Role of endoscopic retrograde cholangiography and nasobiliary drainage in the management of postoperative biliary leak

In order to assess the role of endoscopic retrograde cholangiography in evaluating the patients with post-operative biliary leak and of endoscopic nasobiliary drainage in its management, 36 patients with biliary leak seen over a period of 9 years were studied. Thirty-two had biliary leak following cholecystectomy, 3 following repair of liver trauma and 1 following choledochoduodenostomy. Patients presented at an interval of 4 days to 210 days (mean +/- SEM, 32.4 +/- 6.7 days) following laparotomy. Hyperbilirubinemia was noticed in only 13 patients (36.1%), while abdominal ultrasonogram showed ascites or biloma in 24 (66.7%). Endoscopic retrograde cholangiography showed the leak to involve the common bile duct in 55.6%, cystic duct in 33.3% and intrahepatic biliary radicles in 8.3%. Associated lesions included bile duct obstruction due to stricture or accidental ligature in 20%, bile duct stone in 20% and liver abscess in 2.8%.Endoscopic nasobiliary drainage using a 7 Fr pig-tail catheter was attempted in 14 patients and could be established in 12 of them. Bile duct leak sealed in all but one of these 12 patients after an interval of 3 days to 40 days (mean +/- SEM, 12.2 +/- 3.2 days). A single patient with large defect and a proximal bile duct stricture did not respond and required surgery. Common bile duct stones were removed by endoscopic sphincterotomy in 3 out of 4 patients. One patient with large stone required surgical choledocholithotomy. In conclusion, endoscopic retrograde cholangiography was safe and useful in confirming the presence of leak as well as its site, size and associated abnormalities. Endoscopic nasobiliary drainage proved an effective therapy in post-operative biliary leak and could avoid re-exploration in 71.4% patients.     

Postoperative external and internal biliary fistulas, unassociated with distal bile duct obstruction: endoscopic treatment

Endoscopic drainage was applied in 14 patients with either external or internal (bile ascites) postoperative biliary fistulas. Endoscopic sphincterotomy and/or insertion of a nasobiliary tube or an endoprosthesis was found to be a safe and effective treatment, achieving closure of fistula in all patients.     

Effectiveness of endoscopic treatment modalities in complicated hepatic hydatid disease after surgical intervention

BACKGROUND AND STUDY AIMS: Hepatic hydatid cyst is a common disease in Turkey and the rupture of the cyst into the biliary tract is the most common complication which is difficult to detect and to manage. The aim of this study was to investigate the effectiveness of endoscopic treatment modalities in hydatid cyst patients with biliary complications who had previously undergone surgery. PATIENTS AND METHODS: Over the last 8 years, by means of endoscopic retrograde cholangiopancreatography (ERCP), we have examined 87 patients with postoperative biliary symptoms who had previously undergone surgery for hepatic hydatid disease of the liver. Endoscopic treatment modalities were as follows: endoscopic sphincterotomy (ES) and nasobiliary drainage in patients with biliary fistula; balloon and or bougie dilation and stenting in patients with biliary stricture; and ES and balloon extraction in patients with residual hydatid material within the bile duct. RESULTS: Findings from ERCP included biliary fistula in 55 patients (63.2 %), biliary stricture in 16 (18.4 %), and residual hydatid material within the bile duct in 14 (16.1 %). Two patients had normal findings on ERCP. In total, 85 patients were treated by means of endoscopic modalities. The time to closure of fistula was 17.8 +/- 5 days and the rate of fistula closure was 81 %. Biliary stenting was performed in 13 patients with biliary stricture. Endoscopic removal of hydatid material was achieved in 14 patients. The overall success rate of endoscopic treatment was 86 %, and a second surgical intervention was required only in six patients. No serious complication was encountered after endoscopic procedures. CONCLUSIONS: Endoscopic treatment modalities are safe and helpful methods for the treatment of biliary complications of hepatic hydatid cyst in the postoperative period.     

