However, life expectancy is often difficult to judge, at least in the absence of malignant disease. The fundamental question is whether any other approach to these high risk patients would be safer. Surgery should not be forgotten. Many of the current endoscopic experts formed their attitudes to surgery during the 1970s, when biliary operations carried considerable risks in the elderly and frail. Surgical techniques and perioperative care have improved substantially over the last two decades.
Few data are available, but it is likely that the risks of operation have fallen significantly.
It is noteworthy that there were no operative deaths amongst the 33 Amsterdam patients treated surgically after initial stent therapy. Davidson et al. have made the same point. Operation was performed without major complication or death in 19 elderly patients whose stones could not be extracted endoscopically. These considerations point to the need for more precise documentation of co-morbid risk factors. Several scoring systems are available, but none have been validated or used extensively in this context.