Abstract Between January 1980 and June 1986, 21 patients required surgery for acute necrotizing pancreatitis. Four patients had been transferred from other hospitals: the remaining 17 patients had been treated from the outset at Glasgow Royal Infirmary, representing 3.7 per cent of the 456 patients treated for acute pancreatitis during this time. Necrosectomy was performed on 14 patients and 7 patients were treated by pancreatic resection, with 4 deaths in each group; thus 8 patients (38 per cent) died at a median time of 22 days from onset of their attack. Three of the four patients transferred to our care died, giving a mortality in our own patients of 29 per cent. Of the survivors, all but three had a prolonged and complicated hospital course. Our data confirm that acute necrotizing pancreatitis is still associated with a considerable mortality and morbidity. Early multi-organ failure, advanced age, underlying medical illness and the presence of infected necrosis were associated with a poor outcome. Necrosectomy delayed until the second or subsequent week appeared to be a suitable procedure for the majority of our patients, but shortcomings were apparent with the traditional methods of closed drainage of the pancreatic bed postoperatively. The many demands imposed by this small group of patients suggests that their management is best undertaken in centres in which there is special expertise and this should contribute to a further reduction in the mortality from this condition.