Higher volume providers are associated with improved outcomes following ERCP for the palliation of malignant biliary obstruction
Philip Harvey, Simon Baldwin, Jemma Mytton, Amandip Dosanjh, Felicity Evison, Prashant Patel, Nigel Trudgill
Abstract
Background: Relieving malignant biliary obstruction improves quality of life and permits chemotherapy. Outcomes of endoscopic retrograde cholangio-pancratography(ERCP) in inoperable malignant biliary obstruction have been examined in a national cohort to establish factors associated with poor outcomes. Methods: Hospital Episode Statistics include diagnostic and procedural data for all NHS hospital attendances in England. Patients from 2006 to 2017 with a Hepaticopancreaticobiliary (HPB) malignancy who had undergone ERCP were studied. Patients undergoing a potentially curative operation were excluded. Associations between demographics, co-morbidities, unit ERCP volume and mortality were examined by logistic regression. Findings: 39,702 patients were included; 49.4% were male; median age was 75 (IQR 6688)years. Pancreatic cancer was the most common tumour (63.9%). Mortality was 4.1%, 9.7% and 19.1% for 7-day, in hospital and 30-day respectively. On multivariable analysis: men (OR 1.20(95%CI 1.141.26), p < 0.001); increasing age quintile 7883(1.73(1.591.89), p < 0.001), >83(2.70(2.482.94),p < 0.001); most deprived quintile (1.21 (1.111.32), p < 0.001); increasing co-morbidity score >20(3.36(2.943.84),p < 0.001); small bowel malignancy (1.45(1.221.72), p < 0.001), intrahepatic biliary malignancy(1.10(1.031.17), p = 0.005) and year of ERCP 2006/07 (1.37(1.221.55), p < 0.001) were associated with increased 30-day mortality. Extrahepatic biliary tree cancers (0.67(0.610.73), p<0.001), high volume providers of ERCP (>318 annually, 0.91 (0.840.98), p = 0.01) and high volume of ERCP for malignant obstruction (>40 annually (0.91(0.850.98), p = 0.014) were negatively associated with 30-day mortality. Patients were less likely to require a second ERCP in high volume providers (>318, 8.0%) compared to low volume ((<204, 13.4%), p<0.001). Interpretation: Short term mortality in patients with malignant biliary obstruction following ERCP was high. 30-day mortality was positively associated with increasing age and co-morbidity, men, deprivation, and earlier year of ERCP and negatively with extrahepatic biliary tree cancer and high volume ERCP providers.