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Percutaneous endoscopic gastrostomy—20 Years later: A historical perspective
Percutaneous Endoscopic Gastrostomy--20 Years Later: A Historical Perspective By Michael W.L. Gauderer Greenville, South Carolina
Background/Purpose: Percutaneous endoscopic gastrostomy (PEG), initially developed for children with inability to swallow, had its first presentation at the annual meeting of the American Pediatric Surgical Association in Florida in 1980. Based on the novel concept of the sutureless approximation of a hollow viscus to the abdominal wall, this minimally invasive procedure has become the standard for direct gastric access worldwide. This report is a brief retrospective about the evolution of PEG and the expanded applications of the surgical concept on which it is based. Methods: Information related to PEG was obtained from personal records, a focused literature search, and data from various registries and the industry.
Results: The search identified 836 peer-reviewed publications directly related to PEG. The original Journal of Pediatric Surgery article has received 483 bibliographic citations. The procedure has had a profound impact on nutritional management, particularly among adult patients. Over 216,000 PEGs are performed annually in the United States. Twelve major manufacturers produce PEG or PEG-related enteral
AY 2000 marks the 20th anniversary of the initial presentation of the percutaneous endoscopic gastrostomy (PEG) before the 1 lth Annual Meeting of the American Pediatric Surgical Association, Marco Island, Florida. 1 The technique paper, followed by a short movie, introduced a novel concept: the sutureless approximation of a hollow viscus to the abdominal wall by means of a catheter placed without a celiotomy. The rapidly evolving (then new) field of flexible endoscopy had permitted fulfillment of the criteria set forth earlier2 for a simple yet safe gastrostomy: control of the site of placement in the stomach, protection of surrounding organs, and a reliable approximation of gastric and abdominal wall serosal surfaces. Although originally developed for children, PEG was almost immediately adopted by adult gastroenterologists and general surgeons familiar with endoscopy. Soon pediatric gastroenterologists began using it, but it was only gradually accepted by pediatric surgeons. In the 2 decades since its introduction, PEG has facilitated patient care through improved nutritional management and changed the way we look at enteral access. The term PEG has become a household word, almost synonymous with gastrostomy. However, the scope of this acceptance also has generated
M
Journal of Pediatric Surgery, Vol 36, No 1 (January), 2001: pp 217-219
access devices. Select expanded applications of PEG and its principle include indications beyond feeding, use in high-risk patients, percutaneous jejunostomy, percutaneous cecostomy, correction of gastrostomy leakage and gastric volvulus, multiple PEG portals for intragastric interventions, and laparoscopically assisted gastrostomies.
Conclusions: Over 20 years, percutaneous endoscopic gastrostomy has experienced exponential growth. Improved guidelines and technical refinements have added to its safety. The concept on which it is based has created a ripple effect and led to numerous applications beyond gastric access for feeding. In an era when so many of our procedures are adopted from "adult" general surgery, it is worthwhile to have an historical perspective on PEG, a technique that originated in pediatric surgery. J Pediatr Surg 36:217-219. Copyright © 2001 by W,B. Saunders Company. INDEX WORDS: Percutaneous endoscopic gastrostomy, gastrostomy, enteral access.
concerns about overutilization. The aim of this report is to provide an analytical look at a new procedure's rapid growth and its implications. MATERIALS AND METHODS Information related to PEG was obtained from personal records, files and publications, a focused literature search (MedLine-PEG as subject, limited to human subjects only), data obtained from various registries, and the industry (IMS America, Plymouth Meeting, PA).
