Impact of papillary morphology and diverticular type on needle-knife precut sphincterotomy in patients with periampullary diverticulum with difficult biliary cannulation

Impact of papillary morphology and diverticular type on needle-knife precut sphincterotomy in patients with periampullary diverticulum with difficult biliary cannulation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of papillary morphology and diverticular type on needle-knife precut sphincterotomy in patients with periampullary diverticulum with difficult biliary cannulation Sheng-Fu Wang, Chi-Huan Wu, Mu-Hsien Lee, Yung-Kuan Tsou, Cheng-Hui Lin, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4444498/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background and Aims Several studies have investigated the relationship between the technical success of ERCP and periampullary diverticulum (PAD), but only limited studies have specifically examined advanced cannulation techniques such as needle-knife precut sphincterotomy (NKPS). This study aimed to explore the outcomes of NKPS in patients with PAD. Methods This retrospective study was conducted on 122 patients with PAD who underwent NKPS due to difficult biliary cannulation. Patient characteristics, ERCP indications, CBD diameter, PAD classification, diverticular size, major duodenal papilla (MDP) morphology, and post-ERCP adverse events were assessed. We analyzed factors associated with the outcomes of NKPS in patients with PAD, with a specific focus on the type of PAD and the morphology of MDP. Results Among 122 patients, 82 (67.2%) belonged to the NKPS success group and 40 (32.8%) belonged to the NKPS failure group. Diverticular size was significantly larger in the NKPS failure group. For type I, type II, and type III PAD, the median dimeters of diverticula were 1.2 cm, 0.9 cm, and 0.5 cm, respectively ( P <0.001), and the NKPS success rates were 50%, 66.3%, and 75%, respectively ( P =0.391). Regarding MDP morphology, the NKPS success rates were 73.7%, 38.2%, 92.9%, and 82.4% for types I, II, III, and IV MDP, respectively ( P =0.059). The overall adverse event rate was 16.4%, including pancreatitis (6.6%), delayed bleeding (5.7%), and cholangitis (4.1%). There were no significant differences in adverse event rates between the NKPS success and failure groups. Multivariate analysis showed that MDP morphology (type II vs. type I, OR: 0.256, 95% CI: 0.089-0.734, P =0.011) and bleeding during NKPS (OR: 0.117, 95% CI: 0.039-0.351, P < 0.001) were independent factors associated with NKPS outcome. Conclusions MDP morphology and bleeding during NKPS are independent predictors of NKPS failure in PAD patients with difficult biliary cannulation. Figures Figure 1 Figure 2 Introduction The successful performance of endoscopic retrograde cholangiopancreatography (ERCP) in treating biliary diseases relies significantly on the crucial step of selective biliary cannulation (SBC). Nevertheless, even experienced endoscopists encounter a failure rate of 5–15% when employing conventional biliary cannulation methods for SBC 1 . One reported contributing factor to this failure is the presence of a periampullary diverticulum (PAD) 2 . The presence of PAD can influence the outcome of ERCP by potentially altering the location and orientation of the ampulla. Notably, the literature reports varying rates of successful SBC in the presence of PAD, ranging from 64.5–89.4% 3–5 . The type of PAD may account for the wide variation in SBC success rates 5 , 6 . The diverse SBC success rates may be attributed to the type of PAD, with three classifications existing in the literature based on the major papilla's location relative to the diverticulum 6 – 8 . Among these classifications, the Boix classification, encompassing three PAD types, is likely the most commonly employed 8 . For patients encountering difficulty with conventional cannulation methods due to PAD, guidelines propose precut sphincterotomy as an alternative cannulation technique 9 . However, needle-knife precut sphincterotomy (NKPS), which includes needle-knife papillotomy (NKP) and needle-knife fistulotomy (NFK), does not consistently achieve SBC 10 , 11 . Our previous study indicated a significant association between PAD and NKP failure in univariate analysis, although not in multivariate analysis 12 . Given the variability of PAD among patients, the type of PAD may influence the success of NKPS in PAD patients. Additionally, as the major duodenal papilla (MDP) serves as the gateway to the common bile duct (CBD), the morphology of MDP may also impact the SBC rate in PAD patients undergoing NKPS 13 – 15 . Despite this importance, there are currently no reports on the influence of PAD type and MDP morphology in PAD patients undergoing NKPS due to difficult biliary cannulation. Therefore, this study aims to analyze factors associated with the outcomes of NKPS in patients with PAD, with a specific focus on the type of PAD and the morphology of MDP. Patients and Methods Between January 2004 and December 2020, a total of 592 patients who underwent NKPS due to difficult bile duct cannulation during the ERCP were retrospectively selected from the database of the Therapeutic Endoscopic Center of our institution. Among them, 122 patients (20.6%) with PAD were included in this study. The patients were divided into two groups: the NKPS success group, in which SBC was successfully achieved after NKPS, and the NKPS failure group, where SBC could not be achieved despite NKPS. Comprehensive data, encompassing patient characteristics (age, gender), ERCP indications (choledocholithiasis, benign or malignant stricture, and bile leakage), CBD diameter, bleeding during NKPS, morphology of MDP, classification of PAD, diverticular size, and post-ERCP adverse events (pancreatitis, cholangitis, bleeding, and perforation), were extracted from medical and imaging records. ERCP and NKPS procedures The details of ERCP and NKPS procedures were described in our previous study 12 . In short, the standard cannulation method using a cannula or sphincterotomy, and sometimes the double guidewire method by some endoscopists after the failure of the standard cannulation methods, were considered conventional cannulation methods in this study. Difficult biliary cannulation was defined when the conventional cannulation methods failed to achieve SBC. NKPS was performed for patients with difficult biliary cannulation during the same session of ERCP. The definition of procedure-related adverse events was based on the lexicon for endoscopic adverse events published by ASGE 16 . Rectal nonsteroidal anti-inflammatory drugs were not used to prevent post-ERCP pancreatitis in this study. Classification of periampullary diverticulum PAD was divided into three types according to the Boix classification 8 . Type I was the papilla within the diverticulum (Fig. 1 A); Type II was the papilla at the margin of the diverticulum (Fig. 1 B); Type III was the papilla near the diverticulum (Fig. 1 C). We measured the diameter of the PAD from the endoscopic image using a cannula or sphincterotome as a comparison caliper. Morphology of major duodenum papilla According to the classification proposed by the Scandinavian group, the morphology of MDP was divided into four types: type 1, regular papilla (Fig. 2 A); type 2, small papilla (Fig. 2 B); type 3, protruding or pendulous papilla (Fig. 2 C); Type 4, creased or ridged papilla (Fig. 2 D) 14 . Statistical analysis In both the text and tables, continuous variables were presented as medians with ranges, while categorical variables were expressed as numbers (percentages). To compare the NKPS success and failure groups, the Mann–Whitney U test was employed for continuous variables, and Chi-square or Fisher's exact tests were used for categorical variables. Logistic regression analysis was conducted to identify factors associated with NKPS success or failure. A two-tailed P -value of < 0.05 was considered statistically significant. All statistical analyses were executed using Statistical Product and Service Solutions (SPSS, version 26, IBM, Armonk, NY, USA). Results A total of 122 patients participated in the study, with 82 (67.2%) classified in the NKPS success group and 40 (32.8%) in the NKPS failure group. Results between NKPS success group and NKPS failure group Table 1 outlines comprehensive baseline characteristics for all included patients. The median age was 75 years, with 49.2% being male. No significant differences in age or gender were noted between the two groups. Choledocholithiasis was the predominant ERCP indication in 86.1% of cases, with no significant intergroup variations for each indication. The median CBD diameter was 1.1 cm and did not show significant differences between the success and failure groups. Diverticula were categorized as type I (8/122 or 6.6%), type II (86/122 or 70.5%), and type III (28/122 23%), with no statistically significant differences for each type between the two groups. However, the median diverticulum diameter was 0.8 cm, and it was significantly larger in the NKPS failure group (0.8 cm vs. 1 cm, P = 0.001). MDP types I, II, III, and IV had incidence rates of 46.7%, 27.9%, 11.5%, and 13.9%, respectively. Among the four types, the proportion of type II MDP was significantly lower in the NKPS success group (15.9% vs. 52.5%, P < 0.001), while the proportion of type III MDP was significantly higher (15.9% vs. 2.5%, P = 0.03). Immediate bleeding during primary ERCP occurred in 22.9% of patients, and it was more frequent in the NKPS failure group (12.2% vs. 45%, P < 0.001). Thirty-two patients (26.2%) underwent pancreatic stenting. Pancreatic stent placement was at the discretion of each endoscopist, and there was no significant difference in the frequency of pancreatic stent placement between the NKPS success and NKPS failure groups (28% vs. 22.5%, P = 0.662). Among the patients with surgically altered anatomy (5 in total), 4 were in the NKPS success group, and 1 was in the NKPS failure group (p = 0.736). The overall adverse event rate was 16.4%, including pancreatitis (6.6%), delayed bleeding (5.7%), and cholangitis (4.1%). In the NKPS success group, the incidence of pancreatitis was 4.9%, compared to 10% in the NKPS failure group (p = 0.283). For