Of 348 cases of acute pancreatitis presenting between 1980 and 1985, extensive retroperitoneal necrosis with bacterial or fungal superinfection developed in only 17 (4.8 percent). However, in 14 of the 17 patients (80 percent), multiple surgical interventions and intensive supportive therapy failed to control the process, and they died from complications. Deaths occurred after a prolonged in-hospital course characterized by sequential failure of organ systems. If the salvage of these patients is to be optimized, as in some reports, the timing of the first surgical procedure has to be very carefully made based on the clinical and laboratory findings, and most importantly, the results of computerized tomography. Exploration is probably best carried out through an extended subcostal incision, and a determined attempt must be made to remove all of the necrotic tissue. Little reliance can be placed on the possibility that significant amounts of residual necrotic tissue can be aspirated through sump catheters or evacuated by irrigations. We believe that the poor results in this series lend strong support to those who have already advocated much more universal application of the open abdomen technique in the management of these patients with widespread anterior pararenal space necrosis.