From
Dr. Jeffrey Ponsky
The invention of the PEG tube with Dr. Jeffrey Ponsky
With Dr. Jeffrey Ponsky · hosted by Dr. Dan Shea
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
In 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.
During 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.
The 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.
The 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.
Informed consent for the first PEG cases consisted of telling mothers that if the new technique failed, immediate laparotomy and open gastrostomy would be performed.
The first PEG procedures succeeded easily within a few minutes.
After 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.
Laboratory 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.
John Mellinger, who later worked at the American Board of Surgery, conducted original research on PEG tract formation.
Multiple medical device companies refused to manufacture the PEG tube initially, believing nobody would use it.
A small company in Mentor, Ohio eventually manufactured the PEG tube exactly as designed by Ponsky and Gower.
Ponsky and Gower never patented the PEG tube; they were more interested in publication than patents and wanted to disseminate the technique.
PEG tube complications included rare colonic perforation when the tube traversed the colon en route to the stomach, which still occurs rarely today.
Exit-site infection was a major early PEG complication.
PEG 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.
The PEG technique has remained very much the same as the original with only a few modifications.
Ponsky and the manufacturing company conducted dozens of animal experiments to determine tube removal pressure, tip retention, and optimal tube size for FDA approval.
The 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.
In 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.
In the late 1970s, surgical residents were on call every other night (36 hours on, 12 hours off) for five years of training.
In 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.
Japanese companies (Mashida and Olympus in the US) produced fiber-optic endoscopes with crystal-clear optics that were markedly superior to American models.
1970s 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.
Teaching attachments for 1970s endoscopes consisted of a wire-connected second eyepiece that provided a dim image for trainees in darkened rooms.
Around 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.
In the late 1970s, neonates could tolerate endoscopes approximately 9 millimeters wide, which was the limit for safe use.
The original PEG procedure was performed with an adult endoscope.
In the 1970s, endoscopes were cleaned between procedures using only green soap; high-level disinfection and sterilization protocols did not yet exist.
The 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.
PEG indications expanded beyond feeding to include gastric decompression in gastroparesis or obstruction (including carcinomatosis), delivery of unpalatable feedings, and treatment of gastric volvulus.
The PEG technique was adapted for colonic applications including sigmoid volvulus fixation and Ogilvie syndrome decompression, with multiple PEGs used for sigmoid volvulus.
Many endoscopic procedures developed by surgeons, including PEG, were extensions of surgical operations already performed via laparotomy.
Gastroenterologists rapidly adopted PEG as a therapeutic procedure they could easily accomplish, driving widespread dissemination.
Surgeons 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.
A properly performed PEG procedure takes under 5 minutes when done carefully by an experienced operator.
Current PEG procedures still require patient sedation or anesthesia and constitute an intervention.
Radiologists perform gastrostomy tube placement using ultrasound guidance, though Ponsky does not prefer the tubes they use.
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.
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.
At the same 1980 meeting, a world-renowned ERCP expert stated his only comment was 'I wish I had thought of it.'