Hey there, it's Rod Gerardo from Cincinnati Children's. If you haven't already, download the Stay Current in pediatric surgery app. You can listen to podcasts just like this, start discussions with other surgeons, check out guidelines, videos, you name it. But in the meantime, enjoy the episode. There's so many. Surgical procedures and devices out there today that are just ubiquitous across multiple specialties or fields. You know, think about the procedure or the device that's so intuitive or simple, it just makes sense that you probably use it every day or multiple times a week. For me, that's. The PEG tube, or the percutaneous endoscopic gastrostomy tube. I mean, it was one of the first cases that I ever got to do. And I think very rarely do we stop after the procedure and Question How did this even become a thing? Like who is the surgeon? Who was brave enough or maybe just crazy enough. To Actually try it Well, when it comes to the peg, I'm lucky enough that I got to talk to that surgeon. We took those babies, and we talked to the mothers, and we told them, we will try this. If it doesn't work, uh, we'll do the standard laparotomy. That's Doctor Jeffrey Ponsky. He is a professor of surgery at the Cleveland Clinic. And the pioneer who helped to invent the PEG tube. So, if you're like me and you're a nerd for surgical history, then let's talk. About endoscopes, feeding tubes. And Jeff Um, All right, what did, did you do endoscopy today? All day, yeah, that's what I do, Todd. That is Jeff and his son Todd Ponsky. We set up a Zoom call together and got to talking. Jeff actually listens to my podcast. Yeah, don't quit your day job though. Our interview was littered with jokes like that, because I, I didn't want to put you on the spot and, you know, make you talk for 20 minutes necessarily because I know you, I can talk for 30 hours without stopping. No, no, no, no, no filibuster, it's no problem, whatever you want. He's smiling, he's laughing, he's sitting in his living room still in scrubs after a full day of endoscopy. But he's still gracious enough to sit down and take us back. To 1974. Well, when I was a resident in surgery, we, uh, we weren't given years off to do research. We were given a number of months to uh have an elective. And uh I had been on a very busy services, because at that time, the residents were on call 36 hours on and 12 hours off for 5 years. And it was a real uh gift to be able to take a little bit of time off and have an elective, but I wanted to have an elective that was a little less stressful, and I saw the gastroenterologist fussing around with some new instrument that was called an endoscope, flexible endoscope, and I thought, wow, that would be a great way to spend a few months. Just to uh to get an easier rotation and learn a little bit about this new technology, but I wasn't highly motivated. I can't even imagine trying to log his hours into the ACGME's websites, but I don't blame him, he wanted an easy elective. So Then what? And then about a week before, I called up and I spoke to the chairman of the department uh at university Hospital and said I'd like to come, and he said, I found out you're a surgeon, you're not touching an endoscope at our uh institution, you're not going to be trained. Oof. So This is probably the part in the story where any reasonable general surgery resident would say, OK, I'm just gonna pick a different elective. Jeff didn't do that, he calls the program's chief of general surgery. And it's like, hey, look, they're not gonna, they don't want to teach the competition here. So the chief said. Don't worry about it. Let me call someone for you. So we called him, his name was Jim King, and he was, he had started essentially gastroenterology in Canton, Ohio. He said, I'd love to train this guy. So I literally drove every single day for, it turned out to be almost 5 or 6 months, uh, back and forth from Cleveland to Canton, Ohio, every single day, uh, to amuse myself, I listened to audio tapes of of uh meetings, of surgical meetings called Audio Digest. I cleaned out the library and listened to them on the way there and back. I like to tell myself who would have listened to the Stay Current podcast if it were available, but I digress. When I came back, I had done probably 500 cases. You heard that right, 500 cases in like 5 or 6 months. Now, those are some numbers that I would like to log into ACGME. And I went to the chief of gastroenterology, and said to him, uh, could I help train your, your residents in the endoscopy, cause I really know how to do it now. And he said, you will not touch a scope at this institution. That is a tough 2nd hit there. So now he's got all the skills of an endoscopist. But he's a PGY4 on a resident salary. I mean, it's not like he can go buy a scope. So What was he left to do? A few months after returning from training, I was at a party with my family, and I was relating the story to my family about what had happened, and uh the next day I got a call from my mother-in-law, who said to me, go buy a scope, it's your Hanukkah present. I don't know any resident who owns their own endoscope. I mean, where would you even store that? And I kept that scope, we didn't have the, the high-level disinfection or the machines to clean them that we have now. I kept it in the trunk of my car, with a light source, and I would go where I was called to go in the program. So you have this 4th year surgery resident, run around Cleveland with a scope in the trunk of his car. And he basically. Provided an on-call after hours service to the hospital, he said, hey, attendings, if you need a scope in the middle of the night, just give me a call, GI bleed, whatever you got, I will come in with my own scope, and, I will check out your patient. By the time I had finished my residency, I was literally doing most of the private endoscopies at the university hospital. So now it's 1976, and Jeff is done with his residency and university hospitals, noticing that he's taking all this endoscopic business, they hire him on his faculty, and lucky for Jeff, they let him start a section specifically for endoscopy, but, There's no pediatric gastroenterology, that's like not a thing at this time. So he kind of works in collaboration with some pediatric surgeons, including a young pediatric surgeon named Michael Gauderer. And uh one day, he came to me cause we had seen this light through the baby's belly, and he said, you know, I've been thinking for a while, there must be a better way, a simpler way to do a, a gastrostomy. How can we do this? Inspired by that intraoperative transillumination that they saw, the two of them sit down and they write up the plans for the PEG tube. The procedure, the device, they come up with how they want to do this. Now, today, I mean, if you have an idea, you just 3D print a prototype, right? No. Todd runs off screen, and he grabs for me what seems to be a framed version of the first PEG tube. Uh, it looks like pieces and parts. There's a mushroom tip, there's a rubber catheter that, uh, I'll let Jeff explain it. Take a, a deep pezzer catheter, which is a mushroom catheter, which we use in surgery, made of rubber, and to modify one end of it, so it could act like a dilator. And take a medic cut IV catheter and puncture the abdominal wall. In 1979, I think it was in May, we performed this in a in a neonate. That following year in 1980, they published their technique in the Journal of Pediatric Surgery. And to this day, it's one of the most cited Journal of Pediatric Surgery articles ever published. And on top of that, Hundreds of thousands of PEG tubes are placed annually, just in the US alone. What's ironic is I just received an email from one of my residents at an outlying suburban hospital, who saw a patient that's 41 years old. The patient was accompanied by his mom, who explained that way back when Jeff and Doctor Gowerer actually. Put this peg in when he was a neonate, when he was a baby, and I'm still feeding him with it today. Wait a second. You said he's 41 years old? That's correct. I jumped up in my chair because I had to do a little bit of math in my head, but. That was 1979. This was one of Jeff's first PG patients, and he's still out there and he's still using the gastrostomy tube. But the other thing, Rod, that I want to point out is when you have a new technology in your hand, you turn that that innovation over and over in front of you in your mind, and say, what else can I do with this innovation? I was initially really excited to do this interview because I thought we were putting together this really cool history lesson, but, what I ended up with was this lesson on innovation, and, A little bit on humility, because as much as I tried to put credit to Doctor Ponsky and his work with the PEG tube, He would always circle back to his mentors and the people who gave him opportunities to go out a limb on these crazy ideas. So I think that there's more to unpack with this story than just the PEG tube. And we're looking forward to making more episodes like this for you. So if you haven't already, download the Stay Current Pediatric Surgery app, you can listen to podcasts like this, watch technique videos, look up guidelines, anything you need right there at your fingertips. Until next time, remember, knowledge should be free.
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