PEG - Ponsky

Oh my god, it's Simon Clark calling me. Hey Simon, it's Todd. Oh, really? Babs is doing a whole session on gastrostomy, and you want to do a lecture on the evolution of PEG? Oh my god, I'd be so honored to It's not me you want? It's my dad. No, yo, makes total sense. Yep, absolutely. I'm on it, Simon. Thanks. All right, talk to you later. Here we go. We're going to talk about the evolution of PEG. Who better to do that than my father, Dr. Jeffrey Ponsky, who along with Michael Goulder invented one of the most novel procedures of its time. So, hey dad, how did this and when did this all start? In 1979, I was doing general surgery and gastrointestinal endoscopy, University Hospitals of Cleveland. I had the opportunity to work with wonderful pediatric surgeons, like Robert Ivantz and Michael Goulder. And we were seeing a lot of children at that time without pediatric gastroenterologists. We had the opportunity to do endoscopy on a lot of these children and that led to the development of percutaneous endoscopic gastrostomy. This is Michael and I about 40 years ago, and this is I, Michael and I more recently. Uh this is one of our first patients and when we endoscope these patients, we found that they had light shining through their abdomen. Now Michael was a very innovative man who was always looking for a new way to perform a gastrostomy and other procedures as well. We got together and decided there might be a way to combine endoscopy with percutaneous techniques to achieve that purpose. Okay, so this is really the cool part. They basically were doing an endoscopy in a small child and they saw the light shining through, and they knew there must be a short distance between the abdominal wall and the stomach, and that's what gave them the idea that they could do this percutaneously. So in the early days, PEG was done just for feeding in patients with neurological impairment and over the years it's uh indications have expanded including supplemental feedings, uh gastrointestinal decompression and delivery of unpalatable medications. How is this performed? Originally, we did the pull method, which we'll describe and variations of this method have been developed. Okay, so how do you start off? The most important thing is the location of the exact site of the gastrostomy. Okay, so this is the part I don't get. How do you know exactly from the outside where to put the tube in that would be at the right place on the inside? Do you just look to see where the light's shining through on the abdominal wall and that's where you put the G tube in? And Michael and I found although we like the transillumination, direct pressure on the abdomen was perhaps the best because it showed you exactly where the stomach was in closest contact with the abdominal wall. Greg Fauch, a gastroenterologist in the United States described the safe track technique, where we aspirate with the needle as we go in, looking for air. If we should get air before we hit the stomach endoscopically, we know we're in the wrong place and we pull the needle out, but we look for this air in the needle. Okay, so that was a really important point. So I want to repeat it again, this safe track technique. The idea is one person's on the outside with a syringe and needle, slowly advancing from the abdominal wall into the stomach and they're pulling up on the syringe. The person who's watching with the endoscope should see the tip of the needle enter the stomach at the same time that the other person receives air in the syringe. If they receive air first, that means you're probably not in the stomach, you may be in the colon and you should start over again. But the other cool thing is they can tell exactly with the needle where the position of the G tube will be on the stomach. Once we're in the stomach, we pass a suture into the uh stomach, we capture it with a snare and pull it out through the patient's mouth. And these are the original drawings from the original technique. Okay, okay, so I get it. I know how we find the exact location where to put the tube. But the suspense is killing me. How do you do the technique? What is this pull technique? And by the way, Dad, can you be quick because we only have a few minutes left in this lecture. Once the suture is brought out through the patient's mouth, of course, it's affixed to the end of a tube, a gastrostomy catheter and pulled down through the esophagus and out through the abdominal wall while followed with the gastroscope. That was an amazing history on how this all started, but what they want to hear today is how did the PEG tube evolve over time? So, what happened next? We thought, wow, if we can put in a tube into the stomach, what if there is a patient who needs gastric decompression in concert with jejunal feeding? And we see some of these. So we combined a Daboff tube with jejunal feeding tube alongside a gastrostomy tube and published this paper in 1984, where we would drop the jejunal portion into the