centers. Abandonment of open pancreatic debridement has been based on exceed­ingly high morbidity and mortality rates with no established effect on improved outcome. A single-institution study by Ashley et al. in 2001 evaluated 99 consecu­tive patients with necrotizing pancreatitis, employing a non-operative management strategy followed by delayed intervention [ 4 ]. Mortality was approximately 10 % and in all cases, were related to multisystem organ failure. In 2007, Howard et al. published an observational series of 102 patients undergoing laparotomy for surgi­cal debridement of pancreatic necrosis at a single institution over two time periods: 1993–2001 vs 2002–2005 [ 5 ]. Patients in the latter group were treated in accor- dance with the International Association of Pancreatology guidelines which man­dated use of fi ne needle aspiration or CT evidence of infection as indicators for surgery and avoiding operating on patients within 14 days of the onset of disease unless otherwise indicated. The earlier treatment group (1993–2001) did not differ signifi cantly from the latter group in terms of severity of illness. The latter group showed a decreased operative morbidity (89 % vs 72 %, p = 0.03), length of stay, and overall mortality (18 % vs 4 %, p = 0.03). There were no differences in culture result patterns between the two groups and the average time from acute presentation to surgical debridement were the same. What then made up for the dramatic decrease in mortality over the two time periods? There are likely highly conspicuous differ­ences in management between these two groups that perhaps were not accounted for in the description of the study. For example, were the anesthetics, pain management or surgical debridement approaches different? Were the indications for surgery identical in both groups? Despite no differences in culture results, did patient in the latter group receive broader antibiotics with better pancreatic tissue penetration? Were the antibiotics delivered with greater attention to their pharmacodynamics and pharmacokinetics by pharmacy services in the latter period? The most important fi nding in this study was difference in mortality of 18–4 % and a decrease length of stay of 20 %. Pancreatic fi stula rates were high in both groups (49 vs 60 %). Diabetes incidence was not reported. Despite the lack of detail available in this study to account for the improved mortality rates, today among surgeons dealing with pan­creatitis, there is a general sense that the morbidity and mortality of open surgery to treat necrotizing pancreatitis has decreased signifi cantly perhaps owing to more strict adherence to the indications for surgery, improved imaging, better anesthesia and pain management, better antibiotics and their pharmacologic application and the availability of newer surgical techniques such as the damage control laparotomy and the wound vac. There are few observational trials in the last few years that can substantiate today that fi stula formation, number of procedures (take backs) required, extent of pancreatic debridement, incidence of diabetes development, and multiple organ failure incidence are decreased overall following open surgery. The reason for this is twofold: open surgery is performed less often and less repeatedly for a given patient and the patient populations are extremely heterogeneous making most comparisons problematic. Experienced surgeons are quick to accept that each patient with severe necrotizing pancreatitis represents his or her own unique odys­sey. Patients today, compared to several decades previously, can be safely managed with an open abdomen. Yet distinct from years past, the open abdomen is now