Abstract
Even in the hands of experienced endoscopists, biliary cannulation may fail in up to 5%-10% of all endoscopic retrograde cholangio-pancreatography (ERCP) procedures. Several precut techniques have been performed with either a needle-knife sphincterotome or a pull type sphincterotome to increase the rate of cannulation. Needle-knife precutting papillotomy (NKPP) is one of the standard precut technique. However, NKPP has been considered a risk factor for adverse events such as post-ERCP pancreatitis, bleeding and perforation. NKPP starting at the orifice is in particular the most basic maneuver among the precut techniques, but it has been considered more hazardous than the other precut techniques. Therefore, it is required to master this maneuver to become an expert. The goals of our NKPP procedure are incision of the narrow distal segment and separation of the biliary and pancreatic ducts. To achieve this, it is important to identify the sphincter and inner bile duct mucosa after cutting with the needle-knife. There are two critical points when performing Ban NKPP. The first point is understanding the anatomy of the ampulla of Vater, and the second is to precisely control the length, direction and depth of the incision. Understanding these points provides a more safe and effective precut technique.