Endogenous vasoactive mediators such as bradykinin and nitric oxide ma
y affect the severity and outcome of acute pancreatitis by altering th
e capillary integrity of the pancreatic microcirculation. Protease inh
ibitors such as gabexate have a small beneficial effect on pancreatiti
s-related morbidity but are not cost effective. Secondary pancreatic i
nfection after necrotizing pancreatitis can be mitigated by selective
gut decontamination but requires both oral and intravenous antibiotic
administration. Combined modality treatment of pancreatic duct stones
is safe and effective but may not have better or even equivalent long-
term efficacy as compared with traditional surgery. Duodenum-preservin
g resections (Beger and Frey procedures) are especially useful in pati
ents with chronic pancreatitis who have predominant involvement of the
pancreatic head, and such procedures have fewer metabolic and nutriti
onal consequences as compared with standard pancreatoduodenectomy. Isl
et autotransplantation combined with pancreatic resection for patients
with small-duct disease not amenable to surgical duct decompression i
s safe and provides effective long-term pain relief. Cyst fluid analys
is in patients with problematic pancreatic cysts may help to different
iate neoplastic cysts from pseudocysts, especially when other diagnost
ic studies yield inconsistent results. Mucin-hypersecreting tumors of
the pancreas comprise a recently identified group of tumors with varie
d histopathology and malignant potential. Resection is generally recom
mended. Combined modality staging in patients with pancreatic cancer i
s strongly recommended to identify patients most likely to benefit fro
m attempted surgical resection. Pylorus-sparing resection results in l
ess impairment of digestive function than conventional pancreatoduoden
ectomy with no difference in survival. More effective adjuvant or neoa
djuvant therapies are needed to extend the long-term survival benefits
of surgery in patients with potentially resectable disease.