Background: Acute pancreatitis with necrosis associated with high rates of morbidity and mortality, especially in those undergoing operative debridement. The Atlanta Classification developed in 1992, was recently revised in 2007, to better categorize acute pancreatitis improved imaging techniques.Aims: To utilize the 2007 revision of the Atlanta Classification to assess outcomes, morbidity and mortality in patients undergoing debridement of pancreatic necrosis.Methods: From 1999-2008, patients with pancreatic necrosis who were treated with surgical debridement were included in the analysis. Computed tomography (CT) images were independently reviewed to classify of pancreatic collections according to the revised Atlanta classification. Results: Seventy-three patients (54 males, 74%) with fluid collections were categorized as follows: infected walled off extrapancreatic necrosis (38%), sterile walled off extrapancreatic necrosis (26%), infected walled off pancreatic necrosis (16%), sterile walled off pancreatic necrosis (13%) and post-necrotic pancreatic collection (7%). Forty-one (56%) patients underwent endoscopic drainage prior to surgical consultation, 21 (52%) of which had infected necrosis at the time of operation (p = 0.012). In-hospital mortality was 14% (range 5-107 days). Those undergoing open debridement with external drainage (21, 24%) and open packing (5, 40%) had a significantly higher mortality than those undergoing cystgastrostomy with pancreatic debridement (46, 6.7%) (p = 0.03). Type of collection was not associated with operative procedure or mortality rate. Preoperative albumin levels < 1.5 mg/dl (p < 0.01), fungal (p < 0.05) and bacterial (p < 0.05) infections were associated with longer length of stay. Thirty-one (35%) patients experiencing post-operative complications had a significantly longer hospital stay (mean 36 days vs. 11 days, p < 0.01).Conclusion:With today’s referral pattern at high volume centers, a high percentage of patients undergo endoscopic drainage prior to surgery. Cystgastrostomy and pancreatic debridement is associated with lower mortality rates than external drainage or open packing procedures. Collection type according to the revised Atlanta Classification was not associated with type of debridement morbidity rates. Length of stay was increased in patients with poor nutrition, infected necrosis and in those experiencing complications. Acute necrotizing pancreatitis continues to be associated with significant in-hospital morbidity and mortality rates, and should undergo aggressive treatment at tertiary care centers.