Choledocholithiasis is the most common indication for endoscopic retrograde cholangiopancreatography (ERCP), particularly in older adults, who often present with multiple comorbidities and may carry a higher risk for procedural complications. As the aging population grows, clinicians frequently face the question of whether ERCP remains equally effective and safe in elderly patients compared with younger individuals. The purpose of the present study was to evaluate outcomes of ERCP in these age groups, focusing on therapeutic success, technical difficulty, and the incidence of intra- and postoperative events. By comparing patients aged <75 years with those ≥75 years, the study sought to provide updated real-world data from a high-volume Greek university hospital.

This case–control study was conducted at the University General Hospital of Ioannina and included ERCP procedures performed between September 2023 and September 2025. A total of 804 patients were analyzed. Based on international age-stratification definitions from the World Health Organization (WHO), participants were divided into two predefined groups: patients <75 years (n = 431) and patients ≥75 years (n = 373). For each patient, demographic information, clinical presentation, endoscopic interventions performed during ERCP, and recorded complications were obtained retrospectively from institutional records. Particular attention was given to stone removal success, cannulation difficulty, duration of the procedure, and the frequency of adverse events. A predefined subgroup analysis was used to examine outcomes specifically in elderly individuals with significant comorbidities, allowing a more detailed assessment of risk and therapeutic benefit in frail patients.

When comparing patients ≥75 years with those <75 years, a statistically significant difference was found regarding the rate of complete and partial stone extraction (x2 = 9.503, p = 0.002). This suggests that although ERCP remains effective in both cohorts, stone removal success patterns differ slightly across age groups.The degree of cannulation difficulty, however, did not differ significantly between the two groups (x2 = 1.777, p = 0.411). Older patients did not require more attempts or advanced techniques for ductal access. Similarly, procedure duration for ERCP was comparable between younger and older individuals (b = –0.045, p = 0.912), indicating that advanced age alone did not prolong endoscopic manipulation or therapeutic steps. Regarding safety, elderly patients were not more likely to experience intraoperative or postoperative complications compared with younger patients (x2 = 0.080, p = 0.777). The verall rate of adverse events—including pancreatitis, bleeding, cholangitis, or cardiopulmonary issues—remained consistent across age categories.In the predefined subgroup of older adults with multiple comorbidities, ERCP ontinued to demonstrate high therapeutic efficacy. The procedure was also shown to have an acceptable safety profile even in this more fragile subpopulation, supporting its use as a frontline intervention when indicated.

The findings of this study indicate that ERCP can be performed with a high degree of effectiveness in elderly patients aged ≥75 years, including those with complex medical histories. Although clinicians often hesitate to refer older adults for invasive procedures, the present data show that both technical success and complication rates are comparable to those observed in younger patients.ERCP should be considered a viable and generally safe option for elderly patients with choledocholithiasis, provided that potential intraoperative and postoperative risks are considered during clinical decision-making.