Enlarging pancreatic pseudocysts, as well as those that develop complications such as bleeding, leak, infection, and intestinal or biliary obstruction, require treatment. This treatment is usually surgical and consists of internal or external drainage or, less commonly, excision. Transcutaneous aspiration with or without drain placement has also been reported. We describe four cases of endoscopic cystogastrostomy and cystoduodenostomy undertaken in high risk patients who had either failed previous surgery (two) or were initially refused surgery because of prohibitive operative risk (two). Technique, limitations, and potential use of this procedure are discussed.