The Bo\u161koski-Costamagna ERCP Trainer: From dream to reality

We read with interest the article by Jovanovic et al. on the initial validation of a new mechanical endoscopic retrograde cholangiopancreatography (ERCP) training model [1]. Five trainees and five endoscopists, with and without ERCP experience, were involved in the evaluation of the model. The conclusion was that the model is a useful tool for ERCP training, particularly in improving the position of the scope, handling the wheels and the elevator, targeting the papilla, selectively cannulating the biliary and pancreatic ducts, extracting stones, and placing plastic and metal stents. ERCP is a complex procedure. Teaching the procedure is demanding, as it is difficult to explain the complexity of movements needed to maintain a correct and stable position in front of the papilla. In ERCP it is always a matter of keeping the right axis; if the axis is wrong, the chance of deep cannulation decreases dramatically. The basic issue is therefore how to teach movements to achieve a proper axis. A simple mechanical model to guide fellows on how to reach the correct position in front of the papilla, before they receive training on patients, was therefore imagined. The idea of this ERCP training model (the Bo\u161koski-Costamagna ERCP Trainer; Cook Medical, Limerick, Ireland) arose at the end of 2010. The very first prototype was designed and then built using wires, parts from used accessories, plastic tubes, and sutures ([Fig.\u200a1]). This prototype already had bile and pancreatic ducts, and could be assembled to present different grades of ERCP difficulty. A working team was then created, endorsed by the European Endoscopy Training Center in Rome, with the goal of implementing and further developing the prototype. ERCP training modules were organized, and feedback was collected in order to improve the model. Zoom ImageZoom Image Fig.\u200a1\u2003The Bo\u161koski-Costamagna ERCP Trainer. a The original model (invented by Dr. Ivo Bo\u161koski). b The original model with a duodenoscope. The ERCP simulator was immediately regarded as a useful tool by the trainees. Fellows learned how to move in front of the papilla in order to attain a proper axis and to achieve deep cannulation. Fellows became familiar with movements that are usually difficult to teach and to learn, without losing time in orientation in front of the papilla and without any risk. On the basis of these positive comments, the prototype was then further developed, produced, and distributed. The current version of the ERCP Trainer ([Fig.\u200a2]) is light enough to be transported easily, may simulate different patient positions (prone, oblique, supine), and comes with several easily exchangeable modules featuring variations of the papillary anatomy and biliopancreatic junction. Zoom ImageZoom Image Fig.\u200a2\u2003The second-generation Bo\u161koski-Costamagna ERCP Trainer, which is currently available. It was, indeed, with surprise that we read about this initial validation and the good results reported in the article by Jovanovic et al. These authors used the first generation of the Bo\u161koski-Costamagna ERCP Trainer. The second generation of the ERCP Trainer is currently available, and a third, which will have more advanced features including fluoroscopy, is in development. Although our personal experience and that of Jovanovic et al. are encouraging, further trials are needed. For this purpose, a large multicenter study has been designed in order to identify the role of the training model and to prove the relevance of the ERCP Trainer in training programs