Endoscopic nasobiliary drainage in the management of acute cholangitis: an experience in 143 patients

Acute cholangitis is associated with a high mortality and morbidity and often requires drainage of the obstructed biliary system. The purpose of this study was to evaluate the usefulness and safety of endoscopic nasobiliary drainage in the treatment and prevention of acute cholangitis due to diverse etiology. During a 32-month period, 143 patients (67 males, 76 females) with age range of 15 to 84 years underwent urgent fluoroscopy guided endoscopic nasobiliary drainage using a 7 Fr catheter either to treat acute cholangitis not responding to antibiotics (group A, n = 116) or to prevent its development following endoscopic retrograde cholangiography performed in an obstructed biliary system (group B, n = 27). Underlying etiology included bile duct stones (92), malignant biliary obstruction (34), choledochal cyst (4), chronic pancreatitis (4), ruptured hydatid cyst (3), portal hypertensive cholangiopathy (3) and liver abscess (3). Endoscopic nasobiliary drainage was performed successfully in 129 patients (90.2%). Cholangitis improved within 1 to 3 days (in group A) or did not develop (in Group B) in 125 patients (96.7%) with successful endoscopic nasobiliary drainage. Two patients however required additional drainage by percutaneous transhepatic route, while two died inspite of effective endoscopic drainage. Of the 14 patients (9.8%) with failed endoscopic drainage, 9 were managed by surgical decompression or percutaneous transhepatic drainage, 3 died of septicemia. Endoscopic nasobiliary drainage is a safe and effective method to treat patients with acute cholangitis as well as to prevent its development following cholangiography performed in an obstructed biliary system.     

Endoscopic management of persistent biliary leakage resulting from complete transection of the bile duct at cholecystectomy

BACKGROUND AND STUDY AIMS: Injuries to the bile duct are not uncommon during cholecystectomy. While minor injuries are amenable to endoscopic therapy, major ones, such as complete transection of the duct, require surgical intervention. We report on the endoscopic management of such injuries. PATIENTS AND METHODS: We included in the study ten patients who had persistent postoperative bile drainage (either through a surgically placed catheter or through a biliocutaneous fistula) after their cholecystectomy procedure had been complicated by complete transection of the bile duct. Plastic biliary endoprostheses were placed in the bilioma through the papilla of Vater. In one patient, both the right and the left hepatic ducts were opacified by injecting contrast material through the drainage catheter and it was possible to place stents in both the ducts. RESULTS: All the patients improved clinically after the procedure. In one patient the stent became dislodged and an elective Roux-en-Y hepaticojejunostomy was performed, but it was possible to remove the stents from all the other patients. Two patients were referred for surgery but in both cases the bile flow through the bile duct was shown to be so good on nuclear imaging that they were not operated on. All the non-operated patients are well after a mean +/- SD follow-up of 22.3 +/- 5.5 months. CONCLUSIONS: Placement of biliary stents in the bilioma is a useful adjunct to percutaneous drainage in patients with complete transection of the bile duct. After placement of a biliary stent in the bilioma the percutaneous drainage catheter may be removed. In one of our study patients it was also possible to place stents in the intrahepatic ducts and the bile duct was reconstructed. Long-term follow-up of these patients and further studies are required to assess the role of endoscopic management as an alternative to surgery in patients with this condition.     

Icteric-type hepatoma: magnetic resonance imaging and magnetic resonance cholangiographic features

Background: We evaluated the imaging features of magnetic resonance imaging (MRI) and magnetic resonance cholangiography (MRC) of icteric-type hepatoma and correlated these with the findings of endoscopic retrograde cholangiography (ERC), percutaneous cholangiography, and surgery. Methods: Thirteen patients with viral hepatitis complicated by cirrhosis of the liver and obstructive jaundice underwent MRC and dynamic MRI. Five patients received percutaneous transhepatic cholangiography and drainage; one of these patients also underwent resection of the left hepatic lobe. Another patient received MRC followed by thrombectomy and T-tube insertion. ERC and endoscopic nasobiliary drainage were performed in another patient for bile diversion. Results: Primary liver tumors and dilatation of biliary system were demonstrated in all patients. No capsule formation could be found in any primary liver tumors. MRI showed the simultaneous presence of an intraluminal tumor in the portal trunk and common hepatic duct in eight patients. Three different MRC features were found: (a) an oval defect in the hilar bile duct(s) with dilated intrahepatic ducts (n= 9), (b) dilated intrahepatic ducts with missing major bile ducts (n= 2), and (c) localized stricture of the hilar bile duct(s) (n= 2). Conclusion: The presence of one or more of the following features in multiplanar MRI and MRC help to identify this rare, specific type of hepatocellular carcinoma: (a) the presence of an intraluminal tumor in both the portal trunk and the common hepatic duct, (b) enhancement of the intraluminal tumor in the common hepatic duct on the arterial phase, (c) type I MRC feature, and (d) hemobilia, blood clot within the gallbladder, and/or type II MRC feature. Received: 12 January 2000/Revision accepted: 12 July 2000     

Benign diseases of the biliary tract: evaluation with MR cholangiography.

