Beyond age alone: Outcomes and risk stratification of endoscopic retrograde cholangiopancreatography in the elderly

Since its introduction in 1968, endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard for the management of pancreaticobiliary disease in particular choledocholithiasis, cholangitis, and other pancreaticobiliary disorders.[1,2] Despite higher technical and clinical success, ERCP carries up to 10% of post-operative complications include bleeding, perforation, post-ERCP pancreatitis in addition to the cardio-pulmonary risk from sedation and anesthesia.[3] The risks can be minimized by understanding higher risk population. There are multiple predictors for complications and difficult cannulation in patients undergoing ERCP.[4,5] The aging of populations worldwide has brought the management of pancreaticobiliary diseases in elderly patients to the forefront of gastroenterology. The number of geriatric patients requiring ERCP grows, so balancing efficacy with safety is crucial. The challenge is magnified in elderly patients, where physiological reserve is diminished, comorbidities are prevalent, and peri-procedural risks are often amplified.[6,7] In this issue of the Saudi Journal of Gastroenterology, two important studies address this clinical dilemma from complementary angles: a rigorously developed risk prediction model from China and the prospective Saudi cohort study evaluating outcomes in elderly patients with cholangitis. Together, they provide a comprehensive picture that advances both global and regional perspectives on ERCP in the elderly. Zhang et al.[8] report a multicenter retrospective study establishing a seven-point risk score model specifically tailored to patients aged ≥75 years with choledocholithiasis. Drawing from 718 patients across two institutions, the investigators identified five independent predictors of post-ERCP complications: 1. Charlson Comorbidity Index (CCI) ≥3; 2. Elevated aspartate aminotransferase (AST) above the upper limit of normal; 3. Endoscopic papillary large balloon dilation (EPLBD); 4. Cannulation time >10 min; 5. Multiple large bile duct stones. The predictive model demonstrated excellent discrimination in both derivation (area under the curve [AUC] 0.791) and external validation cohorts (AUC 0.876). Using a cutoff of ≥3 points, the model stratified patients into low- and high-risk categories, enabling individualized prophylactic strategies. This work is notable for directly addressing the elderly subgroup, integrating clinical, biochemical, and procedural parameters into a practical score easily applicable at the bedside. In parallel, Al Masoud et al.[9] provide prospective, single-center evidence from a high-volume tertiary center in Saudi Arabia. Among 403 ERCP procedures performed during the study period, 363 (90.7%) involved patients aged ≥70 years, divided into two cohorts: 70–80 years (n = 199) and ≥81 years (n = 164, up to 103 years). They found a high technical success across both age groups and overall low complication rates in elderly with no reported mortality related to ERCP at 30 days [Figure 1]. This study reinforces that age alone should not preclude ERCP when clinically indicated, provided procedures are performed in expert centers with structured care protocols.[9]Figure 1: Complication rates of ERCP in elderly patients stratified by age group (70–80 years vs. ≥81 years). Both groups showed low overall complication rates with no 30-day procedure-related mortality (Al Masoud et al., 2025). (The graph was created using R Studio Statistical software (RStudio Version 1.4.1564 (Posit PBC)) and the code for the image was created using AI assistant). ERCP = Endoscopic retrograde cholangiopancreatographyWhen viewed together [Figure 2], The analysis suggests that the risk stratification model developed by Zhang et al.[8] is based on sound principles that likely hold true across populations, including in Saudi Arabia. The Al Masoud et al. paper confirms that comorbidities are a key driver of risk. Therefore, Saudi hospitals should consider prospectively validating this model by collecting the missing variables (AST, cannulation time, stone details) to create a tailored, evidence-based tool for improving ERCP safety in their geriatric patients. The takeaway is not that the exact score can be applied directly, but that its methodology should be adopted and validated locally.Figure 2: (a) Risk prediction model for post ERCP complications in elderly patients (Zhang et al., 2025) compared with outcomes from a Saudi cohort (Al Masoud et al., 2025) . (b)Together, the studies highlight comorbidities as a key driver of risk and support individualized, locally validated strategies for safe ERCP practice. (The graphs were created using RStudio Statistical software and the code for the image was created using AI assistant)In conclusion, the complementary contributions of Zhang et al.[8] and Al Masoud et al.[9] mark an important step forward in advancing ERCP safety for elderly patients. By bridging predictive analytics with real-world regional data, these studies chart the pathway toward personalized, risk-adapted ERCP practice in geriatric populations. For clinicians, the message is clear: advanced age should not preclude ERCP, but careful risk stratification and individualized care remain paramount.