In the 1920s bile duct imaging was performed by surgeons Evarts Graham and Warren Cole with the use of intravenously administered iodinated phenolphthalein that was selectively excreted into the bile and recorded radiographically. Oral cholecystography and percutaneous skinny “Chiba” needle cholangiography were subsequently developed to improve the visualization of the bile duct.^1,² What defied the clinician was a nonoperative technique to image the pancreatic duct. In 1965 two innovative radiologists, Rabinov and Simon,³ fashioned a bendable catheter that was inserted through a peroral basket catheter. The medial duodenal wall was “blindly scratched” with the tip of the catheter and resulted in the first nonoperative pancreatogram (Fig. 1.1). In eight attempts, Ravinov and Simon obtained an interpretable pancreatogram in two patients. The gastrointestinal endoscopist now entered the arena. William McCune and his surgical colleagues at George Washington University (Washington, D.C.) are credited with the first report of endoscopic cannulation of the ampulla of Vater in living patients.⁴ McCune used an Eder fiberoptic duodenoscope (Eder Instrument Company, Chicago), which had both a forward and side lens and an endotracheal-type cuff placed on the scope just beyond the lens. The balloon was inflated and deflated to enable adequate focal length for mucosal visualization. McCune taped a small-diameter plastic tube that served as a tract to the endoscope and could house a bendable cannula. The cannula was advanced to the major duodenal papilla under endoscopic guidance. McCune’s cannulation success rate was only 25% (50% duodenal intubation and 50% pancreatic duct opacification) in his report of 50 patients. In his discussion of the first reported series, McCune stated: “Anyone who looks through one of these instruments has to have 2 personality characteristics. First, he has to be honest, and secondly, you have to have an undying, blind, day and night, uncompromising persistence.” ERCP was born, and slowly grew to an established technique due to the honesty and persistence of endoscopic pioneers.

Fig. 1.1 In 1965 two innovative radiologists, Rabinov (A) and Simon from the University of Chicago, fashioned a bendable catheter (B) that was inserted through a peroral basket catheter. The medial duodenal wall was “blindly scratched” with the tip of the catheter and the first pancreatogram was successfully obtained nonoperatively (C). In eight attempts, Rabinov and Simon were successful in obtaining an interpretable pancreatogram in two patients.

In March 1969 in Japan, Oi (Fig. 1.2) and colleagues—in close collaboration with Machida (Machida Endoscope, Ltd., Tokyo) and Olympus corporations (Olympus Optical Co., Ltd., Tokyo)—developed a side-viewing fiberoptic duodenoscope with a channel and an elevator lever to enable manipulation of the cannula. Initially, Oi was able to visualize the ampulla in about half of 105 cases.⁵ In a subsequent report, Oi was able to cannulate the papilla in 41 of 53 patients (71%) without significant morbidity.⁶ By 1972 Jack Vennes and Steven Silvis of the University of Minnesota had published the experience in their first 80 attempts at cannulation of the bile and pancreatic ducts, paving the way for acceptability in the American endoscopic wilderness (Table 1.1).^7,⁸ Over the next 5 years, pioneers with the names Safrany, Cotton, Geenen, Siegel, Classen, and Demling and the Japanese groups (Fig. 1.3) embraced this new technique and reported on the successes (cannulation rates >90%) (Fig. 1.4), the shortcomings (PEP), the nuances (variety of cannula types, cannulation angles), and the practical application of ERCP in our understanding of biliary and pancreatic disorders.⁹^–¹⁵ But what could we as endoscopists do with this newfound knowledge?