INTRODUCTION: The rate of cholecystectomy in northwestern Ontario is double the provincial rate. This paper explores the demographics of cholecystectomy and the role for rural endoscopic retrograde cholangiopancreatography (ERCP) services in the central part of this region.METHODS: We conducted a literature review of ERCP services and cholecystectomy rates, as well as a hospital chart review of patients who underwent laparoscopic cholecystectomies in Sioux Lookout, Ont. We contacted surgeons and gastroenterologists from referral centres in Winnipeg, Man., and Thunder Bay, Ont., for the charts of patients from our catchment area who underwent ERCP.RESULTS: Patients in our region who require urgent and emergent surgery are flown by fixed-wing aircraft to referral centers in Winnipeg and Thunder Bay for assessment and surgery. The rate of ERCP in our population is 150 in 100 000, which is threefold that of other populations, and our cholecystectomy rate is the highest in Ontario.CONCLUSION: Substantial savings in transportation expenses would offset the development costs of an ERCP program and provide more integrated patient care. The volume of patients would support maintenance of competency. This rural area with a high rate of gallbladder disease would benefit from the development of a rural ERCP program.