delayed bleeding, the incidence was 6.1% in the NKPS success group and 5% in the NKPS failure group (p = 0.807). Cholangitis occurred in 4.9% of the NKPS success group and 2.5% of the NKPS failure group (p = 0.534). Notably, there were no instances of perforation in either group. Table 1 Characteristics of the patients in the NKPS success and failure groups Overall (n = 122) NKPS success group (n = 82) NKPS failure group (n = 40) P -value Age, years (range) 75 (35-94) 75 (35-94) 76 (51-92) 0.654 Male, n 60 (49.2%) 42 (51.2%) 18 (45%) 0.519 Indication of ERCP, n Choledocholithiasis 105(86.1%) 70(85.3%) 35(87.5%) 0.585 Malignant stricture 11(9%) 7(8.5%) 4(10.0%) 0.235 Benign stricture 3(2.5%) 2(2.4%) 1(2.5%) 0158 Bile leakage 3(2.5%) 3(8.5%) 0(0.0%) 0.244 CBD diameter, cm 1.1 (0.3-3.0) 1.1(0.3-2.7) 1.0(0.4-3.0) 0.336 Type of diverticulum, n Type I 8 (6.6%) 4(4.9%) 4(10.0%) 0.179 Type II 86 (70.5%) 57(69.5%) 29(72.5%) 0.078 Type III 28 (23.0%) 21(25.6%) 7(17.5%) 0.123 Diverticulum size, cm 0.8 (0.2-2) 0.8 (0.2-2) 1.0 (0.3-1.9) 0.001 Morphology of papilla, n Type I 57(46.7%) 42(51.2%) 15(37.5%) 0.154 Type II 34(27.9%) 13(15.9%) 21(52.5%) < 0.001 Type III 14(11.5%) 13(15.9%) 1(2.5%) 0.030 Type IV 17(13.9%) 14(17.1%) 3(7.5%) 0.158 Bleeding during NKPS, n 28(22.9%) 10(12.2%) 18(45.0%) < 0.001 Pancreatic stent 32 (26.2%) 23 (28.0%) 9 (22.5%) 0.662 Surgically altered anatomy, n 5 4 1 0.736 B-II anastomosis 4(3.3%) 3(3.7%) 1(2.5%) 0.689 Roux-en-Y anastomosis 1(0.8%) 1(1.2%) 0 0.998 Adverse events of ERCP, n Overall 20 (16.4%) 13 (15.9%) 7 (17.5%) 0.485 Pancreatitis 8(6.6%) 4(4.9%) 4(10.0%) 0.283 Delayed bleeding 7(5.7%) 5(6.1%) 2(5.0%) 0.807 Cholangitis 5(4.1%) 4(4.9%) 1(2.5%) 0.534 Perforation 0 0 0 0.999 Abbreviations: ERCP: endoscopic retrograde cholangiopancreatography; CBD: common bile duct; NKPS: needle-knife precut sphincterotomy; B-II: Billroth-II Results based on diverticular type Table 2 summarizes patient characteristics and outcomes based on diverticular type. Type I PAD are predominantly male (87.5%), while type II and III diverticula are evenly distributed between males and females (p = 0.074). Regarding the indications for ERCP, the main indication for type I PAD was malignant biliary stricture (75%), whereas the main indication for type II and type III PAD was choledocholithiasis (88.4% and 78.6%, respectively) (p = 0.076 ). There was no significant difference in median CBD diameter between each type of PAD. There were significant differences in diverticula size within each type of PAD, with diverticula sizes of 1.2 cm, 0.9 cm, and 0.5 cm in type I, type II, and type III PAD, respectively (p < 0.001). Type III PAD had the highest NKPS success rate (75%), followed by type II PAD (66.3%); type I PAD had the lowest SBC success rate (50%). However, the differences did not reach statistical significance (p = 0.391). The occurrence rates of adverse events, such as pancreatitis (0%, 8.1%, and 3.6% for PAD types I, II, and III, respectively; p = 0.164), delayed bleeding (12.5%, 8.1%, and 3.6% for PAD types I, II, and III, respectively; p = 0.225), and cholangitis (0%, 1.2%, and 14.3% for PAD types I, II, and III, respectively; p = 0.365), showed no significant differences among the three PAD types. Table 2 Patient characteristics and outcomes based on diverticular type Type I (n = 8) Type II (n = 86) Type III (n = 28) P -value Age, years 69.5 (69-74.8) 77 (66–84) 72 (62–79) 0.188 Male, n (%) 7 (87.5%) 39 (45.3%) 14 (50%) 0.074 Indication of ERCP, n Choledocholithiasis 1 (12.5%) 76 (88.4%) 22 (78.6%) 0.088 Malignant stricture 6 (75.0%) 7 (8.1%) 3(10.7%) 0.136 Benign stricture 1 (12.5%) 1 (1.2%) 2(7.1%) 0.255 Bile leakage 0 2 (2.4%) 1(3.6%) 0.263 CBD diameter, cm 1.4(0.5–2.8) 1.1(0.3-3.0) 1.0(0.6-8.0) 0.859 Diverticulum size, cm 1.2(0.5–1.9) 0.9(0.3-2.0) 0.5(0.2–1.9) < 0.001 NKPS success, n 4 (50%) 57 (66.3%) 21 (75%) 0.3910 Adverse events, n Overall 1(12.5%) 15(17.4%) 6 (21.5%) 0.385 Pancreatitis 0 7(8.1%) 1(3.6%) 0.164 Delayed bleeding 1(12.5%) 7(8.1%) 1(3.6%) 0.225 Cholangitis 0 1(1.2%) 4(14.3%) 0.365 Abbreviations: ERCP: endoscopic retrograde cholangiopancreatography; CBD: common bile duct; NKPS: needle-knife precut sphincterotomy Results based on papillary morphology Table 3 . revealed the outcomes based on different type of morphology of major papilla. Immediate bleeding incidence during NKPS was 19.3%, 26.5%, 21.4%, and 29.4% for MDP types I, II, III, and IV, respectively (p = 0.29). The corresponding success rates of NKPS were 73.7%, 38.2%, 92.9%, and 82.4% for patients with MDP types I, II, III, and IV, respectively (p = 0.059). The occurrence rates of adverse events, such as pancreatitis (7%, 2.9%, 0%, and 17.6% for MDP types I, II, III, and IV, respectively; p = 0.162), delayed bleeding (5.3%, 2.9%, 14.3%, and 5.9% for MDP types I, II, III, and IV, respectively; p = 0.492), and cholangitis (3.5%, 5.9%, 7.1%, and 0% for MDP types I, II, III, and IV, respectively; p = 0.71), showed no significant differences among the four MDP types. Table 3 Outcomes based on morphology of major duodenal papilla Type I (n = 57) Type II (n = 34) Type III (n = 14) Type IV (n = 17) P -value Bleeding during NKPS 11 (19.3%) 9(26.5%) 3(21.4%) 5(29.4%) 0.290 NKPS success, n 42(73.7%) 13(38.2%) 13(92.9%) 14(82.4%) 0.059 Adverse events, n Overall 9(15.8%) 4(11.7%) 3(21.4%) 4(23.5%) 0.884 Pancreatitis 4(7.0%) 1(2.9%) 0 3(17.6%) 0.162 Delayed bleeding 3(5.3%) 1(2.9%) 2(14.3%) 1(5.9%) 0.492 Cholangitis 2(3.5%) 2(5.9%) 1(7.1%) 0 0.710 Abbreviations: NKPS: needle-knife precut sphincterotomy Factors associated with NKPS outcomes Univariate and multivariate analyses were performed to identify factors associated with NKPS outcomes, as shown in Table 4 . Univariate analysis showed that MDP morphology (Type II vs. type I, odds ratio [OR]: 0.221, 95% confidence interval [CI]: 0.089–0.549], p = 0.001), diverticulum size (OR: 0.213, 95% CI: 0.082–0.555, p = 0.002), and bleeding during NKPS (OR: 0.170, 95% CI: 0.068–0.421, p < 0.001) were significantly associated with the outcome of NKPS. Multivariate analysis showed that MDP morphology (Type II vs. type I, OR: 0.256, 95% CI: 0.089–0.734, p = 0.011) and bleeding during NKPS (OR: 0.117, 95% CI: 0.039–0.351, p < 0.001) were independent factors associated with NKPS outcome. Table 4 Univariate and multivariate analyses of the factors associated with needle knife precut sphincterotomy success or failure Variables Univariate analysis Multivariate analysis OR (95% CI) P -value OR (95% CI) P -value Age > 70 y 1.071(0.486–2.361) 0.864 ≤ 70 y Referent Gender Male 1.283(0.601–2.740) 0.519 Female Referent Choledocholithiasis Yes 0.500(0.054–4.626) 0.570 No Referent Malignant biliary stricture Yes 0.840(0.231–3.055) 0.791 No Referent CBD diameter (cm) > 6 mm 1.029(0.327–3.239) 0.962 ≤ 6 mm Referent Morphology of papilla Type II 0.221(0.089–0.549) 0.001 0.331(0.123–0.887) 0.028 Type III 4.643(0.559–38.590) 0.155 9.122(0.886–93.924) 0.063 Type IV 1.667(0.420–6.620) 0.468 2.66(0.572–12.373) 0.212 Type I Referent Referent Type of diverticulum Type I 0.333(0.065–1.699) 0.402 Type II 0.655(0.250–1.720) 0.502 Type III Referent Diverticulum size Every 1 cm increase 0.213(0.082–0.555) 0.002 0.408(0.252–1.121) 0.202 Surgically altered anatomy Yes 1.481 0.737 No Referent Referent Bleeding during NKPS Yes 0.170(0.068–0.421) < 0.001 0.117(0.039–0.351) < 0.001 No Referent Referent Endoscopist B + C + D + E 0.898 0.688 A Referent Pancreatic stent Yes 1.343(0.554–3.253) 0.514 no Referent Abbreviations: CBD: common bile duct; NKPS: needle knife precut sphincterotomy; OR: odds ratio; CI: confidence interval; Discussion PAD is a factor that has been inconsistently linked to the success rates of SBC in patients undergoing ERCP 3 – 5 . As precut sphincterotomy in difficult cases increases the overall success rate of SBC by 25% points, this study adds valuable insights by examining the influence of PAD classification and MDP morphology on the outcomes of NKPS 9 . There is little data regarding precut sphincterotomy in patients with PAD 17 , 18 . Park et al. reported that among 33 patients with PAD who underwent NKF, type II PAD was the most common, and type I PAD was the least common, which was similar to our findings 18 . However, due to the small number of cases, they did not analyze the success rate of each type 18 . Our results show that type III PAD had the highest success rate (75%) and type I PAD had the lowest success rate (50%). This may be because that the location of the MDP in type III PAD is outside the diverticulum and is therefore minimally affected by the PAD, allowing the endoscopist to perform NKPS commonly with the highest success rate. In comparison, types I and II PAD have more papillae that are difficult to detect or access, or bile duct directions that are more unpredictable 19 . Fernandes et al compared NKF for flat papillae, intradiverticular papillae (corresponding to type I PAD, n = 14), and diverticular marginal papillae (corresponding to type II PAD, n = 14) and reported success rates of 93.9%, 64.3%, and 71.4% (p = 0.005), respectively 17 . They concluded that NKF is feasible in diverticular papillae, but the success rate of initial ERCP is relatively low, which is consistent with our results. The clinical influences of PAD size have rarely been studied. Kim et al. reported that CBD diameter was significantly related to PAD size and that patients with type I PAD had significantly larger CBD diameters than patients with type III PAD 20 . That is, type I PAD presented as larger while type III PAD tended to be smaller 20 . These findings were consistent with our results that type I PAD were significantly larger in size, followed by type II PAD, and type III PAD were significantly smaller. Furthermore, we found that the NKPS success group had a significantly smaller PAD size. However, the precise determination of PAD size is not straightforward. In our study, PAD diameter was measured through endoscopic imaging, whereas other studies used CT or MRCP, resulting in the median PAD diameter in our study being smaller compared with other reports 20 . Several studies have explored the influence of MDP morphology on the technical success of ERCP 14 , 15 , 21 . Since its introduction in 2017, the Scandinavian classification