEG tube patients were neurologically impaired infants with severe psychomotor retardation who were being fed by nasogastric tubes and had no chance of recovery.↗
▶Ep 4 · 6:42
clinicalThe first five PEG procedures were performed in infants, followed by adult stroke patients with similar neurologic prognosis.↗
▶Ep 4 · 7:13
clinicalLaboratory studies on tract formation and tube safety were conducted after the initial clinical procedures, representing a reverse of modern innovation protocols.↗
clinicalMultiple medical device companies initially refused to manufacture the PEG tube because they believed nobody would use it.↗
▶Ep 4 · 9:06
quoteWe never even thought about patenting the tube. It wasn't even on our mind.↗
▶Ep 4 · 9:18
quoteWe were more interested in publication than patents, and we were interested in getting the technique out there.↗
▶Ep 4 · 9:37
clinicalComplications of PEG tube placement include rare instances of the tube passing through the colon en route to the stomach, bleeding (not a major problem), and infection at the skin exit site (initially a significant problem).↗
▶Ep 4 · 10:24
clinicalThe PEG tube technique has remained largely unchanged since the first few years after its introduction, with tubes becoming silicon one-piece designs.↗
▶Ep 4 · 12:09
quoteI said, wow, look at this. What else can we do with this thing?↗
▶Ep 4 · 12:13
quotethe peg tube and was and still is the only time. Any instrument or needle was thrust through the abdominal wall into the GI tract.↗
▶Ep 4 · 12:13
clinicalThe PEG tube was the first and only procedure to thrust an instrument through the abdominal wall into the GI tract percutaneously.↗
▶Ep 4 · 12:55
clinicalEndoscopic tattooing with India ink was developed in 1975 to mark polypectomy sites so surgeons could identify the location if cancer was found on pathology.↗
▶Ep 4 · 13:56
quoteeverybody thinks that everybody's been, everything's been discovered already, that's not true.↗
▶Ep 4 · 15:29
quoteyou wanna know the truth. The truth is that when I was a resident... I said, boy, I'm beat. I wanna have an elective that's a little bit easier.↗
▶Ep 4 · 17:07
quotewhen you see a new technology, whatever that technology is. Investigate it, see if it's something that offers you something that you can uh make it your own and become an expert in it.↗
▶Ep 4 · 17:30
clinicalOlympus fiber-optic endoscopes in the 1970s provided crystal-clear visualization compared to American-made ACMI scopes with joystick controls that were approximately 1 centimeter in diameter and had poor image quality.↗
clinicalFiber-optic endoscopes in the 1970s transmitted images through fiber bundles to the operator's eye, with photographs taken by clipping a camera to the eyepiece, producing small images on film strips.↗
▶Ep 4 · 19:06
clinicalVideo chip technology was introduced around 1980, placing a camera chip at the scope tip and displaying images on a monitor, replacing direct fiber-optic visualization.↗
▶Ep 4 · 19:36
clinicalPediatric patients in the late 1970s could accommodate adult endoscopes approximately 9 millimeters wide, which was the size limit for safe use in infants.↗
▶Ep 4 · 20:56
clinicalEarly endoscope cleaning protocols in the late 1970s used only green soap between procedures, before high-level disinfection or sterilization standards were established.↗
▶Ep 4 · 20:59
quoteAll we did was wash it with green soap in between procedures. We didn't know about high level of sterile disinfection or sterilization then.↗
▶Ep 4 · 21:45
guidelineThe PEG tube received FDA 510(k) approval as a modification of existing gastrostomy tubes used for similar purposes, rather than as an entirely novel device.↗
▶Ep 4 · 22:13
clinicalIndications for PEG tubes expanded beyond feeding to include gastric decompression for gastroparesis or obstruction in carcinomatosis patients, delivery of unpalatable feedings, treatment of gastric volvulus, colonic decompression for Ogilvie syndrome, and sigmoid volvulus fixation.↗
▶Ep 4 · 23:30
