Introduction: Various techniques have been described to achieve resolution without recurrence of complex acute pancreatitis associated pseudocysts (PAC). Many strategies, inclusive of open, minimally invasive and radiological procedures are hampered by high recurrence or failed resolution, particularly for PAC near the pancreatic head. The present series describes a multimodal strategy combining open anterior gastrostomy for the creation of a stapled posterior cystogastrostomy, placement of an 8 french secured silastic tube for intentional formation of a cystogastric fistula tract in combination with gastric drainage and post duodenal enteral alimentation.Material and Methods: Using a prospectively maintained hepatobiliary database, patients with complex PAC undergoing the above management were identified. PAC location, postoperative length of stay (LOS), time to enteral were identified. PAC were assessed by CT scan prior to operation, one month after drainage and patients with PAC resolution were started on oral diet, with the fistula silastic tube kept in place for an additional month. Results: Over the interval 2003-2008, 19 patients were managed with the stated strategy. PACs were located at the pancreatic body/tail in 12 patients and 7 patients had PAC at the level of the pancreatic head/neck area.17/19 had undergone ERCP with decompression stent placement and 13/19 had a failed percutaneous drainage. There was no perioperative mortality after open surgical drainage. All patients started on jejunal tube feeding 24 hs after surgical procedure. Median postoperative LOS was 7 days (4-13). At one month 16/19 (84%) of patients showed complete resolution of the PAC on CT scan and were started on oral diet, 3/19 required additional month for complete resolution. There were no PAC recurrences in any of these patients demonstrated on follow up.Conclusion: The described strategy is safe, efficient and allows early restoration of enteral feeding with early hospital discharge. High resolution rates and absence of PAC recurrences in this series support s this approach for complex PAC.