Stricter national standards are required for credentialing of endoscopic-retrograde-cholangiopancreatography in the United States

Table 4 Grading System for endoscopic-retrograde-cholangiopancreatography difficulty

Grading system for ERCP
Grade I
Deep cannulation of CBD or main pancreatic duct
Extraction of small-to-medium (≤ 10 mm) biliary stones
Biliary stenting for leaks
Grade II
Treatment of extra-hepatic benign or malignant ductal strictures
Placement of prophylactic pancreatic stents
Extraction of larger biliary stones
Grade III
Pancreatic stricture dilation and stenting
Removal of mobile pancreatic stones ≤ 5 mm
Hilar tumor stenting
Treatment of hilar and intrahepatic biliary stricture
Sphincter of Oddi manometry
Limited pancreatic sphincterotomy
Removal of migrated pancreatic stents
Grade IV
Removal of impacted and larger pancreatic stones
Pseudocyst drainage or necrosecetomy
Ampullectomy
ERCP in patient with altered anatomy (e.g., status post Billroth II surgery)
Minor papilla therapy
Grade V
“Rendezvous” procedure to access and stent the biliary and pancreatic systems - requires endoscopic ultrasound training

Adapted with modifications from Cotton[3]. ERCP: Endoscopic retrograde cholangiopancreatography; CBD: Common bile duct.