Patients with pancreatic necrosis should receive a prophylactic antibiotic such as imipenem in the hope of reducing the likelihood of pancreatic infection. Those with severe gallstone pancreatitis should undergo endoscopic sphincterotomy. If common bile duct stones are visualized, endoscopic sphincterotomy and removal of stones should be undertaken. Patients with infected necrosis require surgical debridement. Those with sterile necrosis should generally be managed medically. The role of early surgical debridement for patients with sterile pancreatic necrosis who are experiencing increasing systemic toxicity remains unclear. Whenever possible, it is preferable to maintain prolonged medical supervision for 4-6 weeks, reserving surgical debridement at that time for late complications including inability to wean from respiratory support and refractory abdominal pain with attempts at oral refeeding. Ultimately, progress in the treatment of severe acute pancreatitis will depend on improved methods of limiting systemic complications, preventing pancreatic necrosis, and preventing pancreatic infection.