quoteI like to think that the endoscope is a tube, uh, it's a, it's a, a vehicle that gets us to where we need to be to perform an operation. That's what we think of as surgeons.↗
▶Ep 4 · 24:38
clinicalAt the 1980 presentation in Salt Lake City to 1,500 attendees, gastroenterologists immediately recognized the PEG tube as a therapeutic procedure they could perform, while surgeons were slower to adopt it due to less familiarity with endoscopy.↗
▶Ep 4 · 26:40
clinicalA properly performed PEG tube placement takes under 5 minutes when done correctly and carefully.↗
▶Ep 4 · 26:58
quoteI want you to use your imagination that some day you will place a patient on a table. And have a machine that uses ultrasound or something, and has a gun that goes in and goes boom, and places that right into the stomach without anything, except maybe a little local↗
▶Ep 4 · 27:19
quoteThe world of imagination and innovation does not end because you have a good procedure.↗
clinicalRadiologists have developed ultrasound-guided gastrostomy tube placement techniques, though Ponsky expresses reservations about the tubes they use.↗
▶Ep 4 · 29:32
guidelineInnovative therapy—minor modifications to existing procedures such as changing suture number or technique—can be performed in the operating room without IRB approval, but systematic study of new procedures requires IRB review.↗
▶Ep 4 · 29:45
quoteIt's called innovative therapy. You can try to alter that procedure. You put in 3 stitches instead of 2.↗
▶Ep 4 · 30:14
quoteIt was an innovation. It was an important innovation because it said to the world that surgical procedures can be accomplished endoscopically.↗
▶Ep 4 · 30:15
opinionThe PEG tube demonstrated that surgical procedures could be accomplished endoscopically and established the endoscope as a surgical instrument for delivering surgery at a distance.↗
▶Ep 4 · 31:19
quoteThe idea of standing back. Looking at the problem and saying, wow, can I approach this problem. In a different way, can I approach it from outside or inside or through the wall?↗
▶Ep 4 · 31:36
quoteDon't think that everything's been thought of already. Otherwise we'd still be with radical mastectomy for breast cancer.↗
▶Ep 4 · 31:44
quoteone day PEG tubes will be of the past, but right now it's a good marker for endoscopic surgery.↗
▶Ep 4 · 32:02
quoteanyone who tells you that there's nothing more to be innovated, that there's no, nothing new coming along the pipe, that this is it. I, uh, somewhat to be avoided.↗
▶Ep 4 · 32:38
quotethe best thing to do is to listen to people who don't know anything about the procedure. When your medical students come in and start asking you questions, uh, that's a good person to listen to because they don't have the barriers, uh, to their thought process that we do.↗
▶Ep 4 · 32:57
quoteyou shouldn't take a chance with patients' lives, but you should take a chance on developing new ideas and new procedures and new instruments.↗
Summaries Jeffrey gave as host
· 88 summaries
Recaps of other experts' statements, not Jeffrey's own clinical position.
Summaries Jeffrey gave as host · Acute Cholecystitis6 summaries
host summaryJeffrey 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.↗
Acute Cholecystitis
▶Ep 2 · 4:21
host summaryJeffrey Ponsky summarizes what Dr. John Rodriguez said: Acute cholecystitis is an obstructive diverticulopathy where the cystic duct becomes obstructed (usually by stone), causing backup of pressure in the gallbladder with decreased blood flow in the wall, and the wall can eventually rupture.↗
Acute Cholecystitis
▶Ep 6 · 4:21
host summaryJeffrey Ponsky summarizes what Dr. John Rodriguez said: Acute cholecystitis is one of several obstructive diverticulopathies where a diverticulum (the gallbladder) off the biliary tree becomes obstructed (usually by a stone), causing pressure backup, decreased wall blood flow, wall thickening, and potential rupture.↗
▶Ep 6 · 18:53
host summaryJeffrey Ponsky summarizes what Dr. John Rodriguez said: Dissection should occur at the junction of the cystic duct and gallbladder, and the cystic artery and gallbladder—not as close to the common duct as possible—to avoid bile duct injury.↗
