DDW 2026, Chicago, USA. Day 2

Brief Introduction
Endoscopy training is evolving into a structured, competency-driven process, but the trainee experience remains complex, marked by both rewarding milestones and significant challenges. Understanding this journey is critical to optimizing training outcomes.

Background / Clinical Context
Traditional apprenticeship-based training lacked standardized assessment and often resulted in variable skill acquisition. Modern frameworks emphasize competency-based progression, integrating simulation and digital tools to ensure consistent and measurable learning outcomes.

Key Points from DDW 2026
Endoscopy training offers unique professional fulfillment, particularly through direct visualization of pathology and real-time therapeutic intervention. Early procedural successes build confidence, while progression toward procedural fluency reflects the transition to a more comprehensive clinical approach. Mentorship plays a pivotal role, providing not only technical guidance but also fostering resilience, reflective practice, and professional growth within a psychologically safe environment.

However, the learning curve is inherently steep and non-linear, with trainees experiencing periods of stagnation, self-doubt, and fluctuating performance. High cognitive load, procedural complexity, and performance pressure contribute to burnout and anxiety. System-level constraints, including time pressure and the “takeover” phenomenon by supervisors, may limit hands-on learning and reduce autonomy.

Complications and near-miss events, although challenging, are essential learning opportunities when approached within supportive environments. Additionally, physical strain and ergonomic challenges highlight the need for sustainability in training practices.

Clinical Interpretation
Endoscopy training requires a balanced framework that integrates structured competency assessment with strong mentorship and psychological support to ensure both skill development and trainee well-being.

What Is New or Practice-Changing?
Practice-informing: Recognition of trainee experience, cognitive load, and systemic barriers as central components of training design.

Limitations
The available information is experiential and conceptual. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
Endoscopy training is a dynamic process shaped by technical learning, mentorship, and systemic challenges. While competency-based models and technology-enhanced training offer clear advantages, addressing cognitive, emotional, and structural barriers remains essential to developing skilled and resilient endoscopists.

Brief Introduction
Despite strong guideline recommendations, colorectal cancer (CRC) screening uptake remains suboptimal. Improving participation is critical to reducing CRC incidence and mortality, particularly in populations with low baseline screening rates.

Background / Clinical Context
Current screening strategies face multiple barriers across patient, provider, and healthcare system levels. Colonoscopy-based approaches, while effective, are limited by accessibility, cost, and patient acceptability, creating gaps in population-level screening coverage.

Key Points from DDW 2026
Stool-based testing, particularly fecal immunochemical testing (FIT), offers a practical and scalable alternative that improves accessibility through home-based completion. This reduces logistical barriers and enhances participation, especially in underserved populations. However, screening uptake is influenced by multilevel barriers, requiring coordinated interventions rather than isolated strategies.

Evidence supports multicomponent approaches combining patient outreach, provider engagement, and system-level organization. Among these, mailed FIT programs and patient navigation demonstrate the most substantial impact, with meta-analyses showing improvements in screening rates by approximately 22–28 percentage points. Organized screening systems with centralized outreach and structured follow-up have achieved uptake rates as high as 82%, underscoring the importance of programmatic implementation.

Comparative analyses show that reminder-only or education-based interventions have limited impact, whereas FIT-based outreach strategies consistently outperform usual care, particularly in low-screening populations. These approaches also contribute to reducing disparities and improving long-term population health outcomes.

Clinical Interpretation
Integrating FIT into routine practice, particularly through structured outreach programs, can significantly improve screening uptake and expand preventive care reach.

What Is New or Practice-Changing?
Practice-changing: Strong evidence supporting mailed FIT and multicomponent strategies as the most effective approach to increase CRC screening uptake.

Limitations
Findings are largely derived from programmatic and meta-analytic data, with variability across healthcare settings. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
Stool-based testing, especially FIT, represents a highly effective and scalable strategy to improve CRC screening uptake. When integrated into organized, multicomponent programs, it substantially increases participation, reduces disparities, and enhances population-level cancer prevention outcomes.

Brief Introduction
Colorectal cancer (CRC) in India presents with distinct epidemiological and clinical characteristics, requiring tailored surgical strategies and system-level adaptations to improve outcomes.

Background / Clinical Context
Compared to Western populations, CRC in India is diagnosed at a younger age, often between 45–47 years, with a significant proportion of patients under 40. Advanced-stage presentation and a higher prevalence of aggressive histological subtypes contribute to poorer survival outcomes, emphasizing the need for optimized care pathways.

