Do All Elderly Patients With Asymptomatic Bile-Duct Stones Need ERCP?: CGH | August 2026

Introduction:

Guidelines generally favor removal of common bile-duct stones because of the future risk of cholangitis, pancreatitis, and obstruction. However, in elderly patients, the balance is less straightforward because ERCP itself carries meaningful procedural risk. This target-trial emulation compared early ERCP with observation in patients aged >75 years with uncomplicated choledocholithiasis.

Why was this study needed?

Evidence supporting routine ERCP in elderly patients with uncomplicated stones is limited.

Procedural complications may offset the benefit of prophylactic stone clearance.

Randomized trials in this population are difficult to perform.

A target-trial emulation can approximate the clinical question: intervene now or observe and treat only if necessary?

Results:

5,856 propensity-matched patients were analyzed: 2,928 underwent early ERCP and 2,928 were observed.

The composite adverse outcome occurred in 30.7% with ERCP vs 22.4% with observation, although the adjusted primary time-to-event comparison did not reach statistical significance.

The hierarchical win ratio favored observation (0.71), and sensitivity analyses consistently showed more major adverse events with ERCP.

Importantly, mortality was not significantly improved by early ERCP.

Clinical Impact:

These findings challenge a reflexive “stone detected = ERCP” strategy in older adults. For a carefully selected elderly patient with uncomplicated choledocholithiasis—particularly with frailty, multimorbidity, or high procedural risk—observation with intervention if symptoms or complications develop may be reasonable.

However, this was an observational target-trial emulation, not a randomised trial. Residual confounding and differences in why patients underwent ERCP remain possible. The findings should therefore support individualised decision-making rather than wholesale abandonment of guideline-directed stone clearance.

Bottom Line:

In patients >75 years with uncomplicated choledocholithiasis, early ERCP did not improve survival or overall outcomes and was associated with more adverse events in sensitivity analyses. For selected elderly patients, a watchful “ERCP only when needed” strategy may offer a better benefit–risk balance than routine prophylactic intervention.