of MDP morphology has gradually gained acceptance due to its remarkable intra- and inter-observer agreement 9 , 14 , 21 , 22 . Based on this classification, Haraldsson et al. found that cannulating type II and type III MDPs is more difficult 21 . However, the Scandinavian classification lacks some important papillary subtypes, such as those associated with PAD. Nevertheless, the inclusion of type D to account for PAD, as reported by Mohamed et al., yielded similar findings, indicating increased difficulty in cannulating Type II and III MDPs compared to Type I 15 . Additionally, they observed a higher frequency of NKPS in types II, III, and IV MDP compared to Type I (p < 0.001). Our study further explored the correlation between MDP morphology and NKPS outcomes in patients with PAD: type II MDP had the lowest NKPS success rate (38.2%), whereas type III MDP had the highest NKPS success rate (92.9%). Because most endoscopists consistently perform the same type of precut sphincterotomy over time, different precut techniques based on MDP morphology may be considered to improve success rates in patients with PAD, especially type II MDP 9 , 23 , 24 . Several studies have suggested a potential link between MDP type and adverse events during ERCP 15 . However, in a study by Lyu et al. comparing the safety of NKP among various MDP types in patients with difficult biliary cannulation (8.3% of patients had PAD), no significant difference was found in the incidence of adverse events among the four MDP types 25 . Our findings were in line with this, albeit limited to patients with PAD. Additionally, our study revealed no significant differences in adverse event rates among the three types of PAD. Notably, perforation did not occur in our study, potentially due to its small sample size. Therefore, larger-scale studies may be necessary in the future. This study is subject to various limitations. It was conducted retrospectively and involved a sample size in which procedures were carried out by five endoscopists. Consequently, there may have been an introduction of selection bias and operator bias. Furthermore, although the incidence of adverse events in this study is consistent with previous studies, the limited sample size could potentially impact the results. In addition, because pancreatic stents can reduce the risk of pancreatitis after ERCP and may improve the outcome of NKPS 26 , the utilization rate of pancreatic stents was only 26.2%, which may have affected the results of this study. Therefore, future large-scale prospective studies are necessary to validate our findings. In conclusion, type II MDP morphology and significant bleeding during NKPS were significantly associated with NKPS failure in PAD patients with difficult bile duct cannulation, whereas type III MDP morphology had a trend toward increased NKPS success. These findings may have important implications for practitioners of ERCP, particularly in patients with type II MDP morphology, in whom techniques other than NKPS may be considered. Declarations Disclosures Approval for the study was obtained from the institutional review board of Chang Gung Memorial Hospital (IRB number: 202200541B0). Given the retrospective nature of the study utilizing routine clinical treatment and diagnostic medical records, the Chang Gung Medical Foundation Institutional Review Board granted a waiver for participant consent. All methodologies adhered to relevant guidelines and regulations. Competing interests: Dr. Sheng-Fu Wang, Chi-Huan Wu, Mu-Hsien Lee, Yung-Kuan Tsou, Cheng-Hui Lin, Kai-Feng Sung, Nai-Jen Liu declare that they have no financial or non-financial conflicts of interest. Author Contribution Conceptualization: S.-F.W. and C.-H.L.; Methodology: K.-F.S. and Y.-K.T.; Formal analysis and investigation: S.-F.W. and C.-H.W.; Writing—original draft preparation: S.-F.W.; Writing—review and editing: Y.-K.T.; Resources: Y.-K.T. and M.-H.L.; Supervision: N.-J.L. References Cennamo V, Fuccio L, Zagari RM, et al. 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Macroscopic appearance of the major duodenal papilla influences bile duct cannulation: a prospective multicenter study by the Scandinavian Association for Digestive Endoscopy Study Group for ERCP. Gastrointest Endosc. 2019; 90: 957–63. Angsuwatcharakon P, Thongsuwan C, Ridtitid W, et al. Morphology of the major duodenal papilla for the selection of advanced cannulation techniques in difficult biliary cannulation. Surg Endosc. 2023; 37: 5807–15. Zhang QS, Xu JH, Dong ZQ, Gao P, Shen YC. Success and Safety of Needle Knife Papillotomy and Fistulotomy Based on Papillary Anatomy: A Prospective Controlled Trial. Dig Dis Sci. 2022; 67: 1901–9. Horiuchi A, Nakayama Y, Kajiyama M, Tanaka N. Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla. Clin Gastroenterol Hepatol. 2007; 5: 1113–8. Lyu Y, Ye S, Wang B. Impact of duodenal papilla anatomy on needle knife papillotomy safety and efficacy in patients with difficult biliary canulation. BMC Surgery. 2024; 24: 61. Fogel EL, Sherman S, Lehman GA. Increased selective biliary cannulation rates in the setting of periampullary diverticula: main pancreatic duct stent placement followed by pre-cut biliary sphincterotomy. Gastrointest Endosc. 1998; 47: 396–400. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4444498","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":308765329,"identity":"08701172-9797-418b-b95f-5f48aee8b550","order_by":0,"name":"Sheng-Fu Wang","email":"","orcid":"","institution":"Chang Gung University","correspondingAuthor":false,"prefix":"","firstName":"Sheng-Fu","middleName":"","lastName":"Wang","suffix":""},{"id":308765331,"identity":"2d45af32-23ca-47ec-b1f0-98aa33701202","order_by":1,"name":"Chi-Huan Wu","email":"","orcid":"","institution":"Chang Gung University","correspondingAuthor":false,"prefix":"","firstName":"Chi-Huan","middleName":"","lastName":"Wu","suffix":""},{"id":308765332,"identity":"549dce0f-159b-48ce-a036-c3337b582aee","order_by":2,"name":"Mu-Hsien Lee","email":"","orcid":"","institution":"Chang Gung University","correspondingAuthor":false,"prefix":"","firstName":"Mu-Hsien","middleName":"","lastName":"Lee","suffix":""},{"id":308765335,"identity":"499022f3-f76e-400b-998d-e34b81aecdde","order_by":3,"name":"Yung-Kuan Tsou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYBAC9nYGhgMMDDZgkgFG4gU8h8HK0tC04NMJ0gIEh0nRwsxjeLjg13l5vmsHGD9+zbnDwC99/ALzxza8WgwOz+y7bTjzdgKztOy2ZwySfTkFDAfxaLEHaeHtuc244XYCG7PktsMMBmd4EhgObiNgC2/POXsStfD8OJAI0sL4EayF/QABLWwFh3kbkpNn3k5slmbcdphHsoeH4cDZf3i0sDdv/szzx86273bywY8/tx2W4+dhf/ig4gxuLQwMHAYMjODwYWxg5gGaAUQGB/BpACaZBwwMfyBMxh9wkVEwCkbBKBgFCAAAXytaGGW51qAAAAAASUVORK5CYII=","orcid":"","institution":"Chang Gung University","correspondingAuthor":true,"prefix":"","firstName":"Yung-Kuan","middleName":"","lastName":"Tsou","suffix":""},{"id":308765336,"identity":"bb67bd4d-3f87-4fa8-a3c7-66b07ac26e8f","order_by":4,"name":"Cheng-Hui Lin","email":"","orcid":"","institution":"Chang Gung University","correspondingAuthor":false,"prefix":"","firstName":"Cheng-Hui","middleName":"","lastName":"Lin","suffix":""},{"id":308765338,"identity":"58b8af37-ef87-4eee-9600-eebb5d309045","order_by":5,"name":"Kai-Feng Sung","email":"","orcid":"","institution":"Chang Gung University","correspondingAuthor":false,"prefix":"","firstName":"Kai-Feng","middleName":"","lastName":"Sung","suffix":""},{"id":308765339,"identity":"bce8d7e8-cc1d-4b28-9825-f334b7544d65","order_by":6,"name":"Nai-Jen Liu","email":"","orcid":"","institution":"Chang Gung University","correspondingAuthor":false,"prefix":"","firstName":"Nai-Jen","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2024-05-19 13:38:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4444498/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4444498/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57728801,"identity":"9c93e0a9-bd39-4334-b82e-1aafc6fb8191","added_by":"auto","created_at":"2024-06-04 21:49:26","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2713461,"visible":true,"origin":"","legend":"\u003cp\u003eBased on Boix classification, type I was the papilla within the diverticulum (A); type II was the papilla at the margin of the diverticulum (B); type III was the papilla near the diverticulum (C).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4444498/v1/228d7d159404ea80df209958.png"},{"id":57728802,"identity":"73ac45b4-9797-4c61-83e3-12c7304fa686","added_by":"auto","created_at":"2024-06-04 21:49:26","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":4157726,"visible":true,"origin":"","legend":"\u003cp\u003eBased on classification proposed by the Scandinavian group, the morphology of MDP was divided into four types: type 1, regular papilla (A); type 2, small papilla (B); type 3, protruding or pendulous papilla (C); Type 4, creased or ridged papilla (D).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4444498/v1/279cb325cded4c235ccb08c2.png"},{"id":62161288,"identity":"f702c131-d704-4b64-a700-7e6501ad1fbb","added_by":"auto","created_at":"2024-08-09 23:31:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":671098,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4444498/v1/2d00f990-dc22-45be-bfd6-292f46c97dea.