From
Dr. Jeffrey Ponsky
Innovations in Surgery: PEG Tube
With Dr. Jeffrey Ponsky · hosted by Dr. Dan Shea
Part of
Gastroparesis 8 items
Chapter 1 of 9 · Fundamentals
PEG origins
Origins of the PEG Tube: Transillumination and First Cases
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Ponsky purchased his own Olympus endoscope with financial help from his mother-in-law after being told surgeons could not use gastroenterology equipment.
No pediatric gastroenterologists existed in Cleveland in the mid-1970s, creating an opportunity for Ponsky to perform pediatric endoscopy.
Transillumination 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.
The initial PEG tube was constructed using a Foley catheter (depezar catheter), sutures, and an IV catheter called a medicut as a dilator.
The 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.
Informed consent for the first PEG procedures involved telling mothers that if the new technique failed, an immediate laparotomy would be performed.
The PEG tube procedure was developed in May 1979 by Jeffrey Ponsky and Michael Gower at University Hospitals of Cleveland.
Laboratory studies on PEG tract formation were conducted after the initial clinical cases, reversing the typical research sequence.
Multiple medical device companies initially refused to manufacture the PEG tube, believing nobody would use it.
A small company in Mentor, Ohio eventually manufactured the PEG tube exactly as designed, without patent protection being pursued.
Colonic perforation can occur during PEG placement if the tube goes through the colon on the way to the stomach, though this is rare.
Exit-site infection was a major complication of PEG placement initially.
PEG tubes evolved from multi-piece rubber construction to one-piece silicone, with few modifications after the first few years.
The PEG tube was the first time any instrument or needle was thrust through the abdominal wall into the GI tract and left there.
Endoscopic tattooing with India ink was developed in 1975 to mark polypectomy sites, allowing surgeons to locate the resection area if cancer was found.
Ponsky was initially denied endoscopy training as a surgical resident in the mid-1970s because gastroenterologists claimed the field as their exclusive domain.
American Cystoscope Makers Incorporated (ACMI) produced early endoscopes with joystick controls and poor image quality compared to Japanese Olympus scopes.
Early fiber-optic endoscopes required direct eye-to-lens visualization with images carried by fiber bundles, and photographs were taken on small film strips.
Video chip camera technology emerged around 1980, placing a camera at the scope tip and displaying images on monitors.
Pediatric patients could tolerate adult endoscopes approximately 9 millimeters wide in the late 1970s.
Early endoscope cleaning consisted only of washing with green soap between procedures, without high-level disinfection or sterilization.
The 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.
PEG indications expanded beyond feeding to include gastric decompression for gastroparesis or obstruction in carcinomatosis patients, delivery of unpalatable feedings, and management of gastric volvulus.
The PEG technique was adapted for colonic use in sigmoid volvulus and Ogilvie syndrome decompression.
At the 1980 Salt Lake City presentation to 1,500 attendees, a Mass General surgeon stated he could perform open gastrostomy in 30 minutes.
A prominent ERCP expert told Ponsky at the 1980 presentation that he wished he had thought of the PEG technique.
Gastroenterologists adopted the PEG procedure first as a therapeutic endoscopic technique, while surgeons were slower to adopt it due to less familiarity with endoscopy.
PEG tube placement takes under 5 minutes when performed correctly and carefully.
Radiologic PEG placement exists using ultrasound guidance, though Ponsky prefers the endoscopic tube design.
A Mayo Clinic study by Larson demonstrated that a single perioperative dose of antibiotic almost eliminated infections around PEG tubes.