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Percutaneous ultrasonic gastrostomy (PUG) is a procedure in which a gastrostomy tube (G-Tube) is passed into a patient’s stomach through the abdominal wall via ultrasound guidance. PUG is a novel technique for placing G-Tubes and can be performed at the bedside. PUG is an alternative to both percutaneous endoscopic gastrostomy (PEG) and percutaneous radiologic gastrostomy (PRG). PUG has been proven to be just as safe as the current standard of care (PEG and/or PRG), yet reduces both cost and length of stay. PUG and PUMA-G was invented by Dr. Steven Tropello in 2016, who later that year on March 25, 2016, founded CoapTech to further develop and produce both PUMA-G and PUG.

Indications and Contraindications
The PUMA-G system has the following indications for use:


 * Adults only (22+, according to the FDA)
 * Tissue depth up to 4.5 cm
 * BMI is a useful tool, but can be misleading. Prior imaging should be used to obtain tissue depth measurement
 * Patient has no pacemakers or other active implantable or metallic devices

The PUMA-G system follows all universal guideline gastrostomy contraindications.

Equipment
The PUG procedure is performed using the PUMA-G (percutaneous ultrasound magnet aligned gastrostomy) system. The system is composed of 3 parts: an external magnet, an internal balloon catheter with an embedded magnet, and a guidewire.

Procedure Description
The procedure starts by orally feeding the internal balloon catheter into the stomach. The external magnet is then placed on the patients abdomen, and the two magnets then coapt and bring together all planes of tissue from the stomach wall to the abdominal skin. This is called a temporary magnetic gastropexy. The internal balloon is then filled with blue fluid, which then enables the use of ultrasound to visualize the tissue and the balloon itself. The physician is then able to guide the needle through the tissue into the balloon, which can be confirmed via blue fluidic flashback in the needle syringe. The syringe is then removed and the guidewire is fed through the needle into the balloon via a J straightener (feeder tip). The balloon is then deflated and snared by the guidewire, creating a coupled system. When the balloon is retracted, the guidewire tip is cut to remove the balloon, and through and through access is in place from the guidewire. With this access, a G-Tube can then be placed by either the Ponsky (“Pull”) method or the Sachs-Vine (“Push”) method.

Comparison to Current Methods
PUG is an alternative to both percutaneous endoscopic gastrostomy (PEG) and percutaneous radiologic gastrostomy (PRG). PUG has been proven to be just as safe as the current standard of care (PEG and/or PRG) yet reduces both cost and length of stay

The PUG procedure is an alternative to:


 * Percutaneous endoscopic gastrostomy, which uses a reprocessed endoscope
 * Percutaneous radiologic gastrostomy, which uses ionizing radiation, which is known to cause cancer

The PUG procedure allows for g-tube placement without using general anesthesia, a reprocessed endoscope, nor ionizing radiation

Because PUG can be performed at the bedside, critical care physicians don’t have to wait for a gastrostomy consult. Instead, they can place the G-Tube when the patient needs it, without any delay. This efficient change in gastrostomy workflow reduces hospital length of stay by 8 days on average and has cost-savings of $26,000 per patient.

Because PUG can be done at the bedside, it can be performed concomitantly with percutaneous dilatation tracheostomy (PDT), which is referred to as TPUG.

PUMA-G Pediatric System
The PUMA-G Pediatric System is a spinoff of the PUMA-G system for patients under 22 years old. The pediatric device has been approved by the FDA to start clinical trial.

History
Dr. Steven Tropello was working in 2016 as a critical care physician at St. Joe’s hospital in Maryland when he thought of the PUMA-G system and PUG procedure. As a critical care physician, he was tired of seeing patients waiting days for a g-tube and wished he could perform it himself at the bedside. He then designed and prototyped what would later become the PUMA-G system in his Baltimore home. Later in 2016, he founded CoapTech with Howard Carolan. CoapTech currently has 15 employees and is located in City Garage in Baltimore, MD. More about the company can be found on coaptech.com