Key Points from DDW 2026
Management of CRC in this setting requires a multidisciplinary approach integrating surgery, imaging, and oncology within standardized systems. High-quality surgery remains central, with techniques such as total mesorectal excision (TME) and complete mesocolic excision (CME) critical for achieving optimal oncological outcomes. Outcomes improve significantly in high-volume centers, highlighting the importance of surgical expertise and structured protocols.

Minimally invasive surgery (MIS), including laparoscopic and robotic approaches, has demonstrated reduced perioperative morbidity while maintaining oncological safety, even in advanced cases. Sphincter-preserving procedures are particularly important in improving patient acceptance and quality of life, especially in populations reluctant to accept permanent stomas.

Given the high burden of locally advanced disease, extended resections such as pelvic lymph node dissection and exenteration are frequently required. These complex procedures, along with emerging technologies like robotic surgery and simulation-based training, are shaping modern CRC management but require significant expertise and infrastructure.

Clinical Interpretation
Improving CRC outcomes in India depends on combining high-quality surgical techniques with system-level standardization, multidisciplinary care, and expanded training capacity.

What Is New or Practice-Changing?
Practice-informing: Emphasis on adapting surgical strategies and healthcare systems to the unique epidemiology of CRC in India.

Limitations
Data are largely observational and system-focused, with variability across institutions and access to advanced care. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
CRC in India is characterized by younger age of onset and advanced-stage disease, necessitating aggressive and well-coordinated management. High-quality surgery, increasing adoption of minimally invasive techniques, and strengthening of multidisciplinary systems and training programs are essential to improve outcomes in this setting.

Brief Introduction
Minimally invasive surgery (MIS) in upper gastrointestinal disease is expanding globally, but its implementation in regions like Mexico highlights the interplay between innovation, access, and healthcare system limitations.

Background / Clinical Context
Upper GI diseases, including esophageal and gastric cancers, often present at advanced stages in Mexico, limiting the applicability of MIS. At the same time, high prevalence of GERD and obesity increases demand for advanced surgical and endoscopic interventions. However, disparities in healthcare infrastructure create uneven access to these technologies.

Key Points from DDW 2026
Adoption of MIS techniques, including laparoscopy and robotics, remains variable, with advanced procedures largely confined to specialized centers. Many routine surgeries continue to be performed using open approaches, reflecting gaps in resource availability and training. Barriers include high equipment costs, limited access to disposable devices, regulatory delays, and restricted training opportunities.

Despite these challenges, progress is evident with expanding robotic programs and increasing use of advanced technologies such as fluorescence imaging and hybrid surgical–endoscopic approaches. Endoscopic techniques, including stenting and dilation, provide effective minimally invasive alternatives, particularly in resource-limited settings.

Training remains a critical limitation, with variability in exposure to advanced techniques. Mentorship, proctorship, and international collaboration play essential roles in bridging these gaps and facilitating skill development.

Clinical Interpretation
Improving outcomes requires addressing disparities in access, strengthening training infrastructure, and integrating endoscopic and surgical innovations into routine practice.

What Is New or Practice-Changing?
Practice-informing: Recognition of system-level barriers and the role of global collaboration in advancing MIS adoption.

Limitations
Data are largely descriptive and system-based, with variability across institutions and regions. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
Minimally invasive upper GI surgery in Mexico demonstrates both progress and disparity. While advanced technologies and techniques are expanding, access remains uneven due to cost, training, and infrastructure limitations. Strengthening training pathways, enhancing collaboration, and improving technology access are essential to ensure broader adoption and improved patient outcomes.

Brief Introduction
Distinguishing irritable bowel syndrome (IBS) from overlapping gastrointestinal and systemic conditions remains a key clinical challenge. A balanced diagnostic approach is essential to avoid both over-testing and missed diagnoses.

Background / Clinical Context
IBS has traditionally been diagnosed using symptom-based criteria such as the Rome guidelines. While these frameworks have advanced the understanding of disorders of gut–brain interaction, their limitations in sensitivity raise concerns about relying on them in isolation.

Key Points from DDW 2026
Symptom-based diagnosis alone may miss a subset of clinically relevant conditions, as alarm features are not always present early or reliably. A wide range of gastrointestinal disorders—including celiac disease, microscopic colitis, bile acid diarrhea, pancreatic insufficiency, and small intestinal bacterial overgrowth—can mimic IBS. Additionally, extraintestinal conditions such as endometriosis and malignancy may present with similar symptoms, further complicating diagnosis.

