The place of endoscopic sphincterotomy in the treatment of common duct stones leaving the gallbladder in situ remains controversial. Over a 3-year period, 20 elderly high-operative-risk patients with stones in the common duct and intact biliary tree were treated by endoscopic sphincterotomy leaving the gallbladder in situ. Two patients underwent cholecystectomy for persistent symptoms after endoscopic sphincterotomy, and 18 patients were discharged from hospital, with the gallbladder intact. Of the 18 patients, 6 developed recurrent gallbladder problems, with 3 of the 6 dying as a result of these problems. On review of our data, these six patients were in a group of eight who, at the time of original endoscopic retrograde cholangiography (ERC), were shown to have an obstructed cystic duct. The other 10 patients, with a patent cystic duct and discharged with gallbladder in situ, remained symptom free over a median follow-up period of 9 (range 2–42) months. We conclude that if the gallbladder does not fill at ERC (indicating probable cystic duct obstruction), cholecystectomy is warranted. When the gallbladder fills, regular follow-up alone is justified in the absence of symptoms.