MR cholangiography (MRC) is a noninvasive, rapid means of evaluating the biliary tract that, in many instances, may replace invasive procedures such as diagnostic endoscopic retrograde cholangiography and percutaneous transhepatic cholangiography. This article describes and illustrates the MRC features of benign diseases of the biliary tract such as choledocholithiasis; intrahepatic bile duct calculi; congenital anomalies, including aberrant bile ducts and choledochal cysts; postsurgical strictures; and strictures related to chronic pancreatitis.     

Current management of postoperative complications and benign biliary strictures

Postoperative complications after surgery of the biliary tract are usually amenable to endoscopic treatment. Such complications are most frequent after laparoscopic cholecystectomy. Bile leaks and bile duct strictures are the two main biliary injuries. Bile leaks are usually detected during the early postoperative period and can be treated by endoscopic drainage of the biliary tree (endoscopic sphincterotomy with or without nasobiliary drain). Postoperative biliary strictures are usually identified months or years after surgery. Endoscopic placement of an increasing number of plastic stents can achieve morphologic disappearance of the stricture and persistent dilation on long-term follow-up in most cases.     

Intraoperative fluorescent cholangiography using indocyanine green for laparoscopic fenestration of nonparasitic huge liver cysts

Bile duct injury is one of the known serious complications of laparoscopic fenestration for nonparasitic liver cysts. Herein, we report the case of a huge liver cyst for which we performed laparoscopic fenestration using intraoperative fluorescent cholangiography with indocyanine green. A 71‐year‐old woman with abdominal distention was referred to our hospital. CT demonstrated a 17 × 11.5‐cm simple cyst replacing the right lobe of the liver, so laparoscopic fenestration was performed. Although the biliary duct could not be detected because of compression by the huge cyst, fluorescent cholangiography with indocyanine green through endoscopic naso‐biliary drainage tube clearly delineated the intrahepatic bile duct in the remaining cystic wall. The patient had no complications at 3 months after surgery. Fluorescent cholangiography using indocyanine green is a safe and effective procedure to avoid bile duct injury during laparoscopic fenestration, especially in patients with a huge liver cyst.     

鼻胆管引流术在内镜下乳头气囊扩张治疗术后的应用价值

【目的】探讨鼻胆管引流术在内镜下乳头气囊扩张术后的应用价值。【方法】将93例行内镜下乳头气囊扩张术（EPBD）治疗后的胆总管结石患者分为两组,治疗组43例EPBD术后放置鼻胆引流管,对照组50例EPBD术后未放置鼻胆引流管,比较两组术后并发症的情况。【结果】93例无出血及穿孔等并发症,治疗组并发急性胰腺炎2例（4．7％）,无一例胆道感染,对照组并发胆道感染6例（12％）,并发急性胰腺炎4例（8％）,两组对比有统计学差异（P〈0．05）。【结论】鼻胆引流术能显著减少EPBD后胆道感染及急性胰腺炎的发生率,宜术后常规放置。     

胆道支架和鼻胆管引流在腹腔镜胆总管探查术后一期缝合中的应用

目的 对比胆道支架和鼻胆管引流在腹腔镜胆总管探查术（LCBDE）后一期缝合中的临床疗效。方法 回顾性分析2016年8月－2021年1月在该院行内镜逆行胰胆管造影术（ERCP）取石失败的74例患者的临床资料，分为支架引流组（n = 38）和鼻胆管引流组（n = 36）。支架引流组ERCP取石失败后放置胆道支架引流，鼻胆管引流组ERCP取石失败后放置鼻胆管引流，两组患者均行腹腔镜胆总管切开取石一期缝合术。比较两组患者手术时间、术后住院时间、术后并发症发生率、术后肠道功能恢复时间、术后胆总管结石复发率和住院时间。结果 两组患者胆管缝合方式、手术时间、术中出血量、术后并发症总发生率和住院费用比较，差异均无统计学意义（P > 0.05）。鼻胆管引流组术后胆瘘发生率明显低于支架引流组，住院时间明显短于支架引流组，术后肠道功能恢复时间明显长于支架引流组，术后总补液量多于支架引流组，差异均有统计学意义（P < 0.05）。结论 ERCP取石失败后放置鼻胆管引流，可降低LCBDE术后一期缝合的胆瘘发生率，缩短住院时间，但放置胆道支架引流患者肠道功能恢复更快，补液量更少。因此，在临床操作中，应根据患者具体情况，选择相应的个体化引流方式。     

