Introduction: To evaluate experience with endoscopic ultrasound (EUS)-guided treatment of pancreaticocutaneous fistulas (PCFs) at a tertiary referral center. Methods: Retrospective review of patients who underwent EUS-guided management of PCFs. Demographic, clinical, imaging, procedural, and outcome variables were abstracted. Results: Four patients (3 female, age range 30-71 years) presented with PCFs. In all cases the fistula was due to an obstructed and leaking pancreatic duct in tail: 3 developed PCFs after Whipple procedure for malignancy (n=2) or an inflammatory mass (n=1), and the fourth developed a PCF following percutaneous drainage of a pancreatic fluid collection in the setting of severe acute pancreatitis with disconnected pancreatic duct syndrome. Mean duration of the fistula was 189 days (range: 80-233). PCFs persisted despite trials of nil by mouth with TPN (n=1), octreotide therapy (n=2), and failed attempts at ERCP (n=4). The mean output was 350 cc/day (range: 200-500 cc), and mean amylase concentration was 15,866 U/L. Patients underwent EUS-guided transmural puncture of the pancreatic duct (n=2), fistula track (n=1), or both (n=1), with placement of 1 or 2 plastic transmural stents providing internal drainage to the stomach (n=3) or duodenum (n=1). Patients underwent a mean of 1.75 endoscopic procedures (range: 1-2), with placement of additional stents in the transmural track during the second procedure, as well as transmural drainage of an additional site of pancreatic duct leakage in 1 patient. Drainage from PCFs ceased after the first endoscopic intervention in 3 patients and after the second procedure in the fourth patient, and all percutaneous drains were removed. Stents were left in place indefinitely. One patient was lost to follow-up; mean follow-up for the remainder was 226 days (range: 170-410). In all 3 cases there has been no recurrence of PCFs, and no patient developed symptoms of pancreatitis, pancreatic fluid collections, or hyperglycemia requiring medical therapy. Weight stabilized or increased in all, and PCF-related pain resolved. Follow-up CT or MR performed in all patients after PCF drain removal showed no pancreatitis or fluid collections. Conclusion: EUS-guided pancreatic duct intervention may successfully treat pancreaticocutaneous fistulas, allowing removal of percutaneous drains. EUS-guided therapy is an attractive alternative for patients who might otherwise require pancreatic tail resection or completion pancreatectomy to achieve resolution of a PCF.