In endoscopic retrograde cholangiopancreatography anesthesia, both intubation and non-intubation techniques have their own advantages and disadvantages. However, whether either approach is associated with postoperative and anesthesia-related adverse events remains controversial.We searched the literature in PubMed, Web of Science, Cochrane Library, Scopus, Ovid and Embase databases up to October 2024. All studies comparing intubated vs. non-intubation anesthesia for endoscopic retrograde cholangiopancreatography were included. The main outcome measures were sedation-related adverse events and death. Data were combined using risk ratio with 95% confidence intervals. The study protocol was prospectively registered with PROSPERO (CRD42024608807).We finally included 8 studies with a total of 21,433 patients. Endotracheal intubation was associated with a lower risk of sedation-related adverse events (RR: 2.85, 95% CI 1.33-6.09, p = 0.007). However, the risks of death (RR: 0.59, 95% CI 0.36-0.96, p = 0.03) and intraoperative hypotension (RR: 0.43, 95% CI 0.26-0.69, p = 0.0006) were lower without intubation. In the trial-sequence analysis, the trial-sequence monitoring boundary is crossed, indicating conclusive evidence of a statistically significant effect.Our findings suggest that endotracheal intubation during endoscopic retrograde cholangiopancreatography is associated with a lower risk of sedation-related adverse events but a higher risk of mortality and intraoperative hypotension compared to non-intubation. However, these associations do not establish direct causality and should be interpreted with caution. Further high-quality randomized controlled trials are needed to validate these findings. Clinicians should adopt a patient-centered approach, carefully balancing the potential benefits and risks of intubation to optimize airway management strategies in endoscopic retrograde cholangiopancreatography.