An assertive but targeted workup is recommended when clinical suspicion exists. This involves selective use of investigations guided by symptom patterns, patient characteristics, and prior evaluations, rather than indiscriminate testing. Under-testing carries its own risks, including delayed diagnosis of significant conditions, particularly in the context of rising gastrointestinal malignancies in younger populations.

Clinical judgment remains central, with individualized evaluation based on disease severity, comorbidities, and care setting. Patients in tertiary centers or with persistent symptoms may require more comprehensive assessment. At the same time, patient expectations for thorough evaluation must be balanced with evidence-based practice.

Clinical Interpretation
An optimal strategy integrates symptom-based diagnosis with selective, mechanism-driven testing to ensure diagnostic accuracy without unnecessary burden.

What Is New or Practice-Changing?
Practice-informing: Emphasis on a balanced diagnostic approach combining Rome criteria with targeted evaluation in appropriate patients.

Limitations
The available information is conceptual and lacks specific diagnostic algorithms or outcome data. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
IBS diagnosis requires a nuanced approach that goes beyond symptom criteria alone. While minimal testing is appropriate in many patients, targeted evaluation is essential in selected cases to avoid missed diagnoses. A balanced, individualized strategy remains key to delivering high-quality and patient-centered care.

Brief Introduction
Management of pancreatic duct strictures in chronic pancreatitis continues to evolve, with growing recognition that pain mechanisms extend beyond ductal obstruction. Emerging endoscopic strategies aim to improve outcomes but remain limited by variable clinical response.

Background / Clinical Context
Traditionally, ductal hypertension due to obstruction has been considered the primary driver of pain in chronic pancreatitis. However, increasing evidence suggests that neuropathic mechanisms, including neural remodeling and sensitization, play a more significant role, challenging purely mechanical treatment approaches.

Key Points from DDW 2026
Pain in chronic pancreatitis appears to correlate more strongly with neuropathic changes rather than ductal obstruction, indicating that decompression alone may not adequately address symptoms. ESWL remains an important preparatory step for patients with large (>5 mm) obstructing pancreatic duct stones, improving stone clearance and facilitating subsequent endoscopic therapy.

A prospective multicenter study evaluating fully covered self-expandable metal stents (FCSEMS) in 67 patients demonstrated high technical success (97%), but clinical pain response was limited to 26%. Adverse events were observed in 31% of patients, with a notably high stent migration rate of 48%, highlighting a disconnect between procedural success and symptomatic benefit.

Biodegradable self-expanding stents (BD-SES) offer a removal-free alternative, degrading over 3–6 months. In a small cohort of 19 patients, technical success was 58% and clinical success 52% at 6 months, suggesting moderate efficacy but insufficient evidence for routine adoption.

Clinical Interpretation
These findings suggest that structural interventions alone may not adequately address pain in chronic pancreatitis, emphasizing the need for multimodal and individualized treatment strategies.

What Is New or Practice-Changing?
Research-oriented: Recognition of neuropathic pain predominance and evaluation of newer stent technologies with variable clinical benefit.

Limitations
Data are limited by small sample sizes, modest clinical response rates, and procedural complications. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
Pancreatic duct stricture management is shifting toward a more nuanced understanding of pain mechanisms. While ESWL and stenting remain key tools, their clinical effectiveness is variable, reflecting the dominant role of neuropathic pain. Emerging stent technologies offer potential advantages but require further validation before widespread adoption.

Brief Introduction
Endoscopic ultrasound (EUS) is increasingly recognized as a high-impact modality in gastroenterology, offering significant diagnostic and therapeutic value despite representing a small proportion of overall procedural volume.

Background / Clinical Context
Although EUS contributes meaningfully to clinical decision-making, particularly in pancreatic and oncologic disease, its adoption remains limited by high initial costs and infrastructure requirements. This has created disparities in access, delaying timely diagnosis and intervention in many settings.

Key Points from DDW 2026
EUS delivers substantial system-level value by influencing downstream care, including imaging, oncology treatment, and surgery. Therapeutic EUS further enhances this impact by offering minimally invasive alternatives that reduce hospital stay and procedural morbidity.