RESULTS
Percutaneous endoscopic gastrostomy has been accepted worldwide, an extensive experience has been gained, and a large body of literature has accrued. A search of the literature since the publication of the From the Department of Pediatric Surgery, The Children's Hospital, Greenville Hospital System, Greenville, SC. Presented at the 31st Annual Meeting of the American Pediatric Surgical Association, Orlando, Florida, May 25-29, 2000. Address reprint requests to Michael W.L. Gauderer, MD, Chief Department of Pediatric Surgery, The Children's Hospital, Greenville Hospital System, 890 W. Faris Rd, Suite 440, Greenville, SC 29605. Copyright © 2001 by W.B. Saunders Company 0022-3468/01/3601-0040503.00/0 doi: 10.1053/jpsu.2001.20058 217
218
MICHAEL W.L. GAUDERER
original article in the Journal of Pediatric Surgery 1 identified 2,438 indexed articles listing the term gastrostomy. When the terms percutaneous gastrostomy and percutaneous endoscopic gastrostomy were queried, 1,007 and 836 articles, respectively, were retrieved. Articles comprised a wide range from simple technical notes and letters to the editor to large series, comparative studies and subject reviews. Among these is a recent publication by the American Society for Gastrointestinal Endoscopy that provides a concise "state-of-the-art" overview with references and addresses indications, contraindications, techniques, complications, and comparison with surgical gastrostomy? The original Journal of Pediatric Surgery article 1 received 483 bibliographic citations. A detailed account of the origin and evolution of the PEG concept was published recently. 2 The original "pull" technique 1,4,5 remains the most widely used approach. Variations include the "push" technique, 6 the "introducer" method, 7 and a nonendoscopic, radiologically controlled procedures, s More recently, laparoscopically aided PEGs have been added. 9 Over 216,000 PEGs are performed annually in the United States alone. These patients were 211,000 adults and 5,000 children. PEG is, therefore, the second most common indication for upper tract endoscopy in this country. Feeding remains the primary indication. The procedure is most often performed in the elderly, l° Twelve major manufacturers produce PEG or PEGrelated enteral access devices. Select expanded applications of PEG and its principle include broader feeding and medication-related indications such as nutritional support for patients with oropharyngeal abnormalities, inflammatory bowel disease, cardiac lesions, or trauma, 3,11 continuous nighttime enteral feedings, H and administration of nonpalatable medications or dietll; use in high-risk patients for feeding ~2 or decompression,13 and in those who have undergone previous abdominal surgeryl4; percutaneous jejunostomy, either indirectly is or directly9; percutaneous cecostomy for decompression ~6 or antegrade bowel irrigationl7; correction of gastrostomy leakageJ s gastric volvulus, 19 and temporary control of colostomy prolapse2°; placement of multiple PEG portals to permit intragastric surgical interventions, such as drainage of pancreatic pseudocysts through cyst gastrostomy, control of hemorrhage, resection of polyps, and removal of bezoars21; and development of techniques combining PEG with laparoscopically assisted procedures.3, 9 DISCUSSION The first presentation about PEG at the American Pediatric Surgical Association meeting 20 years ago was received with great interest and curiosity by the younger
colleagues in the audience, but it evoked skepticism fi'om senior members. In general, pediatric surgeons were slow to accept this procedure, which originally had been developed for children, probably because few were performing flexible endoscopy at that time. Indeed, when an experience with 220 pediatric patients was presented at the American Pediatric Surgical Association meeting 10 years later, criticism and even disapproval were a part of the discussion that ensued. 11 Conversely, the second presentation about PEG at the American Society for Gastrointestinal Endoscopy 4 was followed by great enthusiasm. Gastroenterologists and general surgeons performing endoscopy embraced PEG with astonishing rapidity, recognizing the procedure's advantages: general anesthesia usually is not required (for adults), abdominal relaxation is not essential, the procedure can be done in patients with severe musculoskeletal deformities, and there is minimal discomfort in the postoperative period. Because the procedure is short, the cost is decreased. There is no ileus. Because the tube is placed from inside out (in the original technique), it stays securely in place, and accidental catheter removal is rare. Direct gastric access in children differs from that in adults: there is a greater spectrum in sizes, indications, and needs. Children also tend to need their gastric access longer, often lifelong, u Another important difference is the high incidence of foregut dysmotility in the neurologically impaired child, the largest pediatric group requiring a gastrostomy. The question "gastrostomy only or gastrostomy plus antireflux procedure" remains an ongoing debate among those caring for these children. H,22 Because PEG is such a simple procedure, a well-accepted approach is to place the gastrostomy initially in children who can tolerate nasogastric tube feedings and add an antireflux procedure later, if needed. 22 For both adults and children, post-PEG stoma and catheter care are essential for a successful outcome. Unfortunately, long-term catheter care is associated with a significant number of minor and major complications. 23 However, most of these can be prevented with careful attention to detail, close follow-up, and the use of skinlevel devices. It is particularly important to exercise caution when changing gastrostomy access devices and to remember that in PEG the adhesion of the serosal surfaces is proportional to the diameter of the initially placed tube. 24 In analyzing the large number of patients and publications, it is clear that PEG has provided substantial help in the management of adult patients? It offers advantages over the commonly used nasogastric tube and is not as invasive as the traditional gastrostomies with celiotomy. PEG has facilitated nursing care and allowed earlier
PEG AT 20 YEARS
219
discharge from the hospital. 3 The procedure has helped shift the focus from parenteral nutrition back to the advantageous enteral route. However, in part, because of its simplicity and low complication rate, this minimally invasive procedure also lends itself to overutilization. Not surprisingly, PEG often is at the core of discussions involving end-of-life care. a° The 2 goals of PEG--the development of a simplified
catheter placement without celiotomy and the lessening of that procedure's attendant morbidity--were clearly met. The procedure has benefited countless patients, especially when it has been placed for long-term use. As we strive for further refinements in technique and better define the indications, it is worth reflecting on the fact that PEG, a procedure most commonly used in the elderly, had its origin in pediatric surgery.
