Anecdotal and uncontrolled recommendations for programmatic surgical interv
ention in necrotizing pancreatitis are gradually being replaced by nonopera
tive approaches as prospective natural history information becomes availabl
e. In patients with sterile pancreatic necrosis, nonoperative managements h
as now been shown to result in a mortality rate equal or better to surgical
debridement. Moreover, since surgical debridement of sterile pancreatic ne
crosis has not been shown to prevent or ameliorate co-existing organ failur
e, and given that secondary infection of sterile necrosis occurs as a resul
t of operative debridement in 25% of cases and results in a trebling of mor
tality risk, it is becoming increasingly clear that surgical debridement in
sterile necrotizing pancreatitis will become the exception rather than the
rule. However, surgical debridement and drainage remains the preferred app
roach for infected pancreatic necrosis despite occasional anecdotal reports
of successful management by transcutaneous or endoscopic means. While the
optimal post-surgical technique of drainage remains controversial, a select
ive approach is reasonable, with the choice between closed drainage, lesser
sac lavage, or schedule re-explorations being based upon extent of the nec
rotic process.