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Cirrhosis is the terminal stage of progressive liver fibrosis, affecting 1%-2% of the global population and accounting for 1.3 million deaths annually.1,2 Median survival for persons with compensated cirrhosis is approximately 12 years, compared with only 2 years for those with hepatic decompensation. Accurate prediction of hepatic decompensation is an unmet need to enable identification of patients with cirrhosis who could benefit from close monitoring and timely medical interventions. Besides, risk stratification of patients with cirrhosis could help inform patient selection for trials evaluating therapies to prevent hepatic decompensation. Although various clinical scores, such as the albumin-bilirubin (ALBI) and fibrosis-4 (FIB-4) indices (ALBI-FIB4 score) have been proposed to predict long-term risk of hepatic decompensation,3 external validation has often shown suboptimal prognostic capability and revealed room for improvement.4.

Patients with cirrhosis of the liver have a very high risk for developing hepatocellular carcinoma (HCC). Therefore, this group of patients should undergo surveillance to improve mortality. Better tools for stratifying the risk of HCC among patients with cirrhosis are needed. The best strategy for surveillance is the combination of alpha-fetoprotein and ultrasound of the liver every 6 months. This strategy shows a sensitivity of approximately 65% and a specificity of 90%, and importantly, has been shown to improve mortality in these patients. Balancing benefits and harms should be performed when deciding to proceed with surveillance.

Background Hepatocellular carcinoma (HCC) is a common malignancy with a steadily rising incidence and associated morbidity and mortality. Cirrhosis of the liver is presently the leading risk factor for developing HCC. Abdominal imaging, with or without alpha-fetoprotein (AFP) testing, every 6 months is the current surveillance strategy for patients at risk. The available biomarkers for detecting this cancer at an early stage have inadequate sensitivity and specificity. Methods The Hepatocellular carcinoma Early Detection Strategy (HEDS) study, a multi-center initiative of the National Cancer Institutes' (NCI) Early Detection Research Network (EDRN), launched an effort to establish what has become the nation's largest comprehensive biorepository and database on patients at high risk of developing HCC. The cohort has been developed in seven clinical centers across the USA. Subjects are enrolled for a five-year period involving data and specimen collection every six months in accordance with standard surveillance for HCC. Extensive clinical data are collected and specimens are stored at a central repository. Results The database and biorepository contain longitudinally collected clinical data and serum and plasma samples from 1482 participants with cirrhosis and without evidence of HCC at baseline. Fifty-six percent are male, 85% Caucasian, 30% have a history of chronic HCV and 71% have compensated cirrhosis. Conclusions The HEDS cohort provides opportunities for the continued study of the incidence and course of HCC in a comprehensively followed population of patients at high risk for this malignancy. Further, the EDRN biorepository provides a distinct opportunity for the development of novel biomarkers. Trial registry URL: https://edrn.nci.nih.gov/protocols/316-hepatocellular-carcinoma-early-detection-strategy.

Background & Aims Identifying patients in whom ultrasound may be inadequate to exclude the presence of hepatocellular carcinoma (HCC) can inform interventions to improve screening effectiveness. We aimed to characterize correlates of suboptimal ultrasound quality and changes in ultrasound quality over time in patients with cirrhosis undergoing HCC screening. Methods We performed a retrospective cohort study of patients with cirrhosis who underwent ultrasound examination at 2 large health systems between July 2016 and July 2019. Exam adequacy was graded by radiologists using the LI-RADS Visualization Score (A, B, C); we evaluated changes in visualization over time among patients with >1 ultrasound exams. We performed multivariable logistic regression to identify characteristics associated with limited ultrasound visualization (scores B or C). Results Of 2053 cirrhosis patients, 1685 (82.1%) had ultrasounds with score A, 262 (12.8%) had score B, and 106 (5.2%) had score C. Limited visualization was associated with alcohol-related or nonalcoholic fatty liver disease cirrhosis and presence of class II-III obesity. Among 1546 patients with >1 ultrasounds, 1129 (73.0%) had the same visualization score on follow-up (1046 score A, 60 score B, 23 score C). However, 255 (19.6%) of 1301 with score A at baseline had limited visualization when repeated (230 score B, 25 score C), and 130 (53.1%) of 245 patients with baseline limited visualization had good visualization when repeated. Conclusions Nearly 1 in 5 patients with cirrhosis had moderately-severely limited ultrasound visualization for HCC nodules, particularly those with obesity or alcohol-related or nonalcoholic fatty liver disease cirrhosis. Ultrasound quality can change between exams, including improvement in many patients with limited visualization.

