Needle knife fistulotomy (NKF) is known as a rescue technique for difficult biliary cannulation. The aim of this study was to evaluate the safety and efficacy of NKF in patients with subtotal gastrectomy with billroth-II (STG B-II) anastomosis. The records of 110 patients with STG B-II who underwent endoscopic retrograde cholangiopancreatography (ERCP) from 2008 to 2017 were retrospectively reviewed. Patients who failed access to ampulla of Vater (n=18) or had history of previous ERCP (n=6) were excluded. Of 86 patients, 13 (15.1%) underwent NKF for biliary access. The clinical outcomes between NKF group and conventional method group were analyzed and compared. No significant difference regarding baseline characteristics was observed. Final diagnoses were as follows: common bile duct stones (81.4%), suspected passed stones (9.3%). malignant stricture (8.1%) and benign stricture (1.2%). Deep cannulation was successful in 92.3% in the NKF group. Regarding the overall complication rate, no significant difference was observed between the NKF and conventional group (6.8% vs 15.4%, P = 0.627). The rates of post-ERCP pancreatitis were not significantly different between the two groups (0% vs 5.5%, P = 0.881). All pancreatitis cases had full recovery on conservative treatment. Rates of procedure related bleeding and perforation were not significantly different between the two groups (7.7% vs 0%, P = 0.327; 7.7% vs 1.4%, P = 0.693, respectively). There were two in-hospital mortalities due to perforation in the conventional group. NKF appears to be a safe, effective as a salvage technique in patients with STG B-II if it is performed by experienced endoscopists.