The most important lesson learned from this Italian study of ERCP complications is that the experience of the endoscopist is important in determining the outcome of ERCP. This is reflected not only in lower complication rates for experienced endoscopists, but in higher success rates as well. Higher technical success rates may be at least as important as avoidance of complications in determining outcome of ERCP. With failed attempts at therapeutic ERCP, complications are no less common, but extended hospital stay, need for repeat procedures, and additional costs are substantial. How much experience and training are required for an endoscopist to become effective at ERCP? A recent study by Jowell et al. showed that trainees required 180 to 200 supervised procedures to achieve even the modest success rate of 70% at deep bile duct cannulation. It is not known, however, how much ongoing experience is required to maintain proficiency. In the Italian study, centers performing less than 200 ERCP per year had less satisfactory results than higher volume centers, but the case volume of the individual endoscopist may be of ultimate importance. In our study, a reduction in rate of complications and failed bile duct access was observed for endoscopists performing more than 50 biliary sphincterotomies a year, probably representing at least 100 to 150 ERCPs annually. Only a minority of endoscopists in the United States are likely to achieve this volume: an older survey of practicing gastroenterologists in the United States showed that the median number of ERCPs performed per year was 30 procedures, and 25% did five or fewer ERCPs per year, a figure which is incompatible with satisfactorily high success rates and low complication rates. There is also substantial variation in performance between individual endoscopists. A recent survey in the United Kingdom showed surprisingly wide differences between endoscopists in success rates (from 76% to 95%) and serious complications (0% to 16%). This variation in practice and outcomes seems unacceptably high.