Peroral cholangioscopy requires a long and torturous approach to reach the biliary ducts and is limited by poor video quality and lack of imaging modes. By using laser-light scanning, three different imaging modes can be provided in one endoscope: (1) high-resolution wide-field color imaging, (2) enhanced spectral imaging (ESI) of the same 90° field, and (2) fluorescence imaging of the same field. Low-power red, green, and blue (RGB) laser light is combined to a single optical fiber and scanned at the tip of a new cholangioscope to produce 500-line images at 30 Hz. ESI generates higher contrast of blood vessels and helps to discriminate tissue types by enhancing blue over red backscattered light. Fluorescence imaging is generated by exciting the tissue at laser wavelengths (B-442 nm, G-532 nm, and/or R-635 nm) while detecting fluorescence in a longer wavelength channel, respectively (G, R, or near infrared). Currently, ESI imaging is simultaneous with RGB-color imaging, while fluorescence video imaging is generated with a 2-second switch.A prototype ultrathin (1.7-mm diameter, 5 Fr) cholangioscope has been developed with thumbstick control of tip deflection. The forward-viewing cholangioscope extends 2 feet beyond a side-viewing duodenoscope (PENTAX ED-3470TK). At the tip of this cholangioscope, a rigid portion extends beyond the bend mechanism by less than 10 mm, which houses the microscanner and lenses. After a full 180° of bending in the cholangioscope shaft, the range of tip deflection is +/-30° in any direction. Once positioned, the cholangioscope can be used as a guidewire for inserting cannulas and biopsy tools.In vitro testing of the cholangioscope used a synthetic (silicone) casting of a biliary tree model (3 branches from 8 to 2 mm inner diameter) which extends a commercial ERCP trainer (Koken, Japan). Along the luminal wall of the synthetic bile duct were placed (a) rolled paper target with fluorescence and non-fluorescence painted markings, (b) rolled paper target with dried markings of methylene blue, and (c) fluorescence microspheres. Targets were imaged in air with RGB/ESI and fluorescence contrast under attenuated room lighting conditions. No averaging was required to unambiguously visualize the targets, although this method may be used to improve image contrast of weak autofluorescence signals. Future development will allow all three modes of operation concurrently at video rates with appropriate fluorescence biomarkers. Thus, the physician will have a vast arsenal of visual information for analyzing indeterminate biliary strictures and guiding biopsy and other interventions in the pancreatobiliary system.
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