PEG - Ponsky

PEG was developed in 1979 at University Hospitals of Cleveland by Jeffrey Ponsky and Michael Goulder while performing endoscopy on pediatric patients.

During pediatric endoscopy, light was observed shining through the abdominal wall, indicating short distance between stomach and abdominal wall.

Early PEG indications were limited to feeding in patients with neurological impairment; indications have since expanded to include supplemental feedings, gastrointestinal decompression, and delivery of unpalatable medications.

Direct pressure on the abdomen during endoscopy is the best method to identify where the stomach is in closest contact with the abdominal wall, superior to transillumination alone.

The safe-track technique, described by gastroenterologist Greg Fauch, involves aspirating with the needle during advancement; if air is obtained before endoscopic visualization of the needle tip in the stomach, the needle is in the wrong location and should be withdrawn.

Combined gastrostomy-jejunostomy was originally indicated for patients with gastric atony, esophageal reflux, and aspiration.

Original gastrostomy tubes were constructed from locally available materials including Day Pezzar catheter, Bunsen burner tubing, Medi-Cut catheter, and silk suture.

Modern PEG tubes are made of silicone with large head bolsters, which is much less irritating than the original latex material.

Single-dose prophylactic antibiotics preoperatively prevent wound infection after PEG placement and have become routine practice.

Excessive traction on PEG tubes causes ischemia of intervening tissue and premature tube extrusion.

Transcolonic PEG placement can occur as a complication; if the patient has done well, the tube can remain in place temporarily, the colonic opening will close spontaneously after removal, and a new PEG can be placed.

When replacing a PEG tube, the stomach can be disrupted from the abdominal wall; contrast injection should be performed when in doubt, and if contrast is seen in the peritoneal cavity, operative intervention is required to clean out the abdomen.

Patients with short lifespan, severe malnutrition, sepsis, or multi-organ failure are poor candidates for PEG and should be treated and stabilized before the procedure is considered.