Barriers to implementation include the capital cost of equipment and maintenance. However, newer strategies such as compact processors, shared platforms, and high-frequency mini-probes provide cost-effective alternatives. Emerging clip-on ultrasound devices allow standard endoscopes to function as EUS platforms, offering comparable diagnostic performance in selected cases while significantly lowering upfront investment and improving portability.

Artificial intelligence is expected to further enhance EUS by improving lesion detection, diagnostic accuracy, and workflow efficiency. At the same time, appropriate utilization remains essential, as low-yield indications may not justify EUS use. Operational efficiency within endoscopy units—through optimized workflows, use of fine needle biopsy, and ambulatory settings—can further improve access and cost-effectiveness.

Clinical Interpretation
EUS should be viewed as a strategic clinical tool that delivers high value when appropriately integrated into care pathways and supported by efficient systems and targeted use.

What Is New or Practice-Changing?
Practice-informing: Shift toward cost-conscious implementation, AI integration, and expansion of EUS access through innovative technologies.

Limitations
Data are largely based on system-level and implementation perspectives rather than randomized clinical outcomes. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
EUS represents a high-value service with significant clinical and economic impact, particularly in complex GI and pancreatic disease. Expanding access through cost-effective technologies, optimizing utilization, and improving operational efficiency are key to maximizing its potential in modern gastroenterology practice.

Brief Introduction
The diagnostic approach to irritable bowel syndrome (IBS) is shifting from an exclusion-based strategy toward a positive, clinically driven diagnosis aimed at improving efficiency, patient experience, and outcomes.

Background / Clinical Context
Historically, IBS has been over-investigated due to concern for missed organic disease, leading to increased costs, delayed diagnosis, and patient anxiety. However, growing evidence supports a symptom-based diagnosis when alarm features are absent.

Key Points from DDW 2026
IBS should be approached as a positive clinical diagnosis based on symptom criteria and careful history-taking. A detailed clinical history not only guides diagnosis but also improves patient outcomes through effective communication and reassurance. A minimal yet focused diagnostic strategy is recommended, emphasizing selective testing guided by clinical features rather than routine extensive investigations.

Alarm features, except for clear indicators such as rectal bleeding or palpable mass, have limited predictive value. Extensive investigations, including endoscopy, generally have low diagnostic yield in patients without alarm symptoms and rarely alter management. Over-testing is associated with increased healthcare costs, patient anxiety, and reinforcement of disease-related concerns without improving quality of life.

Evidence supports that a positive diagnostic approach is non-inferior to exclusion-based strategies in terms of symptom control and quality of life, while being more cost-effective and safe over long-term follow-up. When testing is required, it should be mechanism-based and individualized, avoiding indiscriminate use of poorly validated tests.

Clinical Interpretation
A structured, history-driven approach with selective testing improves diagnostic efficiency while maintaining safety and patient-centered care.

What Is New or Practice-Changing?
Practice-changing: Strong shift toward a positive diagnostic strategy with minimal, targeted investigations.

Limitations
Data emphasize clinical strategy rather than specific diagnostic tools, and applicability may vary across healthcare settings. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
IBS should be diagnosed using a positive, symptom-based approach supported by focused evaluation rather than extensive exclusionary testing. This strategy reduces unnecessary investigations, lowers healthcare costs, and improves patient outcomes while maintaining diagnostic safety.

Brief Introduction
Pain in chronic pancreatitis (CP) remains one of the most challenging aspects of management, often requiring a multimodal and multidisciplinary approach that extends beyond structural interventions.

Background / Clinical Context
Traditional management has focused on ductal obstruction and stepwise analgesia. However, persistent pain despite adequate decompression highlights the contribution of neuropathic mechanisms and psychosocial factors, necessitating a broader therapeutic framework.

Key Points from DDW 2026
Management begins with structured pain assessment and identification of contributing factors, followed by a stepwise analgesic approach with adjunctive therapies. Evaluation for pancreatic duct obstruction remains important, with endoscopic or surgical intervention considered in selected cases.

Psychological comorbidity is highly prevalent, with anxiety in 46.8%, depression in 38.6%, and both in 29% of patients. These conditions are strongly associated with increased pain perception, functional impairment, and reduced quality of life, underscoring the need for integrated mental health care.

Central sensitization plays a key role, reflecting amplified neural signaling and cortical reorganization that contribute to persistent pain. This supports the concept that CP pain is not purely nociceptive but involves significant neuropathic components.

