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Sixty-four gallstone patients aged 75 or more (mean age 83 ± 5.1 years) were divided prospectively into two groups. They were mostly high-risk patients (average number of major risk factors, 2.2±0.9). Thirty-three showed one or several signs of lithiasis of the common bile duct and were treated with endoscopic sphincterotomy (ES) (31 successful cases, two technical problems) followed by early cholecystectomy (33 cases). Choledocholithiasis was present in 26 cases and stones were extracted in 25 cases. Two patients (6 per cent) died. ES caused no complications. Thirty-one other patients showed no sign of choledocholithiasis and were treated by cholecystectomy with operative cholangiography. Choledocholithiasis was found in two of these patients and treated by extraction and external drainage. Five of these patients (16 per cent) died. I n 30 cases acute cholecystitis was found at operation, 15 in each group. E S is therefore an eficient procedure in highksk patients, which facilitates operation, especially in cases of acute cholecystitis, and it is recommended in all cases of complicated biliary lithiasis. Early cholecystectomy is justified for these patients by the high frequency of associated acute cholecystitis.