Hepatocellular carcinoma (HCC) surveillance is associated with early tumor detection and improved survival in patients with cirrhosis.1 Surveillance is performed using semiannual abdominal ultrasound with or without α-fetoprotein (AFP); however, this strategy misses more than one-third of HCC at an early stage.2 These data highlight a need for novel surveillance strategies with higher accuracy for early HCC detection. GALAD and Doylestown Plus are novel biomarker panels that combine multiple biomarkers with patient demographic and clinical characteristics; both demonstrated promising accuracy in phase II case-control studies;3,4 however, case-control studies can overestimate biomarker performance, highlighting a need for phase III cohort and nested case-control studies.5 Our study aimed to compare multiple biomarkers (including AFP, GALAD, and Doylestown Plus) in a nested case-control study of patients with cirrhosis.

IntroductionThe survival benefit from simultaneous liver-kidney transplantation (SLK) over liver transplant alone (LTA) in recipients with moderate renal dysfunction is not well understood. Moreover, the impact of deceased donor organ quality in SLK survival has not been well described in the literature.MethodsThe Scientific Registry of Transplant Recipients was studied for adult recipients receiving LTA (N = 2700) or SLK (N = 1361) with moderate renal insufficiency between 2003 and 2013. The study cohort was stratified into 4 groups based on serum creatinine (

Background & Aims Racial and ethnic minorities are reported to have higher mortality related to hepatocellular carcinoma (HCC) than non-Hispanic whites. However, it is not clear whether differences in tumor characteristics or liver dysfunction among racial or ethnic groups affect characterization of causes for this disparity. We aimed to characterize racial and ethnic differences in HCC presentation, treatment, and survival. Methods We performed a retrospective study of patients diagnosed with HCC from January 2008 through July 2017 at 2 large health systems in the United States. We used multivariable logistic regression and Cox proportional hazard models to identify factors associated with receipt of curative therapy and overall survival. Results Among 1117 patients with HCC (35.9% white, 34.3% black, 29.7% Hispanic), 463 (41.5%) were diagnosed with early stage HCC (Barcelona Clinic Liver Cancer stage 0/A) and 322 (28.8%) underwent curative treatment. Hispanic (odds ratio [OR], 0.75; 95% CI, 0.55–1.00) and black patients (OR, 0.74; 95% CI, 0.56–0.98) were less likely to be diagnosed with early stage HCC than white patients. Among patients with early stage HCC, Hispanics were less likely to undergo curative treatment than whites (OR, 0.58; 95% CI, 0.36–0.91). Black patients with early stage HCC were also less likely to undergo curative treatment than white patients, but this difference was not statistically significant (OR, 0.66; 95% CI, 0.43–1.03). Black and Hispanic patients had shorter median survival times than white patients (10.6 and 14.4 mo vs 16.3 mo). After adjusting for type of medical insurance, Child–Pugh class, Barcelona Clinic Liver Cancer stage, and receipt of HCC treatment, black patients had significantly higher mortality (hazard ratio, 1.12; 95% CI, 1.10–1.14) and Hispanic patients had lower mortality (hazard ratio, 0.83; 95% CI, 0.74–0.94) than white patients. Conclusions In a retrospective study of patients diagnosed with HCC, we found racial/ethnic differences in outcomes of HCC to be associated with differences in detection of tumors at early stages and receipt of curative treatment. These factors are intervention targets for improving patient outcomes and reducing disparities.

