Sacred Heart Medical Center is looking to a small piece of equipment it has just bought to advance its diagnosis and treatment of bile duct disorders.


Three specialists here are beginning to use the device, a specially designed miniaturized endoscope called the SpyGlass, to perform an expanded form of a common procedure to help diagnose and treat scarring and tumors in the bile duct.


Boston Scientific Corp., of Natick, Mass., introduced the product last May, for use in conjunction with a procedure called endoscopic retrograde cholangiopancreatography (ERCP) that helps to diagnose digestive problems. Boston Scientific says about 100 hospitals around the country have bought the device so far. Outside of Spokane, the nearest facilities with the technology are in Seattle and Portland, the company says.


In a conventional ERCP, a flexible rubber tube is threaded down a patients esophagus and through the stomach to allow a doctor to view and X-ray the digestive organs. The endoscope tube is around 10 to 12 millimeters in diameter and is divided into four smaller tubes, with a two-knob steering mechanism that allows the physician to move the tube up and down and left and right. Through the four tubes, tools used to take biopsies or perform other procedures can be threaded, and the channels allow irrigation and injection of dyes to make the organs show up better on X-rays taken during the procedure.


A standard endoscope, though, is too large to enter the bile ducts, which are 3 millimeter- to 6 millimeter-wide conduits that carry bile produced in the liver from the gallbladder, where it is stored, to the intestines, where the body uses it to help digest fats and to process toxins. To view the bile ducts in an ERCP, a doctor injects dye into the duct to make the organ show up better and takes X-rays during the procedure. It is difficult, however, for the doctor to perform any tests or to get tissue samples from the bile ducts with a standard endoscope, says gastroenterologist Michael Kestell, one of the specialists here who now uses the new device.


The SpyGlass is so small, with a diameter of 1 millimeterabout the diameter of an ink pen tubethat it fits through one of the working channels in the larger endoscope and, like other endoscopes, is itself divided into four tubes. When connected to and threaded through a standard endoscope, it is small enough to be guided into the duct itself so the doctor can see the bile ducts directly, Kestell says.


Its kind of like a Russian nesting doll, says fellow gastroenterologist Klaus Gottlieb, describing it basically as a scope within a scope.


The total initial cost for the device and related new equipment is about $60,000, Kestell says. The SpyGlass system looks like a flexible fishing rod with two knobs for steering the tubejust like the bigger endoscopea single-use catheter tube, and a monitor and camera system. Through the catheter, a fiber-optic camera for lighting and viewing the internal organs in real time video, and accessories, such as a miniature pair of biopsy forceps, are threaded. The fiber-optic thread costs about $4,000 and each thread lasts for 10 to 20 procedures, Kestell says. Kestell says Sacred Heart is in the process of buying a laser that can be used in conjunction with the SpyGlass to help break up tough bile stones that otherwise would require surgery to remove.


Kestell says he believes the technology will benefit patients who have possible bile duct abnormalities by allowing a medical professional to see directly into the patients bile ducts, to take biopsies of possible tumors, and to treat bile ducts that are narrowed by scarring or inflammation. With a conventional ERCP, additional procedures, including surgery, often are needed if something abnormal is seen in the bile ducts, he says.


The miniature scopes steering mechanism attaches to the standard endoscope, allowing one doctor to hold and manipulate both sets of controls. The doctor can then enter the bile duct with the miniature scopes instruments to take samples if needed, while looking at the tissue on a monitor. Before, to get a sample a doctor would use a small brush to scrape cells from a general area identified by an X-ray.


Kestell says the scope also increases the therapeutic procedures that can be accomplished during an ERCP. One of the most useful, he says, is the ability to thread a guide wire through the small scope, which enables the doctor to place a tube called a stent into an abnormally narrow bile duct to open it up.


Boston Scientific compares the new technology to another system developed in the 1990s that used two scopes, but had to be controlled by two specialists working in tandem. Gottlieb says that technique, which was referred to as a mother scope and baby scope, was never used in Spokane. It was cost-prohibitive and difficult to schedule, since two doctors were required for each procedure, he says.


Gottlieb estimates that about three or four procedures a month will be scheduled here using the new technology. With the new miniature scope, however, he and Kestell say any standard ERCP has the potential to become a SpyGlass case, if it is determined in the course of the procedure that a closer look at a bile duct is warranted.


Gottlieb says the technique will expand the options for patients with certain bile duct disorders who otherwise might have to travel to Seattle for monitoring and treatment.


A major bile duct problem the doctors see as an application for the technology is a progressive disease called primary sclerosing cholangitis (PSC), an inflammatory condition that causes scarring of the bile ducts and cirrhosis of the liver, and increases a patients risk of developing cancer in the bile duct. Though PSC is not common, its cause is unknown and the only treatment for it is a liver transplant.


People with PSC typically undergo an endoscopy every two years, Kestell says. Football player Walter Peyton, who suffered from PSC, developed bile duct cancer while awaiting a liver transplant, and died in 1999.


Another application for the scope will be helping to break up difficult bile stones. Bile duct problems also can be caused when gallstones lodge in the bile ducts, Gottlieb says. The laser that Sacred Heart plans to use with the SpyGlass might eliminate the need for surgery for those patients.


He says that ultimately the new equipment adds to the diagnostic tools available, such as ultrasound techniques, and likely will change the course of treatment for a lot of patients because areas of concern can be examined more readily and treated more often without surgery.


Contact Jeanne Gustafson at (509) 344-1264 or via e-mail at jeanneg@spokanejournal.com.