The management of pancreatic pseudocysts is complex. It demands an understanding of the natural history of the disease and an appreciation of the strengths and weaknesses of the treatment options available. Endoscopic therapy represents a valuable alternative to surgery in the subset of patients with appropriate anatomy. Success and relapse rates for endoscopic treatment of pancreatic pseudocysts are comparable to alternative methods, but require careful patient selection and operator expertise. Complication rates vary widely in published studies. It is hoped that technical innovation will reduce the risks. For example, the use of an aspiration needle to localize the pseudocyst and endoscopic ultrasound to define local vascular anatomy are significant advances. Strictly limiting the size of the opening created in cyst-gastrostomy and cyst-duodenostomy should reduce the risk of hemorrhage. Although technically difficult, transpapillary drainage is an option worth considering in patients with fluid collections associated with pancreatic ductal disruption. No single technique offers the desired combination of 100% success and no complications. Surgery, percutaneous drainage, and therapeutic endoscopy offer a variety of treatment options that can be tailored to the needs of individual patients with pancreatic pseudocyst.