Acute Pancreatitis – Conservative Intensive Care or Surgical Therapy? With an incidence of 10–25 cases per 100,000 inhabitants per year, acute pancreatitis is one of the rarer cases of the acute abdomen. However, early diagnosis is pivotal for an adequate therapy. 80% of patients develop the mild edematous pancreatitis. With adequate conservative therapy (hospitalization and observation, initially NPO, recording of water balance and adequate intravenous liquid substitution, sufficient analgesia) the mortality is below 1% and patients can be dismissed after 1 or 2 weeks. In contrast, the severe course of necrotizing pancreatitis, concerning 20% of patients, is still a life-threatening disease. There are two phases in the course of necrotizing pancreatitis. The first 14 days are characterized by the aseptic systemic inflammatory response syndrome with massive release of cytokines. In this phase a thorough observation of organ function in an intensive care unit is necessary. The indication for surgery lies, with few exceptions, only in the presence of infected necrosis in the second phase, 2 weeks after the onset of the disease. Infection of pancreatic or peripancreatic necrosis frequently results in septic multiple organ failure, with a mortality of approximately 100% without surgical therapy. In the natural course of necrotizing pancreatitis, infection of necrosis occurs in 40–70% of patients. However, it can be prevented by prophylactic antibiotic treatment. In the presence of infected necrosis, surgical therapy in the form of organsaving necrosectomy with postoperative removal of necrotic material by continuous closed lavage of the necrotic areas is indicated. With this less aggressive therapeutic strategy according to the status of infection, mortality could be reduced below 10% (12/121) in our own patients with necrotizing acute pancreatitis.