ERCP is increasingly being performed in older adults but there is limited data on its technical success and procedure-related adverse events across different age strata. In this systematic review and meta-analysis, we aimed to synthesize the available evidence on ERCP outcomes stratified by age groups (<65, 65–79, 80–89, ≥90 years).

A comprehensive literature search was performed using OVID MEDLINE, EMBASE, and the Cochrane Library from database inception to October 2025. Studies were included if they enrolled patients aged ≥65 years who underwent diagnostic or therapeutic ERCP. Outcomes included technical success, major procedural adverse events (e.g. post-ERCP pancreatitis (PEP), bleeding, perforation, cholangitis, cardiopulmonary complications), length of stay, and mortality. Study-level proportions were pooled using a random-effects meta-analysis with Freeman–Tukey double arcsine transformation and inverse-variance weighting. Heterogeneity was assessed using the I² statistic, and subgroup differences across four predefined age strata were evaluated using the Chi-square test.

Fifty-two studies (n=26,926) were included in this review. The pooled estimate for technical success was 92% (95% CI 91-94%, I² = 95%). By age subgroups, technical success was 95% (95% CI 93-97%) for <65, 91% (88-94%) for 65–79, 91% (88-94%) for 80–89, and 87% (79-94%) for ≥90, with significant subgroup differences (p = 0.01). Across included studies, the pooled proportion of any adverse event after ERCP was 9.0% (95% CI 7.0–10.0%; I² ≈ 89%) with no statistically significant subgroup differences (p = 0.36). The pooled estimate for PEP 3.0% (95% CI 3.0-4.0%; I² = 81%) and for cardiopulmonary complications was 1.0% (1.0-2.0%, I²= 81%). There were statistically significant differences between subgroups, with elderly patients having lower rates of PEP (p = 0.01) and higher rates of cardiopulmonary complications (p= 0.002). Other pooled estimates were: 2.0% (1.0-2.0%; I² = 61%) for bleeding, 0.0% (0.0-0.1%; I² = 21%) for perforation, and 1.0% (1.0-1.0%; I² = 66%) for cholangitis, with no statistically significant subgroup differences. The pooled length of hospital stay was 10.53 days (95% CI 8.38–12.67; I² ≈ 100%). Subgroup pooled means were: <65 years = 7.53 days (95% CI 5.84–9.23), 65–79 years = 13.19 days (9.05–17.33), 80–89 years = 7.63 days (3.58–11.69), and ≥90 years = 21.96 days (11.91–32.01). Subgroup differences were statistically significant (p= 0.004). Overall mortality after ERCP was low at 1.0% (95% CI 0.0–1.0%; I² = 84.3%). By age subgroups, mortality was 0.0% (0.0–0.1%) for <65 years, 1.0% (0.0–1%) for 65–79 years, 1.0% (0.0–0.1%) for 80–89 years, and 4% (1–8%) for ≥90 years. The test for subgroup differences was significant (p = 0.0008).

Older age is associated with lower technical success, although the overall rate of technical success remains relatively high. Age is also associated with increased risk of cardiopulmonary complications, longer hospital stay, and higher mortality, especially among patients ≥90 years. Conversely, the risk of PEP is consistently lower among older patients. These findings highlight the importance of careful patient selection, individualized risk assessment, and meticulous preoperative optimization to enhance the safety and efficacy of ERCP in the elderly population. Future studies should specifically focus on patient-oriented outcomes in the elderly population undergoing ERCP.