BACKGROUND:?Biliary cast syndrome (BCS) is an unusual complication of orthotopic liver transplantation (OLTx), and its management is dififcult. Limited success using endoscopic retrograde cholangiopancreatography (ERCP) or open exploration to clear casts has been reported, but failure usually results in re-transplantation. We aimed to review our experience with BCS and highlight a novel combined percutaneous and endoscopic approach for duct clearance. A brief review of the literature is given. METHODS:?We retrospectively reviewed our experience of managing BCS using case notes review. Details were also gathered from radiology, where interventional procedures were carried out. RESULTS:?We had a total of three cases of BCS reported between 2002 and 2005. Multiple attempts were made to remove these casts. All three were treated in a variety of ways. Management is discussed along with highlighting a novel combined percutaneous and endoscopic approach for duct clearance. CONCLUSIONS:?BCS is a potential complication of OLTx. Surgical and endoscopic methods of removing casts are used. However, in circumstances where these methods are technically dififcult, a percutaneous endoscopic approach with serial dilatation of the cutaneous port and surgical removal of casts can be done.