duodenum and let gravity take it down. Okay, I get it. So you basically have a PEG in the stomach and a feeding tube in the jejunum. When would you need this? And this was done for patients with gastric athany, esophageal reflux and aspiration. Wait, so sometimes you have a PEG in the stomach just for the purpose of aspirating out gastric contents? We have expanded these today and found that maybe aspiration is not a good indication as these patients can still aspirate from gastric content. And here you can see the jejunal tube taken by peristalsis into the proximal jejunum. In addition to this, people have expanded this technique of PEG to perform direct puncture of the jejunum, as you can see the scope deep into the jejunum here in the exact same manner as we perform PEG. So what about the design of the PEG tube? How has that evolved over time? The original gastrostomy tubes were made out of things that we found locally, like a Day Pezzar catheter and a piece of Bunsen burner tubing and a Medi-Cut catheter and some silk suture. More recently, the tubes have been designed with a large head bolster and made of silicone, which is much less irritating than the latex. And many companies have made these tubes. Dr. Goulder, again, a very innovative man, developed a one-step button where we could develop a skin level device, which could be pulled through in the same manner as a PEG tube, but then by pulling a string at the after delivery of the tube through the abdominal wall, we could turn this into a skin level gastrostomy tube. All right, Dad, I get this. You're talking about a long PEG tube though. And most of us are pediatric surgeons. We want something small, short, something that's at skin level. So a number of devices are made including skin level buttons and balloon devices called the Mickey device, which can be used to replace the original gastrostomy catheter. This is actually great and I will tell you that personally I normally perform a laparoscopic gastrostomy tube. I don't usually do endoscopic gastrostomy tubes in little babies. But when I have a larger patient, I find that the primary buttons are hard. So I usually will do a PEG tube in those patients. But I have a question, Dad. Is there a way to put in a PEG tube, but leave it only as a short skin level device by the time you're done with the procedure? Another innovation that Dr. Goulder himself made was to shorten an existing gastrostomy tube and then put in a uh plastic valve, and this was called the genie device. It's not widely used anymore, but this allowed an original gastrostomy tube to actually be used as a skin level device. All right, so Dad, this device is amazing, but and it never has complications, right? I mean, it works perfectly all the time, right? What about complications from the PEG tube? Initially, we worried about wound infection because we didn't know that a single dose of an antibiotic preoperatively would prevent such infection. And so that's become routine. But peritonitis and catheter migration, even gastrocystic fistula can occur. This was an early peritubal infection which could be drained with a little local and an 11 blade draining the abscess, but these rarely occur since using prophylactic single dose antibiotics. But here we see that the tube is migrating through the abdominal wall because it's on excessive traction. And if we learned anything, it's to not put these tubes on excessive traction. It causes ischemia of the intervening tissue and causes them to extrude prematurely. This is a tube that was placed through the colon and unfortunately, occasionally a transcolonic PEG can occur. And by the way, if we did laparoscopic gastrostomy tubes instead of PEGs, this would also never happen, just saying. If the patient has done well, we can let this stay for a while and then remove it. The colonic opening will close spontaneously and a new PEG can be placed. If you say so. When replacing a PEG tube, occasionally we can sometimes disrupt the the stomach from the abdominal wall. When in doubt, injection of the tube is important and here we see fluid in the peritoneal cavity, contrast in the peritoneal cavity, which means we have to operate on this patient to clean out the abdomen. All right, so great invention, great device. Do you think we put these in a little too much? We have to consider if we really need to do a PEG in somebody. Patients who have a short uh lifespan, severe malnutrition or who have sepsis or multi-organ failure are poor candidates for the procedure. They should be uh treated and gotten into better shape before this is ever considered. It is never an emergency to do a PEG. So what we have to learn in addition to doing PEG is occasionally to say no to PEG and to do these when they're well indicated so that we get the best results. Thank you very much. So there you have it, Babs, the history and the evolution of the percutaneous endoscopic gastrostomy. Thank you very much for the incredible honor to present today.