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Warm Water Ampullary Washing: A Potential Needle-Knife Sphincterotomy Sparing Technique Emilio De la Morena, Elena Perez de Arellano, Yago Gonzalez-Lama, Esperanza Tomas-Moros Background: Needle-knife sphincterotomy (NKS) is an alternative endoscopic sphincterotomy (ES) technique used when selective biliary canulation (SBC) fails, but it is difficult to learn and is an independent risk factor for postERCP pancreatitis. Easier and safer canulation, NKS sparing, handlings are thus desirable. Objective: To report our preliminary results with a new canulation facilitating technique, the warm water ampullary washing (WAW). Method: WAW is performed when guide-wire assisted SBC fails and sphincter of Oddi spasm is one major presumptive cause of the failure. The ampoule is washed with 50 cc of tap water empirically titrated at 38-40 C using a canulotome inserted a few millimetres in the papillary orifice caring not to nail the tip to permit the duodenal reflux of the water and prevent pancreatic injection. After WAW a second SBC attempt is tried and if it fails again a NKS is performed. Results: Along one year 66 ES were indicated in 75 patients. Initially CSB and ES were performed in 54 (82%) and NKS in 5. WAW was tried in 7 and allowed CSB and ES in 4. Thus the final number of ES performed was 58 (88%) and the theoretic 12 (18%) NKS dropped to the real 8 (12%) (pZNS). The 4 WAW issues had healthy papillae (HP) (2 normal and 2 mild papillitis) whereas the 3 WAW failures had ill papillae (IP) (2 severe papillitis, 1 impacted stone). All 8 patients who required NKS had IP. Among the 3 WAW failures 1 mild pancreatitis was registered. Compared with 225 historical controls NKS dropped from 16% to 12% (pZNS). However NKS in IP patients rose from 7% to 12% (pZNS) and NKS in HP patients fell from 9% to 0 (pZ0.00002). Conclusion: With these results we hypothesise that WAW facilitates the SBC and allows ES in HP patients sparing NKS in them and limiting it to IP patients.