Percutaneous transhepatic cholangiography and biliary drainage after liver transplantation: A five-year experience

Evaluation of the biliary tract by percutaneous transhepatic cholangiography (PTC) is often required in liver transplant patients with an abnormal postoperative course. Indications for PTC include failure of liver enzyme levels to return to normal postoperatively, an elevation of serum bilirubin or liver enzyme levels, suspected bile leak, biliary obstructive symptoms, cholangitis, and sepsis.Over a 5-year period 625 liver transplants in 477 patients were performed at the University Health Center of Pittsburgh. Fifty-three patients (56 transplants) underwent 70 PTCs. Complications diagnosed by PTC included biliary strictures, bile leaks, bilomas, liver abscesses, stones, and problems associated with internal biliary stents.Thirty-two percutaneous transhepatic biliary drainage procedures were performed. Ten transplantation patients underwent balloon dilatation of postoperative biliary strictures. Interventional radiologic techniques were important in treating other complications and avoiding additional surgery in many of these patients.     

Endoscopic management of a post-traumatic biliary fistula

A number of techniques of surgical endoscopy have been used in the management of a post-traumatic biliary fistula. The endoscopic sphincterotomy with placement of a perfused nasobiliary catheter, followed by the insertion of a biliary stent allowed the fistula to dry out. A secondary stricture of the left hepatic duct was treated by endoscopic internal drainage after the insertion of a transhepatic guidewire by an epigastric route. This kind of combined transhepatic and endoscopic procedure is useful in some difficult cases.     

Biliary stenting: indications, choice of stents and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline

This article is part of a combined publication that expresses the current view of the European Society of Gastrointestinal Endoscopy about endoscopic biliary stenting. The present Clinical Guideline describes short-term and long-term results of biliary stenting depending on indications and stent models; it makes recommendations on when, how, and with which stent to perform biliary drainage in most common clinical settings, including in patients with a potentially resectable malignant biliary obstruction and in those who require palliative drainage of common bile duct or hilar strictures. Treatment of benign conditions (strictures related to chronic pancreatitis, liver transplantation, or cholecystectomy, and leaks and failed biliary stone extraction) and management of complications (including stent revision) are also discussed. A two-page executive summary of evidence statements and recommendations is provided. A separate Technology Review describes the models of biliary stents available and the stenting techniques, including advanced techniques such as insertion of multiple plastic stents, drainage of hilar strictures, retrieval of migrated stents and combined stenting in malignant biliary and duodenal obstructions.The target readership for the Clinical Guideline mostly includes digestive endoscopists, gastroenterologists, oncologists, radiologists, internists, and surgeons while the Technology Review should be most useful to endoscopists who perform biliary drainage.     

The role of sonography in imaging of the biliary tract

Sonography is the recommended initial imaging test in the evaluation of patients presenting with right upper quadrant pain or jaundice. Dependent upon clinical circumstances, the differential diagnosis includes choledocholithiasis, biliary stricture, or tumor. Sonography is very sensitive in detection of mechanical biliary obstruction and stone disease, although less sensitive for detection of obstructing tumors, including pancreatic carcinoma and cholangiocarcinoma.In patients with sonographically documented cholelithiasis and choledocholithiasis, laparoscopic cholecystectomy with operative clearance of the biliary stone disease is usually performed. In patients with clinically suspected biliary stone disease, without initial sonographic documentation of choledocholithiasis, endoscopic ultrasound or magnetic resonance cholangiopancreatography is the next logical imaging step. Endoscopic ultrasound documentation of choledocholithiasis in a postcholecystectomy patient should lead to retrograde cholangiography, sphincterotomy, and clearance of the ductal calculi by endoscopic catheter techniques.In patients with clinical and sonographic findings suggestive of malignant biliary obstruction, a multipass contrast-enhanced computed tomography (CT) examination to detect and stage possible pancreatic carcinoma, cholangiocarcinoma, or periductal neoplasm is usually recommended. Assessment of tumor resectability and staging can be performed by CT or a combination of CT and endoscopic ultrasound, the latter often combined with fine needle aspiration biopsy of suspected periductal tumor.In patients whose CT scan suggests hepatic hilar or central intrahepatic biliary tumor, percutaneous cholangiography and transhepatic biliary stent placement is usually followed by brushing or fluoroscopically directed fine needle aspiration biopsy for tissue diagnosis.Sonography is the imaging procedure of choice for biliary tract intervention, including cholecystostomy, guidance for percutaneous transhepatic cholangiography, and drainage of peribiliary abscesses.     