Celiac plexus blockade, commonly performed under EUS guidance, provides modest short-term benefit. Meta-analytic data (729 patients) show overall efficacy of 53% with mean pain relief lasting approximately 81 days, but response declines significantly over time, limiting long-term utility.

Clinical Interpretation
Effective pain control requires integration of medical, psychological, endoscopic, and surgical strategies, with increasing emphasis on neuropathic and behavioral components.

What Is New or Practice-Changing?
Practice-informing: Recognition of central sensitization and psychological burden as key drivers of pain, influencing treatment strategies beyond ductal intervention.

Limitations
Evidence for many interventions, including celiac plexus blockade, shows limited durability, and further high-quality trials are needed. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
Pain in chronic pancreatitis is multifactorial, driven by neuropathic mechanisms and psychological comorbidity in addition to structural disease. While conventional interventions provide partial relief, a comprehensive, individualized, and multidisciplinary approach is essential to optimize outcomes and improve quality of life.

Brief Introduction
Blood-based colorectal cancer (CRC) screening is emerging as a promising strategy to improve participation, particularly among individuals unwilling to undergo traditional screening methods. However, its clinical role requires careful evaluation of benefits and limitations.

Background / Clinical Context
Despite effective screening tools, CRC screening rates remain suboptimal, with persistent disparities and incomplete follow-up after abnormal tests. Colonoscopy and stool-based testing, while effective, face barriers related to access, acceptability, and adherence, limiting real-world impact.

Key Points from DDW 2026
Blood-based tests detect circulating tumor-derived biomarkers using advanced sequencing and AI-driven analysis. They demonstrate overall CRC sensitivity of approximately 83% and specificity near 90%, with higher detection rates in advanced disease compared to early-stage cancer. However, sensitivity for advanced precancerous lesions remains low, limiting their preventive potential.

A major advantage is significantly higher adherence, with uptake rates approaching 80–90% and completion rates exceeding 90%. Offering blood-based testing to patients who decline colonoscopy or stool-based tests substantially increases overall screening participation. This positions blood-based testing as an effective tool for engaging previously unscreened populations.

However, trade-offs are important. Blood-based testing may displace established modalities with superior adenoma detection. Additionally, follow-up after abnormal results is suboptimal, with only about 55% undergoing colonoscopy, potentially leading to delayed diagnosis and worse outcomes.

Clinical Interpretation
Blood-based screening should be viewed as an access-enhancing tool rather than a replacement for established screening methods, particularly when preventive detection is the goal.

What Is New or Practice-Changing?
Practice-informing: Blood-based tests improve screening uptake but require cautious integration to avoid compromising preventive effectiveness.

Limitations
Performance limitations in early disease detection and incomplete follow-up remain significant concerns. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
Blood-based CRC screening offers a valuable opportunity to expand access and improve participation, especially among previously unscreened individuals. However, its lower sensitivity for precancerous lesions and challenges with follow-up necessitate careful positioning within screening pathways to balance increased uptake with preservation of long-term preventive outcomes.

Brief Introduction
Management of uncomplicated choledocholithiasis in elderly patients remains controversial, particularly regarding the role of early ERCP. Target trial emulation (TTE) offers a novel approach to generate more reliable real-world evidence to guide this decision.

Background / Clinical Context
Traditional observational studies evaluating ERCP versus conservative management are prone to bias, limiting their clinical applicability. In the absence of randomized trials, TTE attempts to replicate trial conditions within large datasets to improve causal inference and inform clinical decision-making.

Key Points from DDW 2026
Using a large database of over 120 million patients, elderly individuals with first-time uncomplicated choledocholithiasis were matched to early ERCP or observation strategies. Methodological rigor included time-zero alignment, propensity score matching, and hierarchical outcome analysis prioritizing clinically severe events such as death and sepsis.

Clinical outcomes showed a higher burden of adverse events in the ERCP group, largely driven by procedure-related complications including pancreatitis, bleeding, and perforation. Composite major adverse events occurred more frequently with ERCP (30.7%) compared to observation (22.4%), while mortality rates were similar between groups. Win ratio analysis demonstrated superiority of observation (0.71), indicating better overall outcomes when clinically severe events were prioritized.

Sensitivity analyses across multiple cohorts and time windows confirmed consistent findings, with observation maintaining lower complication rates without a clear survival disadvantage.

Clinical Interpretation
These findings suggest that routine early ERCP in elderly patients with uncomplicated disease may not confer survival benefit and may increase harm due to procedural complications.

