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Complications related to endoscopic drainage occur in 5–25% of patients. Transluminal drainage is associated with bleeding, infection, and perforation. Cyst infection occurs independent of the size of the stent used and can even occur when the cavity appears to have completely drained at the time of stent insertion. Periprocedural antibiotics and for a few days after the procedure are therefore advocated, although there is no randomized controlled trial evidence to support their use [3–7]. Repeat imaging is indicated if infection persists or occurs some time after stenting to assess for stent dysfunction which may require further endoscopic intervention.

Significant bleeding at the time of stent placement is uncommon as the use of EUS guidance should prevent injury to significant vessels. Bleeding at the time of stent placement is usually short‐lived, venous, and from the transluminal tract. Massive bleeding at the time of stent placement is rare and may be due to a preexisting pseudoaneurysm, intra‐abdominal varices, or splenic or portal vein injury. Such massive bleeding is typically not amenable to endoscopic therapy and, when it occurs, resuscitation and the urgent assistance of an interventional radiologist or experienced surgeon is required. Late bleeding appears more common with LAMS [12]. LAMS can induce both neovascularization and overgrowth of adjacent retroperitoneal tissues leading to bleeding at the time of removal, hence the need for earlier retrieval than plastic stents. Additionally, collapse of the cyst cavity can bring vessels into contact with the metal flange leading to abrasion and late bleeding.

Perforation due to stent misplacement is uncommon with EUS guidance in expert hands. However, rapid decompression of a large collection (particularly if the wall is not fully mature and adherent) may lead to dehiscence of the cyst wall from the stomach or duodenum and a clinically significant leak. This is less likely when a LAMS is used. ERCP and transpapillary drainage is associated with the additional risk of pancreatitis.