▶Ep 6 · 27:09
host summaryJeffrey Ponsky summarizes what Dr. John Rodriguez said: There is no magic number of trocars—additional ports should be placed wherever needed for adequate exposure and dissection.↗
Acute Cholecystitis
▶Ep 7 · 18:53
host summaryJeffrey Ponsky summarizes what Dr. John Rodriguez said: Dissection should occur at the junction of the cystic duct and gallbladder, and the cystic artery and gallbladder—not as close to the common duct as possible, which is how you get in trouble.↗
Summaries Jeffrey gave as host · Choledocholithiasis4 summaries
host summaryJeffrey Ponsky summarizes what Dr. John Rodriguez said: Acute cholecystitis is an obstructive diverticulopathy where the cystic duct becomes obstructed (usually by stone), causing backup of pressure in the gallbladder with decreased blood flow in the wall, and the wall can eventually rupture.↗
Acute Cholecystitis
▶Ep 7 · 4:21
host summaryJeffrey Ponsky summarizes what Dr. John Rodriguez said: Acute cholecystitis is one of several obstructive diverticulopathies where a diverticulum (the gallbladder) off the biliary tree becomes obstructed (usually by a stone), causing pressure backup, decreased wall blood flow, wall thickening, and potential rupture.↗
▶Ep 7 · 18:53
host summaryJeffrey Ponsky summarizes what Dr. John Rodriguez said: Dissection should occur at the junction of the cystic duct and gallbladder, and the cystic artery and gallbladder—not as close to the common duct as possible—to avoid bile duct injury.↗
▶Ep 7 · 27:09
host summaryJeffrey Ponsky summarizes what Dr. John Rodriguez said: There is no magic number of trocars—additional ports should be placed wherever needed for adequate exposure and dissection.↗
Summaries Jeffrey gave as host · Cholelithiasis1 summary
host summaryJeffrey Ponsky summarizes what Dr. John Rodriguez said: Dissection should occur at the junction of the cystic duct and gallbladder, and the cystic artery and gallbladder—not as close to the common duct as possible, which is how you get in trouble.↗
Summaries Jeffrey gave as host · Foundations of Minimally Invasive & Endoscopic Surgery38 summaries
host summaryJeffrey Ponsky summarizing a resource: I think you should consider 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.↗
▶Ep 3 · 20:47
host summaryJeffrey Ponsky summarizing a resource: Don't you smell? Go back in and smell that. That's the smell of death.↗
▶Ep 3 · 25:29
host summaryJeffrey Ponsky summarizing a resource: We're not training any surgeons, just forget it.↗
▶Ep 3 · 26:19
host summaryJeffrey Ponsky summarizing a resource: You're not gonna touch this scope.↗
▶Ep 3 · 26:51
host summaryJeffrey Ponsky summarizing a resource: Go buy yourself a Hanukkah present. You got the scope.↗
▶Ep 3 · 45:22
host summaryJeffrey 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.↗
SAGES Stories: Dr. Jeffrey Ponsky on surgical endoscopy and the PEG tube legacy
▶Ep 5 · 8:16
host summaryJeffrey Ponsky summarizing a resource: Jeff, I, 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.↗
▶Ep 5 · 25:22
host summaryJeffrey Ponsky summarizing a resource: we're not training any surgeons↗
▶Ep 5 · 26:19
host summaryJeffrey Ponsky summarizing a resource: you're not gonna touch this scope.↗
▶Ep 5 · 26:51
host summaryJeffrey Ponsky summarizing a resource: go buy yourself a Hanukkah present. You got the scope.↗
▶Ep 5 · 45:22
host summaryJeffrey Ponsky summarizing a resource: the dean of the business school said the first day, he said, 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↗
The invention of the PEG tube with Dr. Jeffrey Ponsky
▶Ep 7 · 9:58
host summaryJeffrey Ponsky summarizing a resource: A Mayo Clinic study by Larson demonstrated that a single perioperative antibiotic dose almost eliminated PEG exit-site infections, establishing perioperative antibiotics as standard practice.↗
▶Ep 7 · 16:13
host summaryJeffrey Ponsky summarizing a resource: we're not gonna train a surgeon to do this. It's ours.↗
