Disclosure All authors disclosed no financial relationships relative to the content of this work. Commentary Pancreaticopleural fistulas are uncommon, but gastroenterologists should be aware of this entity. (It remains a favorite question on the GI board examinations!) They typically arise from a “blowout” of a side branch of the pancreatic duct, typically in the setting of chronic pancreatitis. Usually this blowout just creates a pseudocyst, but if the side branch is pointing in the right direction, it can fistulize to the pleural space and create a high-amylase pleural effusion. Treatment is by ERCP with a transpapillary pancreatic stent to re-route the pancreatic juice away from the blowout and back into the duodenum. In this case, transpapillary access was impossible because of duodenal edema resulting from pancreatitis. The authors went to plan B, using EUS to locate the collection. After injection of contrast material, they obtained a unique radiograph (B), which visualized (1) chronic pancreatitis morphology of the main pancreatic duct, (2) identification of the exact side branch that had blown out (green arrowhead), (3) the peripancreatic collection (blue arrowheads), and (4) the fistulous tract to the pleural space (yellow arrowhead). A double-pigtail stent was then placed to drain the collection into the gastric lumen. For good measure (although I am not sure it was strictly necessary), a nasocystic drain was also placed into the cavity. The nasocystic drain was removed before discharge, and the double-pigtail stent was removed 6 months later. No recurrence has been documented more than 2.5 years later. This is endoscopic problem solving at its finest. If the usual method does not work, let’s go to plan B (and if necessary plan C, plan D, and onward). The ability to “fix the plumbing” when the standard ERCP approach is impossible is a great example of the power of therapeutic EUS. David Diehl, MD GIE Senior Associate Editor Amy Tyberg, MD, FASGE, FACG, Associate Editor for Focal Points