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of papillary morphology and diverticular type on needle-knife precut sphincterotomy in patients with periampullary diverticulum with difficult biliary cannulation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe successful performance of endoscopic retrograde cholangiopancreatography (ERCP) in treating biliary diseases relies significantly on the crucial step of selective biliary cannulation (SBC). Nevertheless, even experienced endoscopists encounter a failure rate of 5\u0026ndash;15% when employing conventional biliary cannulation methods for SBC\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. One reported contributing factor to this failure is the presence of a periampullary diverticulum (PAD)\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. The presence of PAD can influence the outcome of ERCP by potentially altering the location and orientation of the ampulla. Notably, the literature reports varying rates of successful SBC in the presence of PAD, ranging from 64.5\u0026ndash;89.4%\u003csup\u003e3\u0026ndash;5\u003c/sup\u003e. The type of PAD may account for the wide variation in SBC success rates\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. The diverse SBC success rates may be attributed to the type of PAD, with three classifications existing in the literature based on the major papilla's location relative to the diverticulum\u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Among these classifications, the Boix classification, encompassing three PAD types, is likely the most commonly employed\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFor patients encountering difficulty with conventional cannulation methods due to PAD, guidelines propose precut sphincterotomy as an alternative cannulation technique\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. However, needle-knife precut sphincterotomy (NKPS), which includes needle-knife papillotomy (NKP) and needle-knife fistulotomy (NFK), does not consistently achieve SBC\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Our previous study indicated a significant association between PAD and NKP failure in univariate analysis, although not in multivariate analysis\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Given the variability of PAD among patients, the type of PAD may influence the success of NKPS in PAD patients. Additionally, as the major duodenal papilla (MDP) serves as the gateway to the common bile duct (CBD), the morphology of MDP may also impact the SBC rate in PAD patients undergoing NKPS\u003csup\u003e\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Despite this importance, there are currently no reports on the influence of PAD type and MDP morphology in PAD patients undergoing NKPS due to difficult biliary cannulation. Therefore, this study aims to analyze factors associated with the outcomes of NKPS in patients with PAD, with a specific focus on the type of PAD and the morphology of MDP.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003eBetween January 2004 and December 2020, a total of 592 patients who underwent NKPS due to difficult bile duct cannulation during the ERCP were retrospectively selected from the database of the Therapeutic Endoscopic Center of our institution. Among them, 122 patients (20.6%) with PAD were included in this study. The patients were divided into two groups: the NKPS success group, in which SBC was successfully achieved after NKPS, and the NKPS failure group, where SBC could not be achieved despite NKPS. Comprehensive data, encompassing patient characteristics (age, gender), ERCP indications (choledocholithiasis, benign or malignant stricture, and bile leakage), CBD diameter, bleeding during NKPS, morphology of MDP, classification of PAD, diverticular size, and post-ERCP adverse events (pancreatitis, cholangitis, bleeding, and perforation), were extracted from medical and imaging records.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eERCP and NKPS procedures\u003c/h2\u003e \u003cp\u003eThe details of ERCP and NKPS procedures were described in our previous study\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. In short, the standard cannulation method using a cannula or sphincterotomy, and sometimes the double guidewire method by some endoscopists after the failure of the standard cannulation methods, were considered conventional cannulation methods in this study. Difficult biliary cannulation was defined when the conventional cannulation methods failed to achieve SBC. NKPS was performed for patients with difficult biliary cannulation during the same session of ERCP. The definition of procedure-related adverse events was based on the lexicon for endoscopic adverse events published by ASGE\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Rectal nonsteroidal anti-inflammatory drugs were not used to prevent post-ERCP pancreatitis in this study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eClassification of periampullary diverticulum\u003c/h2\u003e \u003cp\u003ePAD was divided into three types according to the Boix classification\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Type I was the papilla within the diverticulum (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA); Type II was the papilla at the margin of the diverticulum (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB); Type III was the papilla near the diverticulum (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC). We measured the diameter of the PAD from the endoscopic image using a cannula or sphincterotome as a comparison caliper.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMorphology of major duodenum papilla\u003c/h3\u003e\n\u003cp\u003eAccording to the classification proposed by the Scandinavian group, the morphology of MDP was divided into four types: type 1, regular papilla (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA); type 2, small papilla (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB); type 3, protruding or pendulous papilla (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC); Type 4, creased or ridged papilla (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD)\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eIn both the text and tables, continuous variables were presented as medians with ranges, while categorical variables were expressed as numbers (percentages). To compare the NKPS success and failure groups, the Mann\u0026ndash;Whitney U test was employed for continuous variables, and Chi-square or Fisher's exact tests were used for categorical variables. Logistic regression analysis was conducted to identify factors associated with NKPS success or failure. A two-tailed \u003cem\u003eP\u003c/em\u003e-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant. All statistical analyses were executed using Statistical Product and Service Solutions (SPSS, version 26, IBM, Armonk, NY, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 122 patients participated in the study, with 82 (67.2%) classified in the NKPS success group and 40 (32.8%) in the NKPS failure group.\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003ch2\u003eResults between NKPS success group and NKPS failure group\u003c/h2\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e outlines comprehensive baseline characteristics for all included patients. The median age was 75 years, with 49.2% being male. No significant differences in age or gender were noted between the two groups. Choledocholithiasis was the predominant ERCP indication in 86.1% of cases, with no significant intergroup variations for each indication. The median CBD diameter was 1.1 cm and did not show significant differences between the success and failure groups. Diverticula were categorized as type I (8/122 or 6.6%), type II (86/122 or 70.5%), and type III (28/122 23%), with no statistically significant differences for each type between the two groups. However, the median diverticulum diameter was 0.8 cm, and it was significantly larger in the NKPS failure group (0.8 cm vs. 1 cm, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001). MDP types I, II, III, and IV had incidence rates of 46.7%, 27.9%, 11.5%, and 13.9%, respectively. Among the four types, the proportion of type II MDP was significantly lower in the NKPS success group (15.9% vs. 52.5%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while the proportion of type III MDP was significantly higher (15.9% vs. 2.5%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03). Immediate bleeding during primary ERCP occurred in 22.9% of patients, and it was more frequent in the NKPS failure group (12.2% vs. 45%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Thirty-two patients (26.2%) underwent pancreatic stenting. Pancreatic stent placement was at the discretion of each endoscopist, and there was no significant difference in the frequency of pancreatic stent placement between the NKPS success and NKPS failure groups (28% vs. 22.5%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.662). Among the patients with surgically altered anatomy (5 in total), 4 were in the NKPS success group, and 1 was in the NKPS failure group (p\u0026thinsp;=\u0026thinsp;0.736). The overall adverse event rate was 16.4%, including pancreatitis (6.6%), delayed bleeding (5.7%), and cholangitis (4.1%). In the NKPS success group, the incidence of pancreatitis was 4.9%, compared to 10% in the NKPS failure group (p\u0026thinsp;=\u0026thinsp;0.283). For delayed bleeding, the incidence was 6.1% in the NKPS success group and 5% in the NKPS failure group (p\u0026thinsp;=\u0026thinsp;0.807). Cholangitis occurred in 4.9% of the NKPS success group and 2.5% of the NKPS failure group (p\u0026thinsp;=\u0026thinsp;0.534). Notably, there were no instances of perforation in either group.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eCharacteristics of the patients in the NKPS success and failure groups\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003eOverall\u003c/p\u003e\n\u003cp\u003e(n = 122)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003eNKPS success group\u003c/p\u003e\n\u003cp\u003e(n = 82)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003eNKPS failure group\u003c/p\u003e\n\u003cp\u003e(n = 40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003eAge, years (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e75 (35-94)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e75 (35-94)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e76 (51-92)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e0.654\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003eMale, n\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e60 (49.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e42 (51.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e18 (45%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e0.519\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003eIndication of ERCP, n\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Choledocholithiasis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e105(86.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e70(85.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e35(87.