Since its introduction nearly 50 years ago, there has been considerable evolution in the practice and performance of ERCP. On the one hand, therapeutic ERCP has supplanted surgical and percutaneous radiologic procedures to emerge as the dominant method for pancreaticobiliary intervention. In other instances, the role of ERCP has been eroded by competing technologies, revised by controlled data which question the risk/benefit profile of ERCP-guided intervention for specific indications, and challenged by systems issues such as duodenoscope reprocessing.