REFERENCES 1. Gauderer MWL, Ponsky JL, Izant RJ Jr: Gastrostomy without laparotomy: A percutaneous endoscopic technique. J Pediatr Surg 15:872-875, 1980 2. Gauderer MWL: Twenty years of percutaneous endoscopic gastrostomy: Origin and evolution of a concept and its expanded applications. Gastrointest Endosc 50:879-833, 1999 3. American Society for Gastrointestinal Endoscopy: Role of PEG/ PEJ in enteral feeding. Gastrointest Endosc 48:699-701, 1998 4. Ponsky JL, Gauderer MWL: Percutaneous endoscopic gastrostomy: A nonoperative technique for feeding gastrostomy. Gastrointest Endosc 27:9-11, 1981 5. Ganderer MWL, Stellato TA: Percutaneous endoscopic gastrostomy in children: The technique in detail. Pediatr Surg Int 6:82-87, 1991 6. Sacks BA, Vine HS, Palestrant AM, et al: A nonoperative technique for establishment of a gastrostomy in the dog. Invest Radiol 18:485-487, 1983 7. Russell TR, Brotman M, Norris F: Percutaneous gastrostomy: A new simplified and cost-effective technique. Am J Surg 148:132-137, 1984 8. Wills IS, Oglesby IT: Percutaneous gastrostomy. Radiology 149: 449-452, 1983 9. Stringel G, Geller ER, Lowenheim MS: Laparoscopic-assisted percutaneous endoscopic gastrostomy. J Pediatr Surg 30:1209-1210, 1995 10. Gillick MR: Rethinking the role of tube feeding in patients with advanced dementia. N Engl J Med 342:206-209, 2000 11. Ganderer MWL: Percutaneous endoscopic gastrostomy: A 10 year experience with 220 children. J Pediatr Surg 26:288-294, 1991 12. Stellato TA, Ganderer MWL: Percutaneous endoscopic gastrostomy in the cancer patient. Am Surg 54:419-422, 1988
13. Stellato TA, Gauderer MWL: Percutaneous endoscopic gastrostomy for gastrointestinal decompression. Ann Surg 205:119-122, 1987 14. Stellato TA, Ganderer MWL, Ponsky JL: Percutaneous endoscopic gastrostomy following previous abdominal surgery. Ann Sm'g 200:46-50, 1984 15. Ponsky IL, Gauderer MWL, Stellato TA, et al: Percutaneous approaches to enteral alimentation. Am J Surg 149:102-105, 1985 16. Ponsky JL, Aszodi A, Perse D: Percutaneous endoscopic cecostomy: A new approach to nonobstructive colonic dilation. Gastrointest Endosc 32:108-111, 1986 17. Shandling B, Chait PG, Richards MF: Percutaneous cecostomy: A new technique in the management of fecal incontinence. J Pediatr Surg 31:534-537, 1996 18. Ganderer MWL: A simple technique for correction of severe gastrostomy leakage. Surg Gynecol Obstet 165:170-172, 1987 19. Eckhanser ML, Ferron JP: The use of dual percutaneous endoscopic gastrostomy in the management of chronic intermittent gastric volvulus. Gastrointest Endosc 31:340-342, 1985 20. Gauderer MWL, Izant RJ Jr: A technique for temporary control of colostomy prolapse in children. J Pediatr Surg 20:653-655, 1985 21. Filipi CJ, Perdikis G, Hinder RA, et al: An intraluminal surgical approach to the management of gastric bezoars. Surg Endosc 9:831833, 1995 22. Isch JA, Rescorla FJ, Scherer LR, et al: The development of gastroesophageal reflux after percutaneous endoscopic gastrostomy: J Pediatr Surg 32:321-323, 1997 23. Ganderer MWL, Stellato TA: Gastrostomies: Evolution techniques, indications and complications. Curr Probl Surg 23:661-719, 1986 24. Gauderer MWL: Long-term gastric access: Caveat medicus. Gastrointest Endosc 44:356-358, 1996
Background/Purpose: Percutaneous endoscopic gastrostomy (PEG), initially developed for children with inability to swallow, had its first presentation at the annual meeting of the American Pediatric Surgical Association in Florida in 1980. Based on the novel concept of the sutureless approximation of a hollow viscus to the abdominal wall, this minimally invasive procedure has become the standard for direct gastric access worldwide. This report is a brief retrospective about the evolution of PEG and the expanded applications of the surgical concept on which it is based. Methods: Information related to PEG was obtained from personal records, a focused literature search, and data from various registries and the industry.