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e0.585\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Malignant stricture\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e11(9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e7(8.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e4(10.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e0.235\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003eBenign stricture\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e3(2.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e2(2.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e1(2.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e0158\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003eBile leakage\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e3(2.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e3(8.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e0(0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e0.244\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003eCBD diameter, cm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e1.1 (0.3-3.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e1.1(0.3-2.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e1.0(0.4-3.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e0.336\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003eType of diverticulum, n\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;Type I\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e8 (6.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e4(4.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e4(10.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e0.179\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;Type II\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e86 (70.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e57(69.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e29(72.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e0.078\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; \u0026nbsp;Type III\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e28 (23.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e21(25.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e7(17.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e0.123\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003eDiverticulum size, cm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e0.8 (0.2-2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e0.8 (0.2-2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e1.0 (0.3-1.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003eMorphology of papilla, n\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Type I\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e57(46.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e42(51.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e15(37.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e0.154\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Type II\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e34(27.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e13(15.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e21(52.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Type III\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e14(11.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e13(15.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e1(2.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e0.030\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Type IV\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e17(13.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e14(17.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e3(7.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e0.158\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003eBleeding during NKPS, n\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e28(22.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e10(12.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e18(45.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003ePancreatic stent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e32 (26.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e23 (28.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e9 (22.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e0.662\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003eSurgically altered anatomy, n\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e0.736\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; B-II anastomosis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e4(3.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e3(3.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e1(2.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e0.689\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Roux-en-Y anastomosis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e1(0.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e1(1.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e0.998\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003eAdverse events of ERCP, n\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Overall\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e20 (16.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e13 (15.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e7 (17.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e0.485\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Pancreatitis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e8(6.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e4(4.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e4(10.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e0.283\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Delayed bleeding\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e7(5.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e5(6.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e2(5.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e0.807\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Cholangitis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e5(4.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e4(4.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e1(2.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e0.534\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Perforation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e0.999\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: ERCP: endoscopic retrograde cholangiopancreatography; CBD: common bile duct; NKPS: needle-knife precut sphincterotomy; B-II: Billroth-II\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003ch2\u003eResults based on diverticular type\u003c/h2\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes patient characteristics and outcomes based on diverticular type. Type I PAD are predominantly male (87.5%), while type II and III diverticula are evenly distributed between males and females (p\u0026thinsp;=\u0026thinsp;0.074). Regarding the indications for ERCP, the main indication for type I PAD was malignant biliary stricture (75%), whereas the main indication for type II and type III PAD was choledocholithiasis (88.4% and 78.6%, respectively) (p\u0026thinsp;=\u0026thinsp;0.076 ). There was no significant difference in median CBD diameter between each type of PAD. There were significant differences in diverticula size within each type of PAD, with diverticula sizes of 1.2 cm, 0.9 cm, and 0.5 cm in type I, type II, and type III PAD, respectively (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Type III PAD had the highest NKPS success rate (75%), followed by type II PAD (66.3%); type I PAD had the lowest SBC success rate (50%). However, the differences did not reach statistical significance (p\u0026thinsp;=\u0026thinsp;0.391). The occurrence rates of adverse events, such as pancreatitis (0%, 8.1%, and 3.6% for PAD types I, II, and III, respectively; p\u0026thinsp;=\u0026thinsp;0.164), delayed bleeding (12.5%, 8.1%, and 3.6% for PAD types I, II, and III, respectively; p\u0026thinsp;=\u0026thinsp;0.225), and cholangitis (0%, 1.2%, and 14.3% for PAD types I, II, and III, respectively; p\u0026thinsp;=\u0026thinsp;0.365), showed no significant differences among the three PAD types.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003ePatient characteristics and outcomes based on diverticular type\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eType I\u003c/p\u003e\n\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eType II\u003c/p\u003e\n\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;86)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eType III\u003c/p\u003e\n\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAge, years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e69.5 (69-74.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e77 (66\u0026ndash;84)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e72 (62\u0026ndash;79)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.188\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (87.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e39 (45.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14 (50%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.074\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIndication of ERCP, n\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCholedocholithiasis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (12.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e76 (88.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22 (78.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.088\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMalignant stricture\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (75.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (8.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3(10.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.136\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBenign stricture\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (12.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (1.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(7.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.255\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBile leakage\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (2.