SUMMARY Endoscopic sphincterotomy was undertaken in 186 patients with common bile duct stones and an intact gall bladder who were considered unfit for surgery. One hundred and seventy one patients had jaundice of whom 18 also had clinical cholangitis. The mean age of treated patients was 79.7 years (range 27-92) and only 13 were aged less than 60. Sphincterotomy was successful in 185 (99%) and complete clearance achieved in 172 (92.5%). Early complications occurred in nine patients (4.8%) of whom three died (1.6%). The patients have been followed on average for 32 months (range six to 72 months). Eighteen patients have subsequently required cholecystectomy (9.6%), with six major complications, but no deaths. There have been 27 natural deaths and 156 patients remain alive and symptom free. Endoscopic treatment alone is safe and effective in the majority of frail and elderly patients and can reduce the need for surgery in this high risk group.Obstructive jaundice caused by stones is a common disorder of the elderly. Many of these patients are fit for surgery and are treated successfully by operative clearance of the bile ducts. Unfortunately, the risks of surgical exploration of the bile ducts increase with age. A high morbidity in the elderly, with mortalities of up to 10%, has been described.' The gradual rise in the proportion of very elderly in the population means a growing number of patients are not good candidates for surgery. We have experienced an increasing number of referrals of patients for endoscopic removal of bile duct stones in patients with gall bladders present. The subsequent management of these patients is controversial and the need for cholecystectomy is disputed. It has been suggested that elective surgery is essential because of a high risk of subsequent cholecystitis.2' Other authors have reported low rates of late biliary surgery without many complications in patients with retained gall bladders.`7 We have, therefore, examined the long term outcome of endoscopic biliary clearance without cholecystectomy in a larger series than previously reported, to attempt to determine the role of surgery after endoscopic clearance of the biliary tree.
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