Percutaneous Later: Endoscopic Gastrostomy--20 Years A Historical Perspective By Michael W.L. Gauderer Greenville, South Carolina Background/Purpose: Percutaneous endoscopic gastros- tomy (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 approx- imation of a hollow viscus to the abdominal wall, this mini- mally 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 publica- tions 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 man- agement, particularly among adult patients. Over 216,000 PEGs are performed annually in the United States. Twelve major manufacturers produce PEG or PEG-related enteral access devices. Select expanded applications of PEG and its principle include indications beyond feeding, use in high-risk patients, percutaneous jejunostomy, percutaneous cecos- tomy, correction of gastrostomy leakage and gastric volvu- lus, multiple PEG portals for intragastric interventions, and laparoscopically assisted gastrostomies. Conclusions: Over 20 years, percutaneous endoscopic gas- trostomy 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 ac- cess 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, gas- trostomy, enteral access. M AY 2000 marks the 20th anniversary of the initial presentation of the percutaneous endoscopic gas- trostomy (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 ap- proximation 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 ab- dominal wall serosal surfaces. Although originally developed for children, PEG was almost immediately adopted by adult gastroenter- ologists and general surgeons familiar with endos- copy. 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 nutri- tional management and changed the way we look at enteral access. The term PEG has become a household word, almost synonymous with gastrostomy. How- ever, the scope of this acceptance also has generated 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 ac- cepted 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 Journal of Pediatric Surgery, Vol 36, No 1 (January), 2001: pp 217-219 217