Results: The search identified 836 peer-reviewed publications directly related to PEG. The original Journal of Pediatric Surgery article has received 483 bibliographic citations. The procedure has had a profound impact on nutritional management, particularly among adult patients. Over 216,000 PEGs are performed annually in the United States. Twelve major manufacturers produce PEG or PEG-related enteral
AY 2000 marks the 20th anniversary of the initial presentation of the percutaneous endoscopic gastrostomy (PEG) before the 1 lth Annual Meeting of the American Pediatric Surgical Association, Marco Island, Florida. 1 The technique paper, followed by a short movie, introduced a novel concept: the sutureless approximation of a hollow viscus to the abdominal wall by means of a catheter placed without a celiotomy. The rapidly evolving (then new) field of flexible endoscopy had permitted fulfillment of the criteria set forth earlier2 for a simple yet safe gastrostomy: control of the site of placement in the stomach, protection of surrounding organs, and a reliable approximation of gastric and abdominal wall serosal surfaces. Although originally developed for children, PEG was almost immediately adopted by adult gastroenterologists and general surgeons familiar with endoscopy. Soon pediatric gastroenterologists began using it, but it was only gradually accepted by pediatric surgeons. In the 2 decades since its introduction, PEG has facilitated patient care through improved nutritional management and changed the way we look at enteral access. The term PEG has become a household word, almost synonymous with gastrostomy. However, the scope of this acceptance also has generated
M
Journal of Pediatric Surgery, Vol 36, No 1 (January), 2001: pp 217-219
access devices. Select expanded applications of PEG and its principle include indications beyond feeding, use in high-risk patients, percutaneous jejunostomy, percutaneous cecostomy, correction of gastrostomy leakage and gastric volvulus, multiple PEG portals for intragastric interventions, and laparoscopically assisted gastrostomies.
Conclusions: Over 20 years, percutaneous endoscopic gastrostomy has experienced exponential growth. Improved guidelines and technical refinements have added to its safety. The concept on which it is based has created a ripple effect and led to numerous applications beyond gastric access for feeding. In an era when so many of our procedures are adopted from "adult" general surgery, it is worthwhile to have an historical perspective on PEG, a technique that originated in pediatric surgery. J Pediatr Surg 36:217-219. Copyright © 2001 by W,B. Saunders Company. INDEX WORDS: Percutaneous endoscopic gastrostomy, gastrostomy, enteral access.
concerns about overutilization. The aim of this report is to provide an analytical look at a new procedure's rapid growth and its implications. MATERIALS AND METHODS Information related to PEG was obtained from personal records, files and publications, a focused literature search (MedLine-PEG as subject, limited to human subjects only), data obtained from various registries, and the industry (IMS America, Plymouth Meeting, PA).
