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Introduction Malignant Hilar Biliary Obstruction (MHBO) often presents with jaundice and patients require biliary drainage. Endoscopic retrograde cholangiopancreatography (ERCP) is typically performed however this can be challenging in MHBO. We aim to present the characteristics and outcomes of patients who underwent ERCP for MHBO in a tertiary centre.Method Patients were identified from a prospectively maintained database; all those diagnosed with MHBO at index ERCP were included. Retrospective analysis of electronic patient records was performed.Results 228 patients underwent ERCP for MHBO. 51.8% (n=118) were male and 48.2% (n=110) were female. The mean age was 68 years old (SD ± 13.2), and the median follow-up period was 89.5 days (IQR 38.5-248.75). The commonest aetiology was cholangiocarcinoma in 58.0% of patients (n=130), followed by colorectal metastasis in 12.1% (n=27), gallbladder cancer in 8.0% (n=18) and hepatocellular carcinoma in 4.9% (n=11).Technical success of ERCP, defined as successful placement of stents into intended ducts, was achieved in 82.1% of patients (n=184); 68.5% (n=126) of which had metal stents and 28.8% (n=53) had plastic stents. Of the 40 patients without technical success, 23 underwent further biliary intervention within 30 days (17 percutaneous transhepatic cholangiograms (PTC) and 6 repeat ERCP).Clinical success, defined as reduction of pre-procedural bilirubin to ≤50% within 30 days, was achieved in 57.5%. Of the patients who did not achieve clinical success, 30 patients underwent further biliary re-intervention within 30 days (16 repeat ERCP and 14 PTC).The post-procedural adverse event rate was 35.6% (n=79). Cholangitis occurred in 23.2% (n=51), pancreatitis in 10.5% (n=23), perforation in 0.9% (n=2) and liver abscess in 0.45% (n=1). 31 patients had multiple adverse events. The 30-day mortality rate was 16.1% (n=36); 21 patients died due to disease progression and 10 due to post-operative complications.Of the 94 patients who were deemed technically surgically operable at time of index ERCP, 29.8% (n=28) went on to have surgical intervention, with 19.2% (n=18) having successful curative resection. Surgical resection did not occur in 80.8% of patients due to inoperable disease identified during work up (n=34), poor surgical fitness (n=19), disease progression (n=10), perioperative finding of metastatic disease (n=9), patient declined (n=1) and failed portal vein embolization (n=1). The median time from index ERCP to surgical resection was 76 days (IQR 42-137).Conclusions MHBO occurs most commonly in Cholangiocarcinoma. Post ERCP adverse events occurred in a third of patients, although 30-day mortality was largely due to disease progression, indicating a need for better patient selection for a high-risk intervention. Only a small proportion of patients progressed to surgical resection.