▶Ep 7 · 20:07
host summaryJeffrey Ponsky summarizing a resource: they would give me a nurse in the operating room, but they've had this guy, he's doing this wacko procedure.↗
▶Ep 7 · 24:45
host summaryJeffrey Ponsky summarizing a resource: At the 1980 Salt Lake City GI meeting with approximately 1500 attendees, a prominent Mass General surgeon stated he could perform open gastrostomy in 30 minutes and it was not a big deal.↗
▶Ep 7 · 25:00
host summaryJeffrey Ponsky summarizing a resource: Jeff, I have to tell you this is a very cool technique. He said, but I can do a laparoscopic, I, I mean, it wasn't laparoscopic, and he said, I can do a laparotomy and a gastrostomy in a half an hour, and it's not a big deal.↗
▶Ep 7 · 25:24
host summaryJeffrey Ponsky summarizing a resource: At the same 1980 meeting, a world-renowned ERCP expert stated his only comment was 'I wish I had thought of it.'↗
▶Ep 7 · 25:27
host summaryJeffrey Ponsky summarizing a resource: I only have one thing to say to you. I wish I had thought of it.↗
Jeffrey Ponsky: Portrait of a SAGES Pioneer
▶Ep 18 · 5:11
host summaryJeffrey Ponsky summarizing a resource: You will not touch our instruments. We are not going to let a surgeon do endoscopy.↗
▶Ep 18 · 5:58
host summaryJeffrey Ponsky summarizing a resource: Go buy yourself a Christmas present, Hanukkah present. She said, go buy yourself a scope. We're buying it for you.↗
▶Ep 18 · 8:43
host summaryJeffrey Ponsky summarizing a resource: 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.↗
▶Ep 18 · 9:14
host summaryJeffrey Ponsky summarizing a resource: Look, uh, it's a Jewish hospital. You're a Jewish guy and you're a good teacher. Go, go be the chairman over there.↗
▶Ep 18 · 17:36
host summaryJeffrey Ponsky summarizing a resource: We are the same. Like your brother.↗
▶Ep 18 · 35:28
host summaryJeffrey 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.↗
Innovations in Surgery: PEG Tube
▶Ep 26 · 9:58
host summaryJeffrey Ponsky summarizing a resource: A Mayo Clinic study by Larson demonstrated that a single perioperative dose of antibiotic almost eliminated infections around PEG tubes.↗
▶Ep 26 · 9:58
host summaryJeffrey Ponsky summarizing a resource: if a patient was on any antibiotic uh beforehand or a single dose of an antibiotic beforehand, almost eliminated infections around the tubes↗
▶Ep 26 · 9:58
host summaryJeffrey Ponsky summarizing a resource: if a patient was on any antibiotic uh beforehand or a single dose of an antibiotic beforehand, almost eliminated infections around the tubes↗
▶Ep 26 · 9:58
host summaryJeffrey Ponsky summarizing a resource: A Mayo Clinic study by Larson demonstrated that a single perioperative dose of antibiotic almost eliminated infections around PEG tubes.↗
▶Ep 26 · 25:00
host summaryJeffrey Ponsky summarizing a resource: Jeff, I have to tell you this is a very cool technique. He said, but I can do a laparoscopic, I, I mean, it wasn't laparoscopic, and he said, I can do a laparotomy and a gastrostomy in a half an hour, and it's not a big deal↗
▶Ep 26 · 25:00
host summaryJeffrey Ponsky summarizing a resource: Jeff, I have to tell you this is a very cool technique. He said, but I can do a laparoscopic, I, I mean, it wasn't laparoscopic, and he said, I can do a laparotomy and a gastrostomy in a half an hour, and it's not a big deal↗
▶Ep 26 · 25:27
host summaryJeffrey Ponsky summarizing a resource: I only have one thing to say to you. I wish I had thought of it↗
▶Ep 26 · 25:27
host summaryJeffrey Ponsky summarizing a resource: I only have one thing to say to you. I wish I had thought of it↗
▶Ep 26 · 26:33
host summaryJeffrey Ponsky summarizing a resource: people say, well, this is the standard of care now. There's nothing else. This is so easy↗
▶Ep 26 · 26:33
host summaryJeffrey Ponsky summarizing a resource: people say, well, this is the standard of care now. There's nothing else. This is so easy↗
Behind The Knife: The Surgery Podcast / Innovations in Surgery: PEG Tube
▶Ep 27 · 9:51
