The records of 92 patients with symptomatic pancreatic pseudocysts referred for surgical management over a 27-year period were retrospectively reviewed to compare outcome in 42 patients managed with operative internal drainage procedures (group I) with that in 52 patients managed with computed tomography-directed percutaneous catheter drainage (PCD) (group II). The two groups were similar for patient age, sex, pseudocyst location, and cause. The frequency of antecedent pseudocyst-associated complications was less in group I (16.7 versus 38.5%, p < 0.05). Seven group I patients and four group II patients had major complications (16.7 versus 7.7%, not significant). Group II mean duration of catheter drainage was 42.1 days, and the drain track infection rate was 48.1%. The frequency of antecedent operative cyst drainage was similar (14.2 versus 13.5%), as was the frequency of subsequent operations for complications related to chronic pancreatitis (9.5 versus 19.2%, not significant). Mortality rate was greater in group I (7.1% versus 0%, p < 0.05). Pseudocysts can be effectively managed either by open operation with internal drainage or by PCD. Drawbacks of PCD include the controlled external pancreatic fistula and the risk of drain track infection. Percutaneous catheter drainage has the following advantages: (1) low mortality rate, (2) does not require a major operation, (3) does not violate the operative field in cases when subsequent retrograde duct drainage procedures are required. Neither PCD nor internal drainage is definitive, and with either technique subsequent correction of underlying pancreatic pathology may be necessary.