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(3.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.263\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCBD diameter, cm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.4(0.5\u0026ndash;2.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.1(0.3-3.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.0(0.6-8.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.859\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiverticulum size, cm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.2(0.5\u0026ndash;1.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.9(0.3-2.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.5(0.2\u0026ndash;1.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNKPS success, n\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (50%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e57 (66.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21 (75%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.3910\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAdverse events, n\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOverall\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(12.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15(17.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (21.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.385\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePancreatitis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7(8.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(3.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.164\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDelayed bleeding\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(12.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7(8.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(3.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.225\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCholangitis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4(14.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.365\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\"\u003eAbbreviations: ERCP: endoscopic retrograde cholangiopancreatography; CBD: common bile duct; NKPS: needle-knife precut sphincterotomy\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n\u003ch2\u003eResults based on papillary morphology\u003c/h2\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. revealed the outcomes based on different type of morphology of major papilla. Immediate bleeding incidence during NKPS was 19.3%, 26.5%, 21.4%, and 29.4% for MDP types I, II, III, and IV, respectively (p\u0026thinsp;=\u0026thinsp;0.29). The corresponding success rates of NKPS were 73.7%, 38.2%, 92.9%, and 82.4% for patients with MDP types I, II, III, and IV, respectively (p\u0026thinsp;=\u0026thinsp;0.059). The occurrence rates of adverse events, such as pancreatitis (7%, 2.9%, 0%, and 17.6% for MDP types I, II, III, and IV, respectively; p\u0026thinsp;=\u0026thinsp;0.162), delayed bleeding (5.3%, 2.9%, 14.3%, and 5.9% for MDP types I, II, III, and IV, respectively; p\u0026thinsp;=\u0026thinsp;0.492), and cholangitis (3.5%, 5.9%, 7.1%, and 0% for MDP types I, II, III, and IV, respectively; p\u0026thinsp;=\u0026thinsp;0.71), showed no significant differences among the four MDP types.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eOutcomes based on morphology of major duodenal papilla\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eType I\u003c/p\u003e\n\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;57)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eType II\u003c/p\u003e\n\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eType III\u003c/p\u003e\n\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eType IV\u003c/p\u003e\n\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBleeding during NKPS\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e11 (19.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9(26.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3(21.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5(29.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.290\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNKPS success, n\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e42(73.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e13(38.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13(92.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14(82.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.059\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAdverse events, n\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOverall\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9(15.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4(11.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3(21.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4(23.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.884\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePancreatitis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4(7.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1(2.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3(17.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.162\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDelayed bleeding\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3(5.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1(2.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(14.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(5.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.492\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCholangitis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2(3.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2(5.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(7.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.710\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\"\u003eAbbreviations: NKPS: needle-knife precut sphincterotomy\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n\u003ch2\u003eFactors associated with NKPS outcomes\u003c/h2\u003e\n\u003cp\u003eUnivariate and multivariate analyses were performed to identify factors associated with NKPS outcomes, as shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e. Univariate analysis showed that MDP morphology (Type II vs. type I, odds ratio [OR]: 0.221, 95% confidence interval [CI]: 0.089\u0026ndash;0.549], p\u0026thinsp;=\u0026thinsp;0.001), diverticulum size (OR: 0.213, 95% CI: 0.082\u0026ndash;0.555, p\u0026thinsp;=\u0026thinsp;0.002), and bleeding during NKPS (OR: 0.170, 95% CI: 0.068\u0026ndash;0.421, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were significantly associated with the outcome of NKPS. Multivariate analysis showed that MDP morphology (Type II vs. type I, OR: 0.256, 95% CI: 0.089\u0026ndash;0.734, p\u0026thinsp;=\u0026thinsp;0.011) and bleeding during NKPS (OR: 0.117, 95% CI: 0.039\u0026ndash;0.351, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were independent factors associated with NKPS outcome.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eUnivariate and multivariate analyses of the factors associated with needle knife precut sphincterotomy success or failure\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eVariables\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eUnivariate analysis\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eMultivariate analysis\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eOR (95% CI)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eOR (95% CI)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;70 y\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.071(0.486\u0026ndash;2.361)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.864\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026le;\u0026thinsp;70 y\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReferent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eGender\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.283(0.601\u0026ndash;2.740)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.519\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReferent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCholedocholithiasis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.500(0.054\u0026ndash;4.626)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.570\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReferent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eMalignant biliary stricture\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.840(0.231\u0026ndash;3.055)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.791\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReferent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCBD diameter (cm)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;6\u0026nbsp;mm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.029(0.327\u0026ndash;3.239)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.962\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026le;\u0026thinsp;6\u0026nbsp;mm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReferent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMorphology of papilla\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eType II\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.221(0.089\u0026ndash;0.549)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.331(0.123\u0026ndash;0.887)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.028\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eType III\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.643(0.559\u0026ndash;38.590)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.155\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9.122(0.886\u0026ndash;93.924)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.063\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eType IV\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.667(0.420\u0026ndash;6.620)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.468\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.66(0.572\u0026ndash;12.373)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.212\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eType