The efficacy of long-term chemotherapy in nonresectable alveolar echinococcosis is debated, particularly because of the difficulty in defining therapeutic success. In this study the effect of chemotherapy on the parasitic mass was evaluated in a series of 37 patients. The patients had larval lesions documented by serial computed tomography studies at least 1.5 yr after chemotherapy (mean = 6.4 yr, range = 1.5 to 10.7 yr). The therapeutic regimen consisted of mebendazole (n = 34) or albendazole (n = 3) as previously described. The maximal areas of the parasitic lesions were assessed morphometrically by means of digital image analysis, utilizing the point-integration method, before and after chemotherapy. Marked regression of larval tissue occurred in 18 patients (group A; 48.6%), stationary lesions were noted in 13 patients (group C; 35.1%) and progression was found in 6 patients (group B; 16.2%). The three groups did not differ significantly with regard to age, plasma drug levels, duration of chemotherapy or initial size and composition of lesions (e.g., cystic cavities, degree of calcification). Despite morphologically successful chemotherapy in most patients (e.g., 84%; groups A and C), late cholestatic complications after 1.5 to 11 yr of chemotherapy occurred in 10 patients (group A, n = 7; group C, n = 3; 4 of them died) and esophageal variceal bleeding occurred in 3 patients (relieved by sclerotherapy). These late complications were probably mainly due to posttherapy fibrosis of hilar structures. In conclusion, our data support the efficacy of chemotherapy. However, chemotherapy is not curative, and severe late complications were observed in patients with hilar (fibrotic) involvement. (Hepatology 1994;19:735–742).