Patients with surgically altered anatomy present unique challenges to traditional endoscopic management of foregut pathology, such as drainage of peripancreatic fluid collections. Recent advances in endoscopic techniques have enabled less-invasive access with EUS-directed transgastric intervention or gastric access temporary for endoscopy.1-4 Here we present a case of same session EUS-guided transgastric intervention to facilitate cystgastrostomy (Video 1, available online at www.giejournal.org ).