BACKGROUND As a minimally invasive treatment, ethanol sclerotherapy has been used for large symptomatic hepatic cysts, but there are not many long-term reports on treatment outcomes and safety. OBJECTIVE To evaluate the long-term outcomes of percutaneous ethanol sclerotherapy in patients with large symptomatic hepatic cysts. METHODS This study included 43 symptomatic, enlarging hepatic cysts in 42 patients who had undergone ethanol sclerotherapy from 2003 to 2013 and were followed up for >1 year. The treatment outcomes were evaluated in terms of the reduction of cyst size and resolution of symptoms. The patients were followed up for a mean period of 33 months with either ultrasound or computed tomography examination. RESULTS Thirty-nine hepatic cysts (91%) were successfully treated with ethanol sclerotherapy, showing resolution of symptoms and remarkable reduction in cyst volume. Eight hepatic cysts (19%) disappeared completely, and 31 hepatic cysts (72%) decreased in size during the follow-up period. The mean diameter of the cysts decreased from 12.5 ± 4.4 cm to 3.8 ± 3.4 cm during follow-up. There were no immediate serious complications related to the procedure. There were four cases (9%) of treatment failure requiring subsequent surgical procedures. CONCLUSIONS Percutaneous ethanol sclerotherapy can be considered as an effective first-line treatment for large symptomatic hepatic cysts.