ERCP is being increasingly performed in elderly patients. Clinical decision-making for ERCP in very old patients (≥90 years) requires comparative analysis of the procedural success and procedural adverse events compared to younger old adults (65-89 years). In this study, we compared procedural success, periprocedural adverse events, mortality, and length of hospitalization between patients aged ≥90 years and those aged 65–89 years as a reference group.

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 of interest included technical success, major procedural adverse events (post-ERCP pancreatitis (PEP), bleeding, perforation, cholangitis, cardiopulmonary complications), length of stay, and mortality. We pooled head-to-head data from studies reporting outcomes separately for ≥90 and 65–89-year cohorts. Random-effects meta-analysis (inverse-variance) was used to calculate pooled relative risk (RR) ratios for dichotomous outcomes and mean difference for continuous outcomes.

Nine studies compared outcomes between patients aged ≥90 years (n = 642) and those aged 65–89 years (n = 3,878). There was no statistically significant difference in technical success between the ≥90-year and 65–89-year groups (RR 0.95, 95% CI 0.90–1.01; I² = 81%; p = 0.08). Similarly, no significant differences were observed in peri- or post-procedural adverse events, including bleeding (RR 1.43, 95% CI 0.75–2.75; I² = 0%; p = 0.28), PEP (RR 0.70, 95% CI 0.39–1.24; I² = 0%; p = 0.23), perforation (RR 2.88, 95% CI 0.92–9.07; I² = 0%; p = 0.07), or cardiopulmonary complications (RR 2.60, 95% CI 0.95–7.12; I² = 42%; p = 0.06). However, the mean length of hospital stay was significantly longer among nonagenarians compared to those aged 65–89 years (mean difference = 7.44 days, 95% CI 5.21–9.66; I² = 0%; p < 0.001). Mortality was also significantly higher in the ≥90-year group (RR 3.39, 95% CI 2.16–5.30; I² = 5%; p < 0.001).

ERCP demonstrates comparable technical success and rates of periprocedural adverse events in patients aged ≥90 years and those aged 65–89 years. However, nonagenarians experience significantly longer hospital stays and higher post-ERCP mortality. These findings highlight the importance of thorough pre-procedural evaluation, individualized risk stratification, and enhanced post-procedural monitoring and discharge planning to optimize safety and outcomes in very elderly patients undergoing ERCP. Research focusing on patient-outcomes in the elderly undergoing advanced procedures is warranted.