ERCP Beyond the Ninth Decade: Frailty, Treatment Strategy, and Outcomes in Octogenarians, Nonagenarians, and Centenarians

Evidence regarding endoscopic retrograde cholangiopancreatography (ERCP) in adults in their 90s and 100s remains limited, and chronological age may not adequately reflect procedural vulnerability. We compared ERCP strategy and short-term outcomes across advanced age strata and included a contemporary younger reference cohort. This retrospective cohort included 48 patients aged ≥80 years undergoing ERCP for choledocholithiasis or stone-related acute cholangitis between 2023 and 2025: 80–89 years (n = 20), 90–99 years (n = 21), and ≥100 years (n = 7). A reference group of 15 consecutive patients aged <80 years treated during the same period under the same eligibility criteria was added. Only the first eligible ERCP per patient during the study period was analyzed as the index procedure; subsequent ERCPs were outcomes rather than additional observations. Clinical Frailty Scale (CFS), stone burden, treatment strategy, drainage, adverse events, intensive care use, and 30-day mortality were analyzed using nonparametric and Fisher–Freeman–Halton methods. Frailty–outcome analyses were restricted to the ≥80-year primary cohort and were exploratory and unadjusted. Median CFS was 4.0, 4.5, 6.0, and 8.0 in the <80, 80–89, 90–99, and ≥100-year groups, respectively (p < 0.001). Complete index stone clearance was 93.3%, 90.0%, 76.2%, and 71.4% (p = 0.358), while stenting was used in 6.7%, 10.0%, 33.3%, and 42.9% (p = 0.055). Successful biliary drainage remained 100%, 95.0%, 95.2%, and 100% (p = 1.000). Repeat ERCP occurred in 0%, 0%, 14.3%, and 28.6% (p = 0.027), and median length of stay increased from 3 to 4, 5, and 6 days (p < 0.001). Within the ≥80-year cohort, higher CFS remained associated with failed index clearance, stenting, post-procedure ICU requirement, and 30-day mortality in exploratory analyses. ERCP achieved high biliary drainage rates across age strata, including centenarians. The small younger reference cohort provided clinical context, while the ≥80-year analyses continued to show increasing frailty and more frequent staged management in the oldest groups. The retrospective design, small reference cohort, sparse events, and strong age–frailty correlation preclude causal or independent prognostic claims.