Background & Aims α-Fetoprotein (AFP) is widely used as a surveillance test for hepatocellular carcinoma (HCC) among patients with cirrhosis. Des-γ carboxy-prothrombin (DCP) and lectin-bound AFP (AFP-L3%) are potential surveillance tests for HCC. The aims of this study were to determine performance of DCP and AFP-L3% for the diagnosis of early HCC; whether they complement AFP; and what factors affect DCP, AFP-L3%, or AFP levels. Methods We conducted a large phase 2 biomarker case-control study in 7 academic medical centers in the United States. Controls were patients with compensated cirrhosis and cases were patients with HCC. AFP, DCP, and AFP-L3% levels were measured blinded to clinical data in a central reference laboratory. Results A total of 836 patients were enrolled: 417 (50%) were cirrhosis controls and 419 (50%) were HCC cases, of which 208 (49.6%) had early stage HCC (n = 77 very early, n=131 early). AFP had the best area under the receiver operating characteristic curve (0.80, 95% confidence interval [CI]: 0.77–0.84), followed by DCP (0.72, 95% CI: 0.68–0.77) and AFP-L3% (0.66, 95% CI: 0.62–0.70) for early stage HCC. The optimal AFP cutoff value was 10.9 ng/mL leading to a sensitivity of 66%. When only those with very early HCC were evaluated, the area under the receiver operating characteristic curve for AFP was 0.78 (95% CI: 0.72–0.85) leading to a sensitivity of 65% at the same cutoff. Conclusions AFP was more sensitive than DCP and AFP-L3% for the diagnosis of early and very early stage HCC at a new cutoff of 10.9 ng/mL.

No empirical studies have defined the posttransplant survival that would justify expansion of the Milan criteria for liver transplantation of hepatocellular carcinoma. We created a Markov model comparing the survival benefit of transplantation for a patient with >Milan HCC, versus the harm caused to other patients on the waiting list. In the base-case analysis, the strategy of transplanting the patient with >Milan HCC resulted in a 44% increased risk of death and a utility loss of 3 quality-adjusted years of life across the pre- and posttransplant periods for a nationally representative cohort of patients on the waiting list. This harm outweighed the benefit of transplantation for a patient with >Milan HCC having a 5-year posttransplant survival of less than 61%. This survival threshold was most sensitive to geographic variations in organ shortage, with the threshold varying from 25% (Region 3) to >72% (Regions 1, 5, 7 and 9). In conclusion, expansion of the Milan criteria will require demonstrating high survival rates for the newly eligible patients-approximately 61% at 5 years after transplantation. In regions with less severe organ shortage, a more aggressive approach to transplanting these patients may be justified.

The number of patients who have hepatocellular carcinoma (HCC) is expected to more than double over the next 1 to 2 decades. Patients who have cirrhosis, regardless of cause, are at the highest risk for developing HCC. This article discusses surveillance of these patients for HCC by alpha-fetoprotein and ultrasound, evaluation using imaging, classification of HCC using the Barcelona staging classification, and treatment. Resection, transplantation, and percutaneous ablation are considered curative interventions and are applied to about 30% of all patients who have HCC. Currently, there is no standard therapy for advanced HCC.

Background The incidence and risk factors for adefovir-resistant HBV have not been clearly defined. Aims To characterize the virologic response to adefovir, to determine the rate of adefovir resistance and to explore factors associated with initial virologic response (IVR) and adefovir resistance. Methods All hepatitis B patients who received adefovir for ≥6 months at our center were prospectively monitored for virologic response and adefovir resistance. Results Forty three patients were included; mean treatment duration was 18 months (range 6–45). Thirty four (79%) patients had prior lamivudine. IVR was observed in 44% patients and associated with higher pretreatment ALT ( P =0.05) and the absence of HBeAg ( P =0.02). Six (14%) patients were found to have adefovir-resistant mutations. The cumulative probability of genotypic resistance to adefovir at month 24 was 22%. Patients with adefovir resistance were more likely to have been switched from lamivudine to adefovir monotherapy ( P =0.01), to be older ( P =0.04), and to be infected with HBV genotype D ( P =0.02). Conclusions Roughly 50% of patients failed to achieve IVR on adefovir. The cumulative probability of adefovir resistance at 2 years was 22%. Our data suggest that combination of lamivudine and adefovir may prevent emergence of adefovir resistance in patients with lamivudine-resistant HBV.

The incidence of hepatocellular carcinoma (HCC) is rising throughout the world. HCC meets the criteria for which a disease benefits from screening or surveillance: it is an important health problem; those with cirrhosis are the targets for surveillance; there is acceptable treatment if diagnosed early; surveillance using alpha-fetoprotein and ultrasound has been shown to be cost effective; surveillance is widely implemented by health care professionals and accepted by patients; standardized recall procedures exists; and the screening tests must achieve an acceptable level of accuracy in the population undergoing screening. The latter point is the main limitation of surveillance for HCC. In this review we will discuss the currently available tests for the surveillance of HCC.

