Introduction <p>Elderly patients with common bile duct (CBD) stones often present with large or multiple stones, making endoscopic retrograde cholangiopancreatography (ERCP)-guided extraction a technically complex and potentially high-risk procedure.</p> Aim <p>This study aimed to compare the efficacy and safety of a staged approach—biliary stenting followed by delayed stone extraction—versus immediate stone removal during the initial ERCP in frail elderly patients with large or multiple CBD stones.</p> Methods <p>This prospective study included high-risk elderly patients with large or multiple CBD stones, defined as either a single stone ≥ 15 mm in diameter or three or more stones, each ≥ 10 mm in diameter. Participants were randomly assigned to two equal groups: Group A underwent initial biliary stenting with elective stone retrieval after 8–12 weeks, while Group B underwent immediate stone extraction during the first ERCP.</p> Results <p>A total of 400 patients were included, with 200 in each group. Baseline characteristics and stone extraction methodologies were comparable between the two groups. In Group A, stone size and number significantly decreased after stenting (mean size: 1.42 ± 0.28 cm before vs. 0.98 ± 0.19 cm after stenting; P &lt; 0.001). The overall stone clearance rate was significantly higher in Group A compared to Group B (94% vs. 80%, P &lt; 0.001). Post-ERCP hospital stay was significantly shorter in Group A (6.41 ± 1.27 days vs. 11.3 ± 1.86 days, P &lt; 0.001). Group B had higher rates of complications, including cholangitis (1% vs. 7%, P &lt; 0.05) and pneumonia (2% vs. 11%, P &lt; 0.05).</p> Conclusion <p>In high-risk elderly patients with large or multiple CBD stones, temporary placement of biliary plastic stents followed by elective endoscopic stone removal effectively reduces stone size, simplifies the removal process, enhances stone clearance rates, and decreases ERCP-related complications.</p>