RESULTS
Percutaneous endoscopic gastrostomy has been accepted worldwide, an extensive experience has been gained, and a large body of literature has accrued. A search of the literature since the publication of the From the Department of Pediatric Surgery, The Children's Hospital, Greenville Hospital System, Greenville, SC. Presented at the 31st Annual Meeting of the American Pediatric Surgical Association, Orlando, Florida, May 25-29, 2000. Address reprint requests to Michael W.L. Gauderer, MD, Chief Department of Pediatric Surgery, The Children's Hospital, Greenville Hospital System, 890 W. Faris Rd, Suite 440, Greenville, SC 29605. Copyright © 2001 by W.B. Saunders Company 0022-3468/01/3601-0040503.00/0 doi: 10.1053/jpsu.2001.20058 217
218
MICHAEL W.L. GAUDERER
original article in the Journal of Pediatric Surgery 1 identified 2,438 indexed articles listing the term gastrostomy. When the terms percutaneous gastrostomy and percutaneous endoscopic gastrostomy were queried, 1,007 and 836 articles, respectively, were retrieved. Articles comprised a wide range from simple technical notes and letters to the editor to large series, comparative studies and subject reviews. Among these is a recent publication by the American Society for Gastrointestinal Endoscopy that provides a concise "state-of-the-art" overview with references and addresses indications, contraindications, techniques, complications, and comparison with surgical gastrostomy? The original Journal of Pediatric Surgery article 1 received 483 bibliographic citations. A detailed account of the origin and evolution of the PEG concept was published recently. 2 The original "pull" technique 1,4,5 remains the most widely used approach. Variations include the "push" technique, 6 the "introducer" method, 7 and a nonendoscopic, radiologically controlled procedures, s More recently, laparoscopically aided PEGs have been added. 9 Over 216,000 PEGs are performed annually in the United States alone. These patients were 211,000 adults and 5,000 children. PEG is, therefore, the second most common indication for upper tract endoscopy in this country. Feeding remains the primary indication. The procedure is most often performed in the elderly, l° Twelve major manufacturers produce PEG or PEGrelated enteral access devices. Select expanded applications of PEG and its principle include broader feeding and medication-related indications such as nutritional support for patients with oropharyngeal abnormalities, inflammatory bowel disease, cardiac lesions, or trauma, 3,11 continuous nighttime enteral feedings, H and administration of nonpalatable medications or dietll; use in high-risk patients for feeding ~2 or decompression,13 and in those who have undergone previous abdominal surgeryl4; percutaneous jejunostomy, either indirectly is or directly9; percutaneous cecostomy for decompression ~6 or antegrade bowel irrigationl7; correction of gastrostomy leakageJ s gastric volvulus, 19 and temporary control of colostomy prolapse2°; placement of multiple PEG portals to permit intragastric surgical interventions, such as drainage of pancreatic pseudocysts through cyst gastrostomy, control of hemorrhage, resection of polyps, and removal of bezoars21; and development of techniques combining PEG with laparoscopically assisted procedures.3, 9 DISCUSSION The first presentation about PEG at the American Pediatric Surgical Association meeting 20 years ago was received with great interest and curiosity by the younger
colleagues in the audience, but it evoked skepticism fi'om senior members. In general, pediatric surgeons were slow to accept this procedure, which originally had been developed for children, probably because few were performing flexible endoscopy at that time. Indeed, when an experience with 220 pediatric patients was presented at the American Pediatric Surgical Association meeting 10 years later, criticism and even disapproval were a part of the discussion that ensued. 11 Conversely, the second presentation about PEG at the American Society for Gastrointestinal Endoscopy 4 was followed by great enthusiasm. Gastroenterologists and general surgeons performing endoscopy embraced PEG with astonishing rapidity, recognizing the procedure's advantages: general anesthesia usually is not required (for adults), abdominal relaxation is not essential, the procedure can be done in patients with severe musculoskeletal deformities, and there is minimal discomfort in the postoperative period. Because the procedure is short, the cost is decreased. There is no ileus. Because the tube is placed from inside out (in the original technique), it stays securely in place, and accidental catheter removal is rare. Direct gastric access in children differs from that in adults: there is a greater spectrum in sizes, indications, and needs. Children also tend to need their gastric access longer, often lifelong, u Another important difference is the high incidence of foregut dysmotility in the neurologically impaired child, the largest pediatric group requiring a gastrostomy. The question "gastrostomy only or gastrostomy plus antireflux procedure" remains an ongoing debate among those caring for these children. H,22 Because PEG is such a simple procedure, a well-accepted approach is to place the gastrostomy initially in children who can tolerate nasogastric tube feedings and add an antireflux procedure later, if needed. 22 For both adults and children, post-PEG stoma and catheter care are essential for a successful outcome. Unfortunately, long-term catheter care is associated with a significant number of minor and major complications. 23 However, most of these can be prevented with careful attention to detail, close follow-up, and the use of skinlevel devices. It is particularly important to exercise caution when changing gastrostomy access devices and to remember that in PEG the adhesion of the serosal surfaces is proportional to the diameter of the initially placed tube. 24 In analyzing the large number of patients and publications, it is clear that PEG has provided substantial help in the management of adult patients? It offers advantages over the commonly used nasogastric tube and is not as invasive as the traditional gastrostomies with celiotomy. PEG has facilitated nursing care and allowed earlier
PEG AT 20 YEARS
219
discharge from the hospital. 3 The procedure has helped shift the focus from parenteral nutrition back to the advantageous enteral route. However, in part, because of its simplicity and low complication rate, this minimally invasive procedure also lends itself to overutilization. Not surprisingly, PEG often is at the core of discussions involving end-of-life care. a° The 2 goals of PEG--the development of a simplified
catheter placement without celiotomy and the lessening of that procedure's attendant morbidity--were clearly met. The procedure has benefited countless patients, especially when it has been placed for long-term use. As we strive for further refinements in technique and better define the indications, it is worth reflecting on the fact that PEG, a procedure most commonly used in the elderly, had its origin in pediatric surgery.