Background/Aims Alcohol has been shown to be an important risk factor for hepatocellular carcinoma (HCC). The role of tobacco as a risk factor for HCC is controversial. Recently, obesity has been reported to be a risk factor for HCC. We investigated whether these factors increase the risk of HCC in American patients. Methods Consecutive patients with HCC, cirrhosis without HCC and, control patients without liver disease were enrolled and exposure to risk factors was assessed. Results When HCC cases were compared to cirrhotic controls, the risk of HCC increased 6-fold for alcohol (OR 5.7; 95% CI: 2.4–13.7), 5-fold for tobacco (OR 4.9; 95% CI: 2.2–10.6), and 4-fold with obesity (OR 4.3; 95% CI: 2.1–8.4). Using spline regression, a dose-dependent relationship between alcohol and tobacco exposure with risk of HCC was noted. There was significant interaction between alcohol, tobacco and obesity, with synergistic indices greater than 1. Conclusions Alcohol, tobacco and obesity are independent risk factors for HCC in our patient population, and they interact synergistically to increase the risk of HCC. Data from this study may allow us to stratify cirrhotics into low- and high-risk groups for the development of HCC surveillance strategies.

The incidence of hepatocellular carcinoma (HCC) is increasing worldwide; the overall survival of patients with HCC is grim because most patients are diagnosed late, when curative treatment is not possible. Cirrhosis is the strongest risk factor for the development of HCC. HCC surveillance with alpha-fetoprotein (AFP) and ultrasonography has been recommended for persons with cirrhosis. However, AFP level is insensitive for the early detection of HCC, and ultrasonography is expensive and operator dependent. Clearly, there is a need for novel strategies for the early detection of HCC. The ideal biomarker assay for HCC would be sensitive, specific, noninvasive, reproducible, inexpensive, and acceptable to patients. The Early Detection Research Network of the National Cancer Institute has proposed 5 phases for biomarker validation: preclinical exploratory studies, clinical assay development for disease, retrospective longitudinal study to detect preclinical disease, prospective screening study, and cancer control studies. Several biomarkers, such as des-gamma carboxyprothrombin, lens culinaris agglutinin-reactive AFP, human hepatocyte growth factor, and insulin-like growth factor-1, are promising, but none of these markers has been validated for clinical use. Limitations of the current literature include inadequate sample size, heterogeneity in biomarker assay methods and result reporting, limited analysis of demographics and cause of liver disease as covariates in the expression of these markers, and a scarcity of longitudinal studies evaluating the ability of biomarkers to detect preclinical disease. There is an urgent need for novel biomarkers for the detection of early HCC; the National Cancer Institute proposal provides a framework for future validation studies.

Professional societies recommend hepatocellular carcinoma screening in patients with cirrhosis, but high-quality data evaluating its effectiveness to improve early tumor detection and survival in "real world" clinical practice are needed. We aim to characterize the association between hepatocellular carcinoma screening and early tumor detection, curative treatment, and overall survival among patients with cirrhosis.We performed a retrospective cohort study of patients diagnosed with hepatocellular carcinoma between June 2012 and May 2013 at 4 health systems in the US. Patients were categorized in the screening group if hepatocellular carcinoma was detected by imaging performed for screening purposes. Generalized linear models and multivariate Cox regression with frailty adjustment were used to compare early detection, curative treatment, and survival between screen-detected and non-screen-detected patients.Among 374 hepatocellular carcinoma patients, 42% (n = 157) were detected by screening. Screen-detected patients had a significantly higher proportion of early tumors (Barcelona Clinic Liver Cancer stage A 63.1% vs 36.4%, P.001) and were more likely to undergo curative treatment (31% vs 13%, P = .02). Hepatocellular carcinoma screening was significantly associated with improved survival in multivariate analysis (hazards ratio 0.41; 95% confidence interval, 0.26-0.65) after adjusting for patient demographics, Child-Pugh class, and performance status. Median survival of screen-detected patients was 14.6 months, compared with 6.0 months for non-screen-detected patients, with the difference remaining significant after adjusting for lead-time bias (hazards ratio 0.59, 95% confidence interval, 0.37-0.93).Hepatocellular carcinoma screening is associated with increased early tumor detection and improved survival; however, a minority of hepatocellular carcinoma patients are detected by screening. Interventions to increase screening use in patients with cirrhosis may help curb hepatocellular carcinoma mortality rates.

