Uncomplicated Choledocholithiasis in Elderly Patients: A Target Trial Emulation Comparing Observation and Endoscopic Retrograde Cholangiopancreatography. Clin Gastroenterol Hepatol 2026 Aug;24(8):2129-2139
Date
02/20/2026Pubmed ID
41713828DOI
10.1016/j.cgh.2026.02.010Scopus ID
2-s2.0-105034814800 (requires institutional sign-in at Scopus site)Abstract
BACKGROUND & AIMS: The management of uncomplicated choledocholithiasis in elderly patients remains controversial due to uncertain clinical benefits of intervention and higher complication rates with endoscopic retrograde cholangiopancreatography (ERCP). We emulated a target trial comparing early ERCP vs observation in elderly patients with uncomplicated choledocholithiasis.
METHODS: Target trial emulation using health record data from TriNetX. Patients >75 years with an incident choledocholithiasis diagnosis between 2015 and 2023 were included. The ERCP group underwent ERCP within 60 days of Time Zero; the observation group did not. Cohorts were constructed with propensity score matching. The primary outcome was a composite of major adverse events within 3 years or all-cause mortality within 12 months. Adjusted Cox regression was performed to compare the survival outcome between groups. Win ratio was calculated for reporting the hierarchical composite outcome. Sensitivity analyses were conducted with a 30-day ERCP window and patients diagnosed at ambulatory encounter only.
RESULTS: Among 5856 matched patients (2928 per group), the composite outcome occurred in 30.7% of ERCP vs 22.4% of observation patients; however, there was no significant difference (adjusted hazard ratio [aHR], 1.13; 95% confidence interval [CI], 0.99-1.28). The win ratio favored observation (0.71; 95% CI, 0.64-0.79). In both sensitivity analyses, ERCP was associated with higher major adverse events (30-day ERCP window: aHR, 1.14; 95% CI, 1.00-1.31; ambulatory-only: aHR, 1.61; 95% CI, 1.13-2.29). Mortality did not differ significantly.
CONCLUSIONS: In elderly patients with uncomplicated choledocholithiasis, early ERCP was not associated with improved outcomes. Findings support a selective, 'as-needed' approach to ERCP in this population.
Author List
Smith ZL, Amjad T, Hoard M, Thorgerson A, Chisholm PR, Dua KS, Elmunzer BJ, Forbes N, Madhavan S, Keswani RN, Peller MT, Wani S, Zia H, Dawson AZ, Yu DAuthors
Aprill Z. Dawson PhD, MPH Associate Professor in the Medicine department at Medical College of WisconsinKulwinder S. Dua MD Professor in the Medicine department at Medical College of Wisconsin
Matthew T. Peller MD Assistant Professor in the Medicine department at Medical College of Wisconsin
Zachary Smith DO Associate Professor in the Medicine department at Medical College of Wisconsin
Duo Yu PhD Assistant Professor in the Data Science Institute department at Medical College of Wisconsin
MESH terms used to index this publication - Major topics in bold
AgedAged, 80 and over
Cholangiopancreatography, Endoscopic Retrograde
Choledocholithiasis
Female
Humans
Male
Treatment Outcome
Watchful Waiting