I\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReferent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReferent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eType of diverticulum\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eType I\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.333(0.065\u0026ndash;1.699)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.402\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eType II\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.655(0.250\u0026ndash;1.720)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.502\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eType III\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReferent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiverticulum size\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEvery 1 cm increase\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.213(0.082\u0026ndash;0.555)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.002\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.408(0.252\u0026ndash;1.121)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.202\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eSurgically altered anatomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.481\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.737\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReferent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReferent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBleeding during NKPS\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.170(0.068\u0026ndash;0.421)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.117(0.039\u0026ndash;0.351)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReferent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReferent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEndoscopist\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eB\u0026thinsp;+\u0026thinsp;C\u0026thinsp;+\u0026thinsp;D\u0026thinsp;+\u0026thinsp;E\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.898\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.688\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReferent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePancreatic stent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.343(0.554\u0026ndash;3.253)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.514\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eno\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReferent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\"\u003eAbbreviations: CBD: common bile duct; NKPS: needle knife precut sphincterotomy; OR: odds ratio; CI: confidence interval;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003ePAD is a factor that has been inconsistently linked to the success rates of SBC in patients undergoing ERCP\u003csup\u003e\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. As precut sphincterotomy in difficult cases increases the overall success rate of SBC by 25% points, this study adds valuable insights by examining the influence of PAD classification and MDP morphology on the outcomes of NKPS\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThere is little data regarding precut sphincterotomy in patients with PAD\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Park et al. reported that among 33 patients with PAD who underwent NKF, type II PAD was the most common, and type I PAD was the least common, which was similar to our findings\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. However, due to the small number of cases, they did not analyze the success rate of each type\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Our results show that type III PAD had the highest success rate (75%) and type I PAD had the lowest success rate (50%). This may be because that the location of the MDP in type III PAD is outside the diverticulum and is therefore minimally affected by the PAD, allowing the endoscopist to perform NKPS commonly with the highest success rate. In comparison, types I and II PAD have more papillae that are difficult to detect or access, or bile duct directions that are more unpredictable\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Fernandes et al compared NKF for flat papillae, intradiverticular papillae (corresponding to type I PAD, n\u0026thinsp;=\u0026thinsp;14), and diverticular marginal papillae (corresponding to type II PAD, n\u0026thinsp;=\u0026thinsp;14) and reported success rates of 93.9%, 64.3%, and 71.4% (p\u0026thinsp;=\u0026thinsp;0.005), respectively\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. They concluded that NKF is feasible in diverticular papillae, but the success rate of initial ERCP is relatively low, which is consistent with our results.\u003c/p\u003e \u003cp\u003eThe clinical influences of PAD size have rarely been studied. Kim et al. reported that CBD diameter was significantly related to PAD size and that patients with type I PAD had significantly larger CBD diameters than patients with type III PAD\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. That is, type I PAD presented as larger while type III PAD tended to be smaller\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. These findings were consistent with our results that type I PAD were significantly larger in size, followed by type II PAD, and type III PAD were significantly smaller. Furthermore, we found that the NKPS success group had a significantly smaller PAD size. However, the precise determination of PAD size is not straightforward. In our study, PAD diameter was measured through endoscopic imaging, whereas other studies used CT or MRCP, resulting in the median PAD diameter in our study being smaller compared with other reports\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSeveral studies have explored the influence of MDP morphology on the technical success of ERCP\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Since its introduction in 2017, the Scandinavian classification of MDP morphology has gradually gained acceptance due to its remarkable intra- and inter-observer agreement \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Based on this classification, Haraldsson et al. found that cannulating type II and type III MDPs is more difficult\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. However, the Scandinavian classification lacks some important papillary subtypes, such as those associated with PAD. Nevertheless, the inclusion of type D to account for PAD, as reported by Mohamed et al., yielded similar findings, indicating increased difficulty in cannulating Type II and III MDPs compared to Type I\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Additionally, they observed a higher frequency of NKPS in types II, III, and IV MDP compared to Type I (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Our study further explored the correlation between MDP morphology and NKPS outcomes in patients with PAD: type II MDP had the lowest NKPS success rate (38.2%), whereas type III MDP had the highest NKPS success rate (92.9%). Because most endoscopists consistently perform the same type of precut sphincterotomy over time, different precut techniques based on MDP morphology may be considered to improve success rates in patients with PAD, especially type II MDP\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSeveral studies have suggested a potential link between MDP type and adverse events during ERCP\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. However, in a study by Lyu et al. comparing the safety of NKP among various MDP types in patients with difficult biliary cannulation (8.3% of patients had PAD), no significant difference was found in the incidence of adverse events among the four MDP types\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Our findings were in line with this, albeit limited to patients with PAD. Additionally, our study revealed no significant differences in adverse event rates among the three types of PAD. Notably, perforation did not occur in our study, potentially due to its small sample size. Therefore, larger-scale studies may be necessary in the future.\u003c/p\u003e \u003cp\u003eThis study is subject to various limitations. It was conducted retrospectively and involved a sample size in which procedures were carried out by five endoscopists. Consequently, there may have been an introduction of selection bias and operator bias. Furthermore, although the incidence of adverse events in this study is consistent with previous studies, the limited sample size could potentially impact the results. In addition, because pancreatic stents can reduce the risk of pancreatitis after ERCP and may improve the outcome of NKPS\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e, the utilization rate of pancreatic stents was only 26.2%, which may have affected the results of this study. Therefore, future large-scale prospective studies are necessary to validate our findings.\u003c/p\u003e \u003cp\u003eIn conclusion, type II MDP morphology and significant bleeding during NKPS were significantly associated with NKPS failure in PAD patients with difficult bile duct cannulation, whereas type III MDP morphology had a trend toward increased NKPS success. These findings may have important implications for practitioners of ERCP, particularly in patients with type II MDP morphology, in whom techniques other than NKPS may be considered.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eDisclosures\u003c/h2\u003e \u003cp\u003e Approval for the study was obtained from the institutional review board of Chang Gung Memorial Hospital (IRB number: 202200541B0). Given the retrospective nature of the study utilizing routine clinical treatment and diagnostic medical records, the Chang Gung Medical Foundation Institutional Review Board granted a waiver for participant consent. All methodologies adhered to relevant guidelines and regulations. Competing interests: Dr. Sheng-Fu Wang, Chi-Huan Wu, Mu-Hsien Lee, Yung-Kuan Tsou, Cheng-Hui Lin, Kai-Feng Sung, Nai-Jen Liu declare that they have no financial or non-financial conflicts of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization: S.-F.W. and C.