Bringing Bile, Pancreatic Ducts into Better Focus

Published in Inside Tract - Summer 2016

For years, many endoscopists have been reluctant to explore bile and pancreatic ducts. In most cases, camera technology to observe the intricate and hard-to-reach duct systems has failed to keep up with other high-definition imaging tools.

Until now.

Mouen Khashab uses a next-generation cholangioscope system to see directly inside the elusive ducts of the pancreas and biliary tree. Khashab and colleagues are among the first clinicians applying the technology in Maryland and the surrounding region.

“Now you can see the bile duct and pancreatic duct the same as you see the esophagus, the colon, the stomach,” says Khashab. “So our diagnostics and therapeutics within the pancreatic and biliary systems have gotten much better because of the improvement in the device.”

Khashab says the first generation of this scope was fiber optic, which provides a far lower-definition image than the current digital version. “It was much harder to see fine detail,” he says, adding that, rather than direct visualization, endoscopists relied on radiography.

“Let’s say somebody presented with an indeterminate bile duct stricture or pancreatic duct stricture,” Khashab proposes. “We couldn’t be sure whether they were benign or malignant.” Even biopsies of these areas are only 40 percent accurate, says Khashab.

“So we biopsy this patient and let’s say it comes back negative for malignancy. We can’t tell him or her ‘you have a benign stricture.’ We can’t rely on those biopsies, so we end up repeating the procedure and doing more diagnostics.”

But now, says Khashab, “we can actually see tumors with this new device.”

A patient needing a cholangioscopy rests sedated on a table, prepped and ready for endoscopy. Khashab suspects the 43-year-old man with jaundice symptoms has a stricture or a stone. Next to the patient are three high-definition screens: a screen for x-ray guidance, a screen for endoscopy and a screen devoted solely to the new camera.

The scope is inserted through the channel of the standard ERCP scope and guided gently into the bile duct. Images of the tiny duct come to life on the screen, magnified hundreds of times. Irrigation and biopsies are possible, as are laser probes to manage stones.

Khashab found that the patient did indeed have a benign biliary stricture caused by a prior procedure and he inserted a stent into the duct, holding it open for proper function.