host summaryJeffrey Ponsky summarizing a resource: A study by Larson at Mayo Clinic demonstrated that a single perioperative dose of antibiotic almost eliminated infections around PEG tube exit sites.↗
▶Ep 27 · 25:00
host summaryJeffrey Ponsky summarizing a resource: Jeff, I have to tell you this is a very cool technique. He said, but I can do a laparoscopic, I, I mean, it wasn't laparoscopic, and he said, I can do a laparotomy and a gastrostomy in a half an hour, and it's not a big deal.↗
▶Ep 27 · 25:27
host summaryJeffrey Ponsky summarizing a resource: I only have one thing to say to you. I wish I had thought of it.↗
▶Ep 27 · 26:33
host summaryJeffrey Ponsky summarizing a resource: people say, well, this is the standard of care now. There's nothing else. This is so easy.↗
Summaries Jeffrey gave as host · Gastroparesis16 summaries
The invention of the PEG tube with Dr. Jeffrey Ponsky
▶Ep 6 · 9:58
host summaryJeffrey Ponsky summarizing a resource: A Mayo Clinic study by Larson demonstrated that a single perioperative antibiotic dose almost eliminated PEG exit-site infections, establishing perioperative antibiotics as standard practice.↗
▶Ep 6 · 16:13
host summaryJeffrey Ponsky summarizing a resource: we're not gonna train a surgeon to do this. It's ours.↗
▶Ep 6 · 20:07
host summaryJeffrey Ponsky summarizing a resource: they would give me a nurse in the operating room, but they've had this guy, he's doing this wacko procedure.↗
▶Ep 6 · 24:45
host summaryJeffrey Ponsky summarizing a resource: At the 1980 Salt Lake City GI meeting with approximately 1500 attendees, a prominent Mass General surgeon stated he could perform open gastrostomy in 30 minutes and it was not a big deal.↗
▶Ep 6 · 25:00
host summaryJeffrey Ponsky summarizing a resource: Jeff, I have to tell you this is a very cool technique. He said, but I can do a laparoscopic, I, I mean, it wasn't laparoscopic, and he said, I can do a laparotomy and a gastrostomy in a half an hour, and it's not a big deal.↗
▶Ep 6 · 25:24
host summaryJeffrey Ponsky summarizing a resource: At the same 1980 meeting, a world-renowned ERCP expert stated his only comment was 'I wish I had thought of it.'↗
▶Ep 6 · 25:27
host summaryJeffrey Ponsky summarizing a resource: I only have one thing to say to you. I wish I had thought of it.↗
Innovations in Surgery: PEG Tube
▶Ep 7 · 9:58
host summaryJeffrey Ponsky summarizing a resource: A Mayo Clinic study by Larson demonstrated that a single perioperative dose of antibiotic almost eliminated infections around PEG tubes.↗
▶Ep 7 · 9:58
host summaryJeffrey Ponsky summarizing a resource: if a patient was on any antibiotic uh beforehand or a single dose of an antibiotic beforehand, almost eliminated infections around the tubes↗
▶Ep 7 · 25:00
host summaryJeffrey Ponsky summarizing a resource: Jeff, I have to tell you this is a very cool technique. He said, but I can do a laparoscopic, I, I mean, it wasn't laparoscopic, and he said, I can do a laparotomy and a gastrostomy in a half an hour, and it's not a big deal↗
▶Ep 7 · 25:27
host summaryJeffrey Ponsky summarizing a resource: I only have one thing to say to you. I wish I had thought of it↗
▶Ep 7 · 26:33
host summaryJeffrey Ponsky summarizing a resource: people say, well, this is the standard of care now. There's nothing else. This is so easy↗
Behind The Knife: The Surgery Podcast / Innovations in Surgery: PEG Tube
▶Ep 8 · 9:51
host summaryJeffrey Ponsky summarizing a resource: A study by Larson at Mayo Clinic demonstrated that a single perioperative dose of antibiotic almost eliminated infections around PEG tube exit sites.↗
▶Ep 8 · 25:00
host summaryJeffrey Ponsky summarizing a resource: Jeff, I have to tell you this is a very cool technique. He said, but I can do a laparoscopic, I, I mean, it wasn't laparoscopic, and he said, I can do a laparotomy and a gastrostomy in a half an hour, and it's not a big deal.↗
▶Ep 8 · 25:27
host summaryJeffrey Ponsky summarizing a resource: I only have one thing to say to you. I wish I had thought of it.↗
▶Ep 8 · 26:33