Surveillance of patients with cirrhosis increases early detection of hepatocellular carcinoma (HCC) and prolongs survival. However, its effectiveness is limited by underuse, particularly among racial/ethnic minorities and individuals of low socioeconomic status. We compared the effectiveness of mailed outreach strategies, with and without patient navigation, in increasing the numbers of patients with cirrhosis undergoing surveillance for HCC in a racially diverse and socioeconomically disadvantaged cohort.We performed a prospective study of patients with documented or suspected cirrhosis at a large safety-net health system from December 2014 through March 2016. Patients were assigned randomly (1:1:1) to groups that received mailed invitations for an ultrasound screening examination (n = 600), mailed invitations for an ultrasound screening examination and patient navigation (barrier assessment and motivational education for patients who declined screening; n = 600), or usual care (visit-based screening; n = 600). Patients who did not respond to outreach invitations within 2 weeks received up to 3 reminder telephone calls. The primary outcome was completion of abdominal imaging within 6 months of randomization.Baseline characteristics were similar among groups. Cirrhosis was documented, based on International Classification of Diseases, 9th revision, codes, for 79.6% of patients, and suspected, based on noninvasive markers of fibrosis, for 20.4%. In an intent-to-treat analysis, significantly greater proportions of patients who received the mailed invitation and navigation (47.2%) or the mailed invitation alone (44.5%) underwent HCC screening than patients who received usual care (24.3%) (P.001 for both comparisons). However, screening rates did not differ significantly between outreach the outreach groups (P = .25). The effects of the outreach program were consistent in all subgroups, including Caucasian vs non-Caucasian race, documented vs suspected cirrhosis, Child-Pugh A vs B cirrhosis, and receipt of gastroenterology care.In a prospective study, we found outreach strategies to double the percentage of patients with cirrhosis who underwent ultrasound screening for HCC. However, adding patient navigation to telephone reminders provided no significant additional benefit. ClinicalTrials.gov no: NCT02312817.

Background: Pancreatic abscess is one of the serious complications of acute pancreatitis. Traditionally, pancreatic abscess has been treated by operative drainage. Based on experience with endoscopic transpapillary drainage of pseudocysts, a similar technique was used in patients with pancreatic abscess. Method: Patients were evaluated by endoscopic retrograde cholangiopancreatography. In those with pancreatic abscess communicating with the main pancreatic duct, pancreatic sphincterotomy, saline irrigation of the abscess cavity, and catheter dilation followed by 10F pancreatic stent placement were done. Instillation of gentamicin and nasopancreatic catheter drainage were used in difficult cases. Results: Of 22 patients with pancreatic abscess, 11 underwent endoscopic transpapillary drainage with technical success in 10 patients (90%); 8 patients (74%) had resolution of pancreatic abscess, clinically and radiographically. Intracavitary instillation of gentamicin and nasopancreatic catheter drainage were used in 2 patients. Two patients in whom endoscopic transpapillary drainage failed underwent operative drainage with a favorable outcome, and the one patient in whom endoscopic treatment was technically unsuccessful underwent successful percutaneous drainage. One patient had mild pancreatitis. Conclusion: Endoscopic transpapillary drainage is an effective nonoperative therapy for selected cases of pancreatic abscess and is associated with minimal morbidity and no mortality. (Gastrointest Endosc 2000;51:391-5.)