What Is New or Practice-Changing?
Potentially practice-informing: High-quality real-world evidence supporting a selective, observation-first strategy in elderly patients.

Limitations
Despite advanced methodology, this remains a non-randomized analysis with potential residual confounding. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
Target trial emulation data suggest that in elderly patients with uncomplicated choledocholithiasis, early ERCP may lead to higher adverse events without improving survival. A conservative, individualized approach appears safe in selected patients, reinforcing the need to avoid routine intervention in asymptomatic or low-risk cases.

Brief Introduction
Endoscopy training is undergoing a major shift as modern clinical demands require faster, safer, and more standardized skill acquisition. The traditional apprenticeship model is increasingly being supplemented by structured, technology-enabled educational strategies.

Background / Clinical Context
Conventional training often detects competence late in the learning curve and lacks uniform assessment standards. This creates variability in skill acquisition and delays early identification of deficiencies. There is growing emphasis on competency-based education, where measurable performance outcomes define training progression rather than time-based exposure.

Key Points from DDW 2026
Modern endoscopy education is structured around three core pillars: engagement, assessment, and curation. Engagement focuses on active learner participation through strategies such as microlearning, gamification, and simulation-based training, which improve retention and procedural confidence. Assessment is evolving toward objective, data-driven methods, incorporating structured feedback, video-based review, and remote proctoring to enable consistent and reflective learning. Curation ensures organized and accessible delivery of educational content, supporting efficient progression across training stages.

Technology integration, particularly artificial intelligence, is emerging as a key enabler by providing real-time feedback, tracking procedural metrics, and identifying performance gaps. Parallelly, there is a shift toward personalized learning pathways tailored to individual learner progression. Mentorship and deliberate practice remain central, ensuring refinement of both technical and cognitive skills within a supportive environment.

Clinical Interpretation
This model represents a transition toward precision education, where training is individualized, measurable, and continuously optimized using technology and structured feedback systems.

What Is New or Practice-Changing?
Practice-informing: Integration of AI, structured frameworks, and personalized pathways into endoscopy training.

Limitations
The available information is largely conceptual and based on evolving educational strategies. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
Endoscopy education is moving toward a structured, learner-centered, and technology-driven model that combines engagement, objective assessment, and personalized training pathways. This evolution has the potential to standardize skill acquisition, enhance training efficiency, and ultimately improve procedural quality and patient outcomes.

Brief Introduction
The role of ERCP in elderly patients with choledocholithiasis, particularly those who are asymptomatic or minimally symptomatic, remains uncertain. Decision-making is increasingly complex due to age-related vulnerability and competing procedural risks.

Background / Clinical Context
While ERCP is the standard approach for bile duct clearance, its routine use in uncomplicated cases—especially in the elderly—is debated. The absence of clear evidence defining the natural history of untreated stones in this population creates a clinical grey zone, where intervention may not always translate into benefit.

Key Points from DDW 2026
ERCP carries a measurable risk profile, including post-ERCP pancreatitis (~5.9%), bleeding (~1.5%), cholangitis (~2.5%), and mortality (~0.2%). Notably, asymptomatic patients may experience higher complication rates, raising concerns about potential overtreatment in elderly individuals. Imaging findings often do not correlate with clinical severity, with persistent or evolving biliary abnormalities observed without clear symptom progression. This highlights the limitation of relying solely on radiology to guide intervention decisions.

Evidence remains conflicting. Some studies suggest increased adverse events with intervention in asymptomatic patients, while observational data indicate that selected patients managed conservatively may have low recurrence of biliary events. Registry data suggest worse outcomes without intervention, but these findings are influenced by selection bias and lack focused evaluation in elderly cohorts.

Clinical Interpretation
Management should be individualized, integrating symptom burden, comorbidities, functional status, and patient preference rather than relying on imaging alone.

What Is New or Practice-Changing?
Practice-informing: Emphasis on selective rather than routine ERCP in elderly, particularly in asymptomatic cases.

Limitations
Data are largely observational with limited elderly-specific analysis and absence of randomized trials. The available information is limited, so the interpretation should be cautious.

Final Clinical Summary
ERCP in elderly patients with choledocholithiasis requires careful risk–benefit assessment. While intervention remains essential in symptomatic disease, routine ERCP in asymptomatic individuals may expose patients to unnecessary harm. A personalized, clinically driven approach remains central until stronger evidence becomes available.