Biliary parasitic diseases including clonorchiasis,opisthorchiasis and fascioliasis

Parasitic infection of the biliary tree is caused by liver flukes, namely Clonorchis sinensis and Opisthorchis viverrini. These flukes reside in the peripheral small bile ducts of the liver and produce chronic inflammation of the bile duct, bile duct dilatation, mechanical obstruction, and bile duct wall thickening. On imaging, peripheral small intrahepatic bile ducts are dilated, but the large bile ducts and extrahepatic bile ducts are not dilated or slightly dilated. There is no visible caused of obstruction. Sometimes, in heavy infection, adult flukes are demonstrated on sonography, CT or MR cholangiography as small intraluminal lesions. The flukes in the gallbladder may appear as floating, small objects on sonography. Chronic infection may result in cholangiocarcinoma of the liver parenchyma or along the bile ducts. Human infection of Fasciola hepatica, a cattle flukes, may occur inadvertently, and the flukes migrate in the liver (hepatic phase) and reside the bile ducts (biliary phase). Image findings in the hepatic phase present with multiple, small, clustered, necrotic cavities or abscesses in the peripheral parts of the liver, showing “tunnels and caves” sign, reflecting parasite migration in the liver parenchyma. In the biliary phase, the flukes are demonstrated in the intra- and extrahepatic bile ducts and the gallbladder as small intraluminal flat objects, sometimes moving spontaneously. Bile ducts are dilated.     

经T管超声胆管造影评估肝移植术后早期肝内外胆管

目的 探讨以经T管超声胆管造影(CEUSC)评估肝移植术后早期肝内外胆管的可行性。方法 纳入17例接受肝移植患者,均于术后早期(中位时间28天)因血清学检查异常接受经T管二维、三维CEUSC及X线胆管造影检查;对比3种方法显示肝外胆管(尤其是吻合口区域),左、右叶肝内胆管及其不同级别分支的能力。结果 17例中,3例发生胆道并发症,包括T管脱出2例、胆管结石1例。二维、三维CEUSC均可清晰显示并明确诊断;X线胆管造影仅显示2例T管脱出,未显示胆管结石。除2例因T管脱出未能显示肝内外胆管外,3种检查对其余15例均能完整显示肝外胆管及1、2级肝内胆管,符合诊断要求。3种检查方法所示肝右叶最远端胆管级别均高于肝左叶(P均＜0.05),其间差异无统计学意义(P＞0.05)。3种方法对1~4级肝内胆管评分差异均无统计学意义(P均＞0.05),对5级肝内胆管评分差异有统计学意义(P＜0.01),其中二维CEUSC评分高于X线胆管造影和三维CEUSC (P均＜0.05)、X线胆管造影与三维CEUSC差异无统计学意义(P＞0.05)。结论 经T管CEUSC可于肝移植术后早期显示肝内外胆管,辅助诊断胆道并发症。     

Outcome of endoscopic sphincterotomy in patients with pain of suspected biliary or papillary origin and inconclusive cholangiography findings