REFERENCES 1. Gauderer MWL, Ponsky JL, Izant RJ Jr: Gastrostomy without laparotomy: A percutaneous endoscopic technique. J Pediatr Surg 15:872-875, 1980 2. Gauderer MWL: Twenty years of percutaneous endoscopic gastrostomy: Origin and evolution of a concept and its expanded applications. Gastrointest Endosc 50:879-833, 1999 3. American Society for Gastrointestinal Endoscopy: Role of PEG/ PEJ in enteral feeding. Gastrointest Endosc 48:699-701, 1998 4. Ponsky JL, Gauderer MWL: Percutaneous endoscopic gastrostomy: A nonoperative technique for feeding gastrostomy. Gastrointest Endosc 27:9-11, 1981 5. Ganderer MWL, Stellato TA: Percutaneous endoscopic gastrostomy in children: The technique in detail. Pediatr Surg Int 6:82-87, 1991 6. Sacks BA, Vine HS, Palestrant AM, et al: A nonoperative technique for establishment of a gastrostomy in the dog. Invest Radiol 18:485-487, 1983 7. Russell TR, Brotman M, Norris F: Percutaneous gastrostomy: A new simplified and cost-effective technique. Am J Surg 148:132-137, 1984 8. Wills IS, Oglesby IT: Percutaneous gastrostomy. Radiology 149: 449-452, 1983 9. Stringel G, Geller ER, Lowenheim MS: Laparoscopic-assisted percutaneous endoscopic gastrostomy. J Pediatr Surg 30:1209-1210, 1995 10. Gillick MR: Rethinking the role of tube feeding in patients with advanced dementia. N Engl J Med 342:206-209, 2000 11. Ganderer MWL: Percutaneous endoscopic gastrostomy: A 10 year experience with 220 children. J Pediatr Surg 26:288-294, 1991 12. Stellato TA, Ganderer MWL: Percutaneous endoscopic gastrostomy in the cancer patient. Am Surg 54:419-422, 1988
13. Stellato TA, Gauderer MWL: Percutaneous endoscopic gastrostomy for gastrointestinal decompression. Ann Surg 205:119-122, 1987 14. Stellato TA, Ganderer MWL, Ponsky JL: Percutaneous endoscopic gastrostomy following previous abdominal surgery. Ann Sm'g 200:46-50, 1984 15. Ponsky IL, Gauderer MWL, Stellato TA, et al: Percutaneous approaches to enteral alimentation. Am J Surg 149:102-105, 1985 16. Ponsky JL, Aszodi A, Perse D: Percutaneous endoscopic cecostomy: A new approach to nonobstructive colonic dilation. Gastrointest Endosc 32:108-111, 1986 17. Shandling B, Chait PG, Richards MF: Percutaneous cecostomy: A new technique in the management of fecal incontinence. J Pediatr Surg 31:534-537, 1996 18. Ganderer MWL: A simple technique for correction of severe gastrostomy leakage. Surg Gynecol Obstet 165:170-172, 1987 19. Eckhanser ML, Ferron JP: The use of dual percutaneous endoscopic gastrostomy in the management of chronic intermittent gastric volvulus. Gastrointest Endosc 31:340-342, 1985 20. Gauderer MWL, Izant RJ Jr: A technique for temporary control of colostomy prolapse in children. J Pediatr Surg 20:653-655, 1985 21. Filipi CJ, Perdikis G, Hinder RA, et al: An intraluminal surgical approach to the management of gastric bezoars. Surg Endosc 9:831833, 1995 22. Isch JA, Rescorla FJ, Scherer LR, et al: The development of gastroesophageal reflux after percutaneous endoscopic gastrostomy: J Pediatr Surg 32:321-323, 1997 23. Ganderer MWL, Stellato TA: Gastrostomies: Evolution techniques, indications and complications. Curr Probl Surg 23:661-719, 1986 24. Gauderer MWL: Long-term gastric access: Caveat medicus. Gastrointest Endosc 44:356-358, 1996