The SpyGlass® system is a recently developed, well-validated method for performing cholangioscopy, the direct visual examination of the bile ducts. It is used in conjunction with Endoscopic Retrograde Cholangiopancreatography (ERCP). While ERCP provides diagnostic imaging of the bile and pancreatic duct, SpyGlass® enables the endoscopist to get a better visualization of the bile ducts and obtain a better sample of any suspicious lesions or tumors. The procedure also allows for fragmentation of bile or pancreatic duct stones using lasers or other methods.

The SpyGlass® instrument is attached to the standard ERCP equipment and is performed during the ERCP procedure. Preparation and recovery for this procedure are the same as with ERCP. The duration of the procedure is longer, however.

Biliary Radiofrequency Ablation (RFA) is done during ERCP and targets malignant biliary strictures that are deemed inoperable, even if there is a prior metal biliary stent. This can occur when the bile ducts (which transport bile from the liver to the small intestine to help with digestion) get smaller, causing a buildup of bile. This leads to difficulty in digesting food, especially fatty foods and can affect absorption of vitamins A, D, E and K. Biliary RFA helps open the bile ducts.

The patient will undergo an upper GI endoscopy to identify the location of the malignancy. The doctor will then choose the appropriate ablation catheter for the treatment. During Biliary RFA, the endoscopist applies heat to the tissue via electric current, locally destroying the malignant tissue. Radiofrequency ablation can be a safe, effective option for unresectable malignant biliary strictures.

In some cases, the bile ducts are not accessible through regular ERCP, often due to severe stricture or cancer of the bile duct or pancreas. In this situation, patients would typically get tubes placed through the skin into the bile ducts in the liver. The tube is connected to a bag that needs to be periodically emptied in the sink or toilet. These tubes may risk infection, cause pain, leak, and need to be exchanged from time to time. To avoid this, the bile ducts can be accessed internally to avoid external biliary drainage and preserve natural flow of bile. This procedure typically involves using internal endoscopic ultrasound to precisely visualize the internal anatomy and allow placement of a stent for internal drainage. Patients may return to work the day after the procedure.

When the gallbladder gets infected, it typically needs to be surgically resected. However, patients who are too sick for surgery (like those who have metastatic cancer) or patients who decline surgery, would typically have a tube inserted from the skin into the gallbladder. This tube may be inadvertently pulled, cause pain, leak, get infected and affect quality of life. Instead, the gallbladder can be drained internally by use of endoscopic ultrasound to locate the gallbladder precisely to allow placement of a stent for internal gallbladder drainage.

During ERCP, biliary duct stones may be encountered. On occasion, the stones are so large that they cannot safely be removed in one piece. A stent in the bile duct might be placed but repeat ERCP may show a persistently large stone. To remove these stones, a specialized technique called Photodynamic therapy and Laser therapy can be used to safely break up the stones and restore normal biliary flow. Patients may return to work the day after the procedure.

The ampulla connects the pancreas and bile duct to the small intestine. It serves as a gate that allows digestive enzymes to enter the duodenum (the first part of the small intestine that helps to further digest food) during meals. Precancerous lesions on the ampulla can occur and even block the bile duct, causing jaundice and/or icterus (yellowing of the skin and eyes). In the past, this was typically treated with a major surgery called a Whipple procedure. However, advanced training allows of FDHS third-space endoscopists allows them to remove the ampulla endoscopically. This procedure, called an Ampullectomy, is minimally invasive, provides the physicians greater control and vision during surgery, and allows for a safer, less invasive and more precise treatment.