host summaryJeffrey Ponsky summarizing a resource: people say, well, this is the standard of care now. There's nothing else. This is so easy.↗
Summaries Jeffrey gave as host · Pancreatitis1 summary
host summaryJeffrey 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.↗
Summaries Jeffrey gave as host · Psychomotor Retardation22 summaries
host summaryJeffrey Ponsky summarizing a resource: I think you should consider 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.↗
▶Ep 1 · 20:47
host summaryJeffrey Ponsky summarizing a resource: Don't you smell? Go back in and smell that. That's the smell of death.↗
▶Ep 1 · 25:29
host summaryJeffrey Ponsky summarizing a resource: We're not training any surgeons, just forget it.↗
▶Ep 1 · 26:19
host summaryJeffrey Ponsky summarizing a resource: You're not gonna touch this scope.↗
▶Ep 1 · 26:51
host summaryJeffrey Ponsky summarizing a resource: Go buy yourself a Hanukkah present. You got the scope.↗
▶Ep 1 · 45:22
host summaryJeffrey 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.↗
SAGES Stories: Dr. Jeffrey Ponsky on surgical endoscopy and the PEG tube legacy
▶Ep 2 · 8:16
host summaryJeffrey Ponsky summarizing a resource: Jeff, I, 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.↗
▶Ep 2 · 25:22
host summaryJeffrey Ponsky summarizing a resource: we're not training any surgeons↗
▶Ep 2 · 26:19
host summaryJeffrey Ponsky summarizing a resource: you're not gonna touch this scope.↗
▶Ep 2 · 26:51
host summaryJeffrey Ponsky summarizing a resource: go buy yourself a Hanukkah present. You got the scope.↗
▶Ep 2 · 45:22
host summaryJeffrey Ponsky summarizing a resource: the dean of the business school said the first day, he said, 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↗
The invention of the PEG tube with Dr. Jeffrey Ponsky
▶Ep 3 · 9:58
host summaryJeffrey Ponsky summarizing a resource: A Mayo Clinic study by Larson demonstrated that a single perioperative antibiotic dose almost eliminated PEG exit-site infections, establishing perioperative antibiotics as standard practice.↗
▶Ep 3 · 16:13
host summaryJeffrey Ponsky summarizing a resource: we're not gonna train a surgeon to do this. It's ours.↗
▶Ep 3 · 20:07
host summaryJeffrey Ponsky summarizing a resource: they would give me a nurse in the operating room, but they've had this guy, he's doing this wacko procedure.↗
▶Ep 3 · 24:45
host summaryJeffrey Ponsky summarizing a resource: At the 1980 Salt Lake City GI meeting with approximately 1500 attendees, a prominent Mass General surgeon stated he could perform open gastrostomy in 30 minutes and it was not a big deal.↗
▶Ep 3 · 25:00
host summaryJeffrey Ponsky summarizing a resource: Jeff, I have to tell you this is a very cool technique. He said, but I can do a laparoscopic, I, I mean, it wasn't laparoscopic, and he said, I can do a laparotomy and a gastrostomy in a half an hour, and it's not a big deal.↗
▶Ep 3 · 25:24
host summaryJeffrey Ponsky summarizing a resource: At the same 1980 meeting, a world-renowned ERCP expert stated his only comment was 'I wish I had thought of it.'↗
▶Ep 3 · 25:27
host summaryJeffrey Ponsky summarizing a resource: I only have one thing to say to you. I wish I had thought of it.↗
Behind The Knife: The Surgery Podcast / Innovations in Surgery: PEG Tube
▶Ep 4 · 9:51
host summaryJeffrey Ponsky summarizing a resource: A study by Larson at Mayo Clinic demonstrated that a single perioperative dose of antibiotic almost eliminated infections around PEG tube exit sites.↗
▶Ep 4 · 25:00
host summaryJeffrey Ponsky summarizing a resource: Jeff, I have to tell you this is a very cool technique. He said, but I can do a laparoscopic, I, I mean, it wasn't laparoscopic, and he said, I can do a laparotomy and a gastrostomy in a half an hour, and it's not a big deal.↗
▶Ep 4 · 25:27
host summaryJeffrey Ponsky summarizing a resource: I only have one thing to say to you. I wish I had thought of it.↗
▶Ep 4 · 26:33
host summaryJeffrey Ponsky summarizing a resource: people say, well, this is the standard of care now. There's nothing else. This is so easy.↗