BACKGROUND AND STUDY AIMS: We prospectively studied the outcome of endoscopic sphincterotomy in symptomatic patients with elevated liver enzyme levels but no clear evidence of biliary pathology on transabdominal ultrasound and diagnostic endoscopic retrograde cholangiography (ERC). METHODS: 29 consecutive patients with biliary-type pain (two or more out of eight criteria), elevated liver enzyme levels and no evidence of gallstones or significant common bile duct dilatation were evaluated. Elevated bilirubin levels (up to 7.2 mg/dl) were found in 18 patients. The majority of patients (n = 21) had a gallbladder in situ. The findings from bile duct exploration following sphincterotomy were recorded, and pain (as measured by visual analogue scale) as well as laboratory findings was assessed. RESULTS: Wire-guided sphincterotomy was successful in all patients while uncomplicated pancreatitis occurred in one instance. In 16 patients (55%) there was macroscopic evidence of small stones (n = 2), sludge (n = 12) or both (n = 2) following bile duct exploration. In addition, microscopy showed bile crystals in all four patients who had no macroscopic findings. All four patients with elevation of pancreatic enzymes prior to treatment, and four of those eight patients with previous cholecystectomy, showed evidence of biliary pathology. The initial median pain intensity was 8 (range 1-10); 26 patients became pain-free within 3 months following endoscopic sphincterotomy. While 26 of 28 patients (93%) remained asymptomatic over a median follow-up period of 19 months (range 12-26), one died of an unrelated malignancy 6 months after therapy. CONCLUSIONS: Endoscopic sphincterotomy may be acceptable in patients with typical clinical presentation suggesting a papillary or biliary origin of pain without further diagnostic work-up. Contrary to expectations, diagnostic ERC was insensitive in detection of the biliary etiology of symptoms in this selected group of patients.     

原位肝移植后胆管狭窄与胆道内镜下球囊扩张及支撑管治疗

背景：肝移植术后胆管狭窄主要是胆管吻合口的狭窄，介入球囊扩张只能暂时通畅胆道，没有根本解决问题。 目的：观察应用胆道内镜技术诊断和治疗原位肝移植后胆管狭窄的效果。 设计、时间及地点：病例分析，于2001—07／2005—10在大连市肝胆外科研究所，大连市友谊医院肝胆外科住院患者10例，天津第一中心医院器官移植科住院患者4例均在行原位肝移植术后发生胆管狭窄。 对象：纳入14例中男10例，女4例，平均年龄46岁，肝移植术均采用供、受者胆管端一端吻合。 方法：对14例原位肝移植术后发生胆管狭窄的病例进行胆道内镜的诊断和分析，同时采用胆道镜下球囊扩张后支撑管方法治疗肝移植后胆道狭窄。 主要观察指标：T管造影、内镜下肝内外胆管黏膜直观：结石的分布、吻合口胆管黏膜的；供-受体胆管吻合口的愈合情况：炎症水肿的情况、狭窄；经内镜取石、狭窄扩张治疗后上述指标的复查。结果：①胆管狭窄的诊断：经胆道造影和内镜诊断胆管吻合口狭窄13例，其中1例是结石导致的狭窄假象；非吻合口狭窄1例。②胆管狭窄的治疗：通过胆道造影明确的吻合口狭窄中，1例采取球囊扩张1次治愈，2例行经内镜十二指肠乳头括约肌切开术＋网篮取石芊鼻胆引流术后仍然发生胆系感染和黄疸而行手术以及纤维胆道镜治疗。通过T型管造影，1例发现条状负影，无狭窄，纤维胆道镜观察胆管吻合口愈合佳，黏膜移行良好；2例肝内显影差或不显影而呈胆管消失改变，纤维胆道镜取净结石后，扩张吻合口的狭窄后支撑三四个月后狭窄消失，黏膜移行良好。8例肝内外胆管显影模糊，肝外和肝内Ⅰ、Ⅱ级胆管有条索状、柱状、树枝状负影和非吻合性狭窄征象，纤维胆道镜观察取净结石后观察吻合口处均有不同程度的狭窄、充血水肿，扩张支撑平均2．5个月后，狭窄消失，黏膜移行佳。1例造影提示吻合口狭窄，狭窄扩张后，内镜观察未发现结石，支撑2个月后拔管治愈。结论：胆道内镜可直观原位肝移植术后胆管狭窄的情况，进行可靠的诊断，并有效完成支撑管扩张治疗胆管狭窄。     

Endoscopic management of biliary hydatid disease: report on six cases.

Six patients with a ruptured Echinococcus liver cyst were treated by means of endoscopy. The treatment consisted of endoscopic sphincterotomy, cyst material extraction and hypotonic saline lavage via a nasobiliary catheter. In five patients successful complete endoscopic treatment was achieved, including removal of daughter cysts. In the sixth patient only partial treatment could be performed with clearance of daughter cysts since there was no communication with the main liver cyst. Follow-up ultrasonography, CT and ERCP in all patients showed complete cure and no evidence of disease recurrence in five of them. The sixth patient required surgery one month after endoscopic treatment of the acute biliary obstruction.