-H.L.; Methodology: K.-F.S. and Y.-K.T.; Formal analysis and investigation: S.-F.W. and C.-H.W.; Writing\u0026mdash;original draft preparation: S.-F.W.; Writing\u0026mdash;review and editing: Y.-K.T.; Resources: Y.-K.T. and M.-H.L.; Supervision: N.-J.L.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCennamo V, Fuccio L, Zagari RM, \u003cem\u003eet al.\u003c/em\u003e Can early precut implementation reduce endoscopic retrograde cholangiopancreatography-related complication risk? Meta-analysis of randomized controlled trials. Endoscopy. 2010; 42: 381\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJayaraj M, Mohan BP, Dhindsa BS, \u003cem\u003eet al.\u003c/em\u003e Periampullary Diverticula and ERCP Outcomes: A Systematic Review and Meta-Analysis. Dig Dis Sci. 2019; 64: 1364\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTyagi P, Sharma P, Sharma BC, Puri AS. Periampullary diverticula and technical success of endoscopic retrograde cholangiopancreatography. Surgical Endoscopy. 2009; 23: 1342\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohammad Alizadeh AH, Afzali ES, Shahnazi A, \u003cem\u003eet al.\u003c/em\u003e ERCP features and outcome in patients with periampullary duodenal diverticulum. \u003cem\u003eISRN Gastroenterol\u003c/em\u003e. 2013; 2013: 217261.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTabak F, Ji GZ, Miao L. Impact of periampullary diverticulum on biliary cannulation and ERCP outcomes: a single-center experience. Surg Endosc. 2021; 35: 5953\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYue P, Zhu KX, Wang HP, \u003cem\u003eet al.\u003c/em\u003e Clinical significance of different periampullary diverticulum classifications for endoscopic retrograde cholangiopancreatography cannulation. World J Gastroenterol. 2020; 26: 2403\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLobo D, Balfour T, Iftikhar S. Periampullary diverticula: consequences of failed ERCP. Annals of the Royal College of Surgeons of England. 1998; 80: 326.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoix J, Lorenzo-Z\u0026uacute;\u0026ntilde;iga V, A\u0026ntilde;a\u0026ntilde;os F, Dom\u0026egrave;nech E, Morillas RM, Gassull MA. Impact of periampullary duodenal diverticula at endoscopic retrograde cholangiopancreatography: a proposed classification of periampullary duodenal diverticula. Surgical Laparoscopy Endoscopy \u0026amp; Percutaneous Techniques. 2006; 16: 208\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTestoni PA, Mariani A, Aabakken L, \u003cem\u003eet al.\u003c/em\u003e Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016; 48: 657\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsou YK, Pan KT, Lee MH, Lin CH. Endoscopic salvage therapy after failed biliary cannulation using advanced techniques: A concise review. World J Gastroenterol. 2022; 28: 3803\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLo M-H, Lin C-H, Wu C-H, \u003cem\u003eet al.\u003c/em\u003e Management of biliary diseases after the failure of initial needle knife precut sphincterotomy for biliary cannulation. Scientific Reports. 2021; 11: 14968.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee M-H, Huang S-W, Lin C-H, \u003cem\u003eet al.\u003c/em\u003e Predictive factors of needle-knife pre-cut papillotomy failure in patients with difficult biliary cannulation. Scientific Reports. 2022; 12: 4942.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCanena J, Lopes L, Fernandes J, \u003cem\u003eet al.\u003c/em\u003e Influence of a novel classification of the papilla of Vater on the outcome of needle-knife fistulotomy for biliary cannulation. BMC Gastroenterol. 2021; 21: 147.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaraldsson E, Lundell L, Swahn F, \u003cem\u003eet al.\u003c/em\u003e Endoscopic classification of the papilla of Vater. Results of an inter- and intraobserver agreement study. United European Gastroenterol J. 2017; 5: 504\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohamed R, Lethebe B, Gonzalez-Moreno E, \u003cem\u003eet al.\u003c/em\u003e Morphology of the major papilla predicts ERCP procedural outcomes and adverse events. Surgical endoscopy. 2021; 35: 6455\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCotton PB, Eisen GM, Aabakken L, \u003cem\u003eet al.\u003c/em\u003e A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc. 2010; 71: 446\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFernandes J, Canena J, Moreira M, \u003cem\u003eet al.\u003c/em\u003e Needle knife fistulotomy in flat and diverticular papillae: Is it time for redemption? Hepatobiliary Pancreat Dis Int. 2022; 21: 175\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark CS, Park CH, Koh HR, \u003cem\u003eet al.\u003c/em\u003e Needle-knife fistulotomy in patients with periampullary diverticula and difficult bile duct cannulation. J Gastroenterol Hepatol. 2012; 27: 1480\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim HW, Kang DH, Choi CW, \u003cem\u003eet al.\u003c/em\u003e Limited endoscopic sphincterotomy plus large balloon dilation for choledocholithiasis with periampullary diverticula. World J Gastroenterol. 2010; 16: 4335\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim CW, Chang JH, Kim JH, Kim TH, Lee IS, Han SW. Size and type of periampullary duodenal diverticula are associated with bile duct diameter and recurrence of bile duct stones. J Gastroenterol Hepatol. 2013; 28: 893\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaraldsson E, Kyl\u0026auml;np\u0026auml;\u0026auml; L, Gr\u0026ouml;nroos J, \u003cem\u003eet al.\u003c/em\u003e Macroscopic appearance of the major duodenal papilla influences bile duct cannulation: a prospective multicenter study by the Scandinavian Association for Digestive Endoscopy Study Group for ERCP. Gastrointest Endosc. 2019; 90: 957\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAngsuwatcharakon P, Thongsuwan C, Ridtitid W, \u003cem\u003eet al.\u003c/em\u003e Morphology of the major duodenal papilla for the selection of advanced cannulation techniques in difficult biliary cannulation. Surg Endosc. 2023; 37: 5807\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang QS, Xu JH, Dong ZQ, Gao P, Shen YC. Success and Safety of Needle Knife Papillotomy and Fistulotomy Based on Papillary Anatomy: A Prospective Controlled Trial. Dig Dis Sci. 2022; 67: 1901\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoriuchi A, Nakayama Y, Kajiyama M, Tanaka N. Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla. Clin Gastroenterol Hepatol. 2007; 5: 1113\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLyu Y, Ye S, Wang B. Impact of duodenal papilla anatomy on needle knife papillotomy safety and efficacy in patients with difficult biliary canulation. BMC Surgery. 2024; 24: 61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFogel EL, Sherman S, Lehman GA. Increased selective biliary cannulation rates in the setting of periampullary diverticula: main pancreatic duct stent placement followed by pre-cut biliary sphincterotomy. Gastrointest Endosc. 1998; 47: 396\u0026ndash;400.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4444498/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4444498/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground and Aims\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral studies have investigated the relationship between the technical success of ERCP and periampullary diverticulum (PAD), but only limited studies have specifically examined advanced cannulation techniques such as needle-knife precut sphincterotomy (NKPS). This study aimed to explore the outcomes of NKPS in patients with PAD.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study was conducted on 122 patients with PAD who underwent NKPS due to difficult biliary cannulation. Patient characteristics, ERCP indications, CBD diameter, PAD classification, diverticular size, major duodenal papilla (MDP) morphology, and post-ERCP adverse events were assessed. We analyzed factors associated with the outcomes of NKPS in patients with PAD, with a specific focus on the type of PAD and the morphology of MDP.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong 122 patients, 82 (67.2%) belonged to the NKPS success group and 40 (32.8%) belonged to the NKPS failure group. Diverticular size was significantly larger in the NKPS failure group. For type I, type II, and type III PAD, the median dimeters of diverticula were 1.2 cm, 0.9 cm, and 0.5 cm, respectively (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001), and the NKPS success rates were 50%, 66.3%, and 75%, respectively (\u003cem\u003eP\u003c/em\u003e=0.391). Regarding MDP morphology, the NKPS success rates were 73.7%, 38.2%, 92.9%, and 82.4% for types I, II, III, and IV MDP, respectively (\u003cem\u003eP\u003c/em\u003e =0.059). The overall adverse event rate was 16.4%, including pancreatitis (6.6%), delayed bleeding (5.7%), and cholangitis (4.1%). There were no significant differences in adverse event rates between the NKPS success and failure groups. Multivariate analysis showed that MDP morphology (type II vs. type I, OR: 0.256, 95% CI: 0.089-0.734, \u003cem\u003eP\u003c/em\u003e=0.011) and bleeding during NKPS (OR: 0.117, 95% CI: 0.039-0.351, \u003cem\u003eP\u003c/em\u003e\u0026lt; 0.001) were independent factors associated with NKPS outcome.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMDP morphology and bleeding during NKPS are independent predictors of NKPS failure in PAD patients with difficult biliary cannulation.\u003c/p\u003e","manuscriptTitle":"Impact of papillary morphology and diverticular type on needle-knife precut sphincterotomy in patients with periampullary diverticulum with difficult biliary cannulation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-04 21:49:21","doi":"10.21203/rs.3.rs-4444498/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"73683639-9c0f-4019-b50b-5195eb17b158","owner":[],"postedDate":"June 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-10-01T13:38:35+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-04 21:49:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4444498","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4444498","identity":"rs-4444498","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}