Goals: To assess the outcome differences following different precut biliary sphincterotomy needle-knife techniques. Background: Precut biliary needle-knife sphincterotomy (NKS) allows biliary access when standard cannulation techniques fail. Little comparative data exist on the outcome of precut NKS. Study: Retrospective comparison of outcome differences of three NKS techniques performed by three pancreaticobiliary endoscopists at a tertiary referral center. Results: A total of 139 consecutive biliary NKS were performed. In 44 cases (technique A), NKS was performed using a precut fistulotomy technique avoiding the papillary orifice, with pure cutting current, and occasional pancreatic duct (PD) stenting (6 of 44). In 47 cases (technique B), NKS was performed starting from the papillary orifice cutting upward with blended current, and no PD stenting. In 48 cases (technique C), NKS was performed as B but using pure cutting current and frequent PD stenting (15 of 48).NKS was successful in 95.5% ,95.7% , and 89.6% at initial endoscopic retrograde cholangiopancreatography and 100% , 97.8% , and 95.6% after a second endoscopic retrograde cholangiopancreatography. Total complications were not significantly different between the three groups; however, a lower incidence of pancreatitis occurred using technique A compared with techniques B and C (not significant). Conclusions: NKS techniques result in a high success rate of biliary cannulation with a similar overall complication rate. Avoiding cutting at the papillary orifice may reduce the risk of pancreatitis. When cutting at the papillary orifice, pancreatic duct stenting, pure cutting current, or both may reduce the incidence of pancreatitis. Goals: To assess the outcome differences following the different precut biliary sphincterotomy needle-knife techniques. Background: Precut biliary needle-knife sphincterotomy (NKS) allows biliary access when standard cannulation techniques fail. Little comparative data exist on the outcome of precut NKS. Study: Retrospective comparison of outcome differences of three NKS techniques performed by three pancreaticobiliary endoscopists at a tertiary referral center. Results: A total of 139 consecutive biliary NKS were performed. In 44 cases (technique A), NKS was performed using a precut fistulotomy technique avoiding the papillary orifice, with pure cutting current, and occasional pancreatic duct (PD) stenting (6 of 44). In 47 cases (technique B), NKS was performed starting from the papillary orifice cutting upward with blended current, and no PD stenting. In 48 cases (technique C), NKS was performed as B but using pure cutting current and frequent PD stenting (15 of 48) .NKS was successful in 95.5%, 95.7%, and 89.6% at initial endoscopic retrograde cholangiopancreatography and 100%, 97.8%, and 95.6% after a second endoscopic retrograde cholangiopancreatography. However, a lower incidence of pancreatitis using techniques A compared with techniques B and C (not significant). Conclusions: NKS techniques result in a high success rate of biliary cannulation with a similar overall complication rate. Avoiding cutting at the papillary orifice may reduce the risk of pancreatitis. the papillary orifice, pancreatic duct stenting, pure cutting current, or both may reduce the incidence of pancreatitis.