When determining the prognosis of patients with solid tumors, tumor staging and tumor grading are important factors to take into account. Tumor staging describes the extent of an individual’s tumor burden in the original primary organ and spread throughout the body. Staging is important because it helps plan treatment, it can be used to estimate the person’s prognosis (such as the Duke’s classification for colon cancer), and it provides a standardized platform to evaluate new treatment and to compare the results of different studies [1]. In the majority of solid organ tumors, staging is determined at the time of surgery by pathological examination of the resected specimen leading to the Tumor Node Metastasis (TNM) classification. In addition to tumor burden, histological tumor grading systems have been shown to offer prognostic information in some cancers such as prostate, breast and kidney. The importance of tumor grade in planning treatment and in estimating a patient’s prognosis is greater for certain types of cancers, such as the Gleason score in prostate cancer [2]. Tumor burden and grade cannot be assessed in most patients with hepatocellular carcinoma (HCC), because only about a third of the patients will undergo surgical therapies and some of these patients may have received local ablation or intra-arterial chemoembolization prior to surgery limiting the histological examination. The presence of underlying liver cirrhosis in patients with HCC adds an important dimension that cannot be ignored when discussing prognosis and treatment for these patients, and it is what differentiates HCC from other solid tumors. The majority of patients with HCC have underlying cirrhosis, and the degree of hepatic dysfunction determines which treatment can be applied [3]. Another important factor in the prognosis of patients with HCC is performance status, though it is not HCC-specific. Performance status has been shown to be an important prognostic factor in HCC [4]. Therefore, the prognosis of patients with HCC will rely on tumor burden, hepatic function and performance status. Several staging systems have been proposed for HCC that includes the Okuda [5], BCLC (Barcelona Clinic Liver Cancer) [6], CLIP (Cancer of Liver Italian Program) [7], French (Groupe d’Etude de Traitement du Carcinoma Hepatocellulaire) [8], CUPI (Chinese University Prognostic Index) [9], and JIS (Japanese Integrated System) [10] classifications. The CLIP, GRETCH, and CUPI systems were each determined based on the results of a multivariate analysis for survival factors in a cohort of patients with HCC. This leads to several problems limiting their value: applicable only to the population studied (leading to lack of transportability), validation in an independent cohort is critical for the development of such a system and not always performed, not all factors that determine tumor burden, hepatic function or performance status were included, and lack of a link to treatment. Okuda realized that tumor burden and hepatic function were the most important factors that determine prognosis in HCC. However, assessment of tumor burden was crude and applicable only to advanced stages of HCC: tumor occupying more or less than 50% of the liver, and measures of hepatic function included only ascites, albumin, and bilirubin.

A 24-year-old Jordanian man presented with epigastric pain radiating to the back associated with vomiting; identical episodes had been occurring since age 12 years. He had no weight loss, jaundice or diarrhea, and there was no history of alcohol abuse, abdominal trauma, hyperlipidemia, or family history of pancreatitis. Physical examination revealed an acutely ill man with a temperature of 100° F. The abdominal examination demonstrated hypoactive bowel sounds, epigastric tenderness, and no rebound or guarding. Laboratory data revealed a white blood cell count of 13,700/mm3, a hematocrit of 40%, and 395,000/ mm3 platelets. There was no eosinophilia. His amylase was 571 units/L (normal 25-125), lipase 757 units/L (normal 8-70), and liver function tests were normal. US of the abdomen showed no stones in the gallbladder or biliary ductal dilation but did reveal a dilated pancreatic duct (PD) with calcifications. CT disclosed enlargement of the head of the pancreas with atrophy and calcifications in the body and tail. There was marked dilation of the main PD, and a 2.5 × 3.5 cm cystic lesion was seen projecting from the tail (Fig. 1). A diagnosis of idiopathic chronic pancreatitis and pseudocyst of the pancreas was made and endoscopic therapy was considered. ERCP revealed a dilated main PD with multiple filling defects consistent with stones (Fig. 2). A stricture was seen in the PD in the head, with upstream dilation of the remaining duct. An abrupt “cutoff ” of the duct was observed in the region of the presumed pseudocyst. A PD sphincterotomy to facilitate stone extraction was performed, followed by placement of a 7F × 9 cm PD stent. The cholangiogram was normal. The patient was readmitted for recurrent pain 1 month later, and ERCP was repeated. The PD stent was removed and found to be occluded. Several filling defects thought to be pancreatic stones were again observed, and on sweeping the pancreatic duct with an 11.5 mm balloon-tipped catheter, copious amounts of milky white gelatinous secretions poured out of the papillary orifice. This material had given rise to the filling defects in the duct, as contrast instillation at the termination of the procedure showed a dilated PD but no filling defects. The patient improved clinically, only to return with pancreatitis again, and surgery was consulted. At laparotomy, a cystic mass was present in the body and tail of the pancreas that was adherent to the spleen. A partial pancreatectomy followed by pancreaticojejunostomy was performed. Opening of the cystic mass disclosed a hydatid cyst containing multiple daughter cysts (Fig. 3), and the histopathologic findings were consistent with Echinococcus granulosus. There was a communication between the cyst cavity and the main PD through a defect in the cyst wall. Postoperatively the patient was treated with albendazole at an oral dose of 400 mg BID for 12 weeks. He has remained symptom free to date (12 months).