We have tried laparoscopic approach for 6 cases of cholecystoenteric fistula since 1996. Five cases had cholecystoduodenal fistula and one case had cholecystogastric fistula. Preoperatively, cholecystoenteric fistula was diagnosed in five cases. Two cases were diagnosed as having cholecystoenteric fistula and no residual gallstone. Therefore we followed these cases without biliary surgery expecting spontaneous closure of the fistel, but they finally received cholecystectomy and fistula repair because of repeated cholangitis. All procedures were started laparoscopically, but two cases were converted to laparotomy because of sever adhesion. In three cases cholecystectomy and fistelectomy was done, but in the last case the atrophic gallbladder was preserved. Laparoscopic fistelectomy was done using by the endoscopic linear stapler. One case had intra-abdominal abscess and another had leakage from the closure site of the duodenum. There was no delayed complication.

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ERCP (endoscopic retrograde cholangiopancreatography) is a fundamental procedure of endoscopic diagnosis and treatment of biliopancreatic diseases. After its development, ERCP was widely indicated in patients with known or suspected biliopancreatic diseases for a long time, as it was the only examination that allowed visualization of the biliopancreatic ductal system. With the development of other imaging modalities such as MRCP (magnetic resonance cholangiopancreatography), the role of ERCP is changing. Many therapeutic procedures based on ERCP have been developed and the diagnostic role of ERCP continues to evolve. However, the incidence of complications relevant to ERCP has not yet decreased. Education on ERCP, therefore, is gaining more attention than before. In this issue, four high-volume centers for ERCP in Japan introduce their practice in the education and training of their personnel in the use of ERCP, which will hopefully be of help to all the readers in their efforts to achieve improved performance in ERCP.

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I described education of ERCP-related procedures in our department. Since ERCP procedure require skill technique and severe complications may occur, the trainees should be educated in high volume facilities in which skilled trainers are. I think that it may be better to divide ERCP procedure into some sections from insertion of duodenoscope to endoscopic sphincterotomy. At the same time, it is better to learn not only ERCP technique but also theory of procedures or pathophysiologic knowledges of pancreatobiliary diseases.

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The diagnostic and therapeutic usefulness of ERCP for pancreato-biliary diseases is widely recognized. It is, however, a relatively complex procedure and the occurrence of complications is not rare. Therefore, it is important for endoscopists who take a training course in ERCP to understand the incidence of ERCP-related complications and their treatment well. Obtaining written informed consent after sufficient information has been given, including that on complication, is mandatory before performance of the procedure. This will contribute to a decrease in the number of lawsuits. For the prevention of accidents or complications, in addition to the precautions taken in esophagogastroduodenoscopy, recognition of the following conditions should be kept in mind: 1) dehydration while fasting (that may lead to the manifestation of ischemic diseased),2) hypoxemia due to sedation,3) bradycardia or hypotention caused by cholangio-vagal reflex,4) pain resulting from an increase in the elevation of intraductal pressure of the biliary tree,5) hypertension due to pain or suffering during the procedure (possibly resulting in cerebral hemorrhage),6) pancreatitis due to burden on the papilla of Vater, and so on. During hands-on training, it should be emphasized that insertion of the duodenoscope should be performed under direct guidance of the endoscopic view and that recording and interpreting the images during injecting of contrast medium is important. Training by comparing ERCP images with those of other imaging modalities, as well as with resected specimens in surgical cases, is critical for the improvement of the ability to establish a diagnosis via ERCP. ERCP and ERCP-related procedures should only be perfomed by the novice endoscopist after he/she has received training by experts on ERCP and in cooperation with other team members.

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We have two types training course in education for ERCP, one is the “consistent training”, and another is the “open type training”. The “consistent training” starts from mainly third year from graduate, in two years after graduate. In two years post graduation, basically clinical education in all departments of clinical divisions was made, so called “Super Rotate Course”. About six to seven years need to master the various techniques of ERCP and advanced ERCP. The “Open type training” is available for the residents who had educated for five to six years in another hospitals, and it costs of about three years to finish the training. In both of trainings, trainee should study all procedures about digestive diseases, ex. extracorporeal ultrasonography, upper GI endoscope, lower GI endoscope, angiography and IVR and so on; moreover trainee should have the responsibility of all clinical procedures for the patient as the physician in charge. The training systems in our hospital is long term course than the training in another hospitals, however these systems are suitable system for bringing up the endoscopist who has sense of responsibility and of clinical thinking.

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For the training of ERCP,1) smooth introduction of the duodenoscope to the papilla Vater,2)appropriate view of papilla Vater, and 3) deep cannulation to the bile duct are essential. The operator must know the difference between the side viewing endoscope and the panendoscope for the smooth introduction of the duodenoscope. The rotation of the body of the operator, the switching of the wrist, and the angulation of the endoscope are essential for the appropriate view of papilla Vater. The training of ERCP using a phantom is useful for the purpose. Tactics of deep cannulation to the bile duct should be selected according to the type of papilla, for example, slit type, onion type, and tongue protrusion type.

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An 81-year-old male received cholecystectomy, choledocholithotomy, and hepaticoduodenostomy for cholecystolithiasis, choledocholithiasis, and a perivaterian diverticulum of the duodenum in May 2003. During surgery, an intraductal papillary mucinous neoplasm (IPMN) of 18mm in diameter was found in the uncinate process of the pancreas, for which the patient was followed up postoperatively. As the patient then had multiple episodes of upper abdominal pain, a detailed examination was performed. The findings showed enlargement of IPMN, which was considered to be attributable to abdominal pain. In February 2005, PPPD was performed. Examination of a biopsy sample revealed a small nodule of 15mm in diameter in the pancreatic site of the bile duct stump. Histopathological evaluation of the nodule showed that it was a amputation neuroma of the biliary tract, while the IPMN of the pancreas was proved to be an adenoma. The postoperative course was uneventful without recurrence of abdominal pain. The histopathological findings suggested that the amputation neuroma of the biliary tract, as well as the IPMN of the pancreas, might have caused the postoperative upper abdominal pain.

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A 73-year-old woman was admitted for further examination of gallbladder mass. Abdominal ultrasonography depicted multiple small elevated lesions. Endoscopic ultrasonography displayed broad-based elevated lesions surrounded by irregular mucosal thickening. Since the outer hyperechoic layer was not disrupted, the tumor was diagnosed as early gallbladder carcinoma and the surgeons performed cholecystectomy with liver bed resection. Macroscopic observation of the resected specimen showed widespread granular mucosa and short elevated lesion. A discolored polyloid lesion about 5 mm in size was located near the main elevated lesion. The pathological findings revealed early gallbladder carcinoma and widespread dysplasia. The polypoid lesion was diagnosed as hyperplastic polyp of pylorus metaplasia, the surface of which was covered by carcinoma. In this present case, a carcinoma and a hyperplastic polyp coexisted in very impressive shape.

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