Benchmarking outcomes of endoscopic retrograde cholangio-pancreatography for malignant biliary obstructions: A multicenter real-world study

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) quality measures are critical to define standards of care and guide improvement strategies. AIMS: This study aimed to determine risk-adjusted outcomes following ERCP for malignant biliary obstruction(MBO). METHODS: Using an intention-to-treat approach, we analyzed data from a multicenter database including 23 Italian hospitals (2017-2022). Inter-center heterogeneity was assessed with I² statistic. To account for case-mix confounding, multivariable mixed-effects models estimated risk-adjusted outcomes. RESULTS: Clinical and procedural characteristics showed considerable heterogeneity across centers (I²>75%). In the intention-to-treat cohort (n = 3148), the risk-adjusted technical success rate was 91.3%; the intraclass correlation coefficient (ICC) was 11.6%, suggesting that 11.6% of the outcome variance resides at the hospital level. In the per-successful-procedure cohort (n = 2665), the risk-adjusted technical success rate was 91.3% (ICC 22.7%). Post-ERCP pancreatitis occurred in 5.4% (ICC 12.9%), additional ERCPs were required in 23.7% (ICC 4.1%), and 30-day mortality was 4.2%. Treatment in high-volume hospitals (>350ERCPs/year) was associated with lower mortality(p = 0.001). CONCLUSIONS: Most variability in ERCP outcomes across hospitals reflects differences in patient selection and technical strategies. After risk adjustment, outcomes were similar across centers, supporting consistent quality of care. This study provides exploratory, risk-adjusted benchmarks derived from real-world practice for ERCP in MBO and supports their use for quality monitoring and referral planning.