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Background: Site and extent of pancreatic necrosis are evaluated as tools in assessment of severity and prognosis in acute pancreatitis in previous studies. The aim of the present study was to assess whether the site and maximum extent of pancreatic necrosis during the stay has role in guiding the therapeutic modality in Severe Acute PancreatitisMethods: Retrospective analysis of prospectively maintained database of 70 consecutive patients with SAP from April 2008 to December 2009. All the patients underwent CT abdomen after 4 days after the onset of acute pancreatitis and CT scans were repeated as and when required. As a step up approach, patients were initially managed conservatively and as per the indication underwent Percutaneous Catheter Drainage (PCD) and Surgery. The maximum extent of pancreatic necrosis was categorized into three groups, i.e less than 30% necrosis, 30-50% necrosis and more than 50% necrosis. The site of pancreatic necrosis was also categorized into two groups, i.e pancreatic necrosis involving head region and necrosis sparing the head region. The Maximum Extent and Site of Pancreatic Necrosis in patients managed with different modalities were compared. Results: Of the 70 consecutive patients with SAP, 14 patients were managed conservatively, 29 underwent PCD alone and the remaining 27 underwent initial PCD followed by surgery. < 30% necrosis was present in 12 patients. There were significantly higher number of patients managed conservatively compared to those undergoing PCD (Table). 30-50% necrosis was noted in 17 patients. Significantly higher number of patients underwent management with PCD alone in this group compared to those also requiring necrosectomy (Table). More than 50% necrosis was present in 41 patients. Proportion of patients requiring open necrosectomy as step up approach were significantly higher in this group compared to those managed with PCD alone (Table).Pancreatic necrosis of head of pancreas with or without involvement of body or tail was noted in 36 patients (Table) and pancreatic necrosis involving only the body and or tail was noted in 34 patients (Table). No significant difference was noted in management based on site of necrosis (Table). Conclusions: Site of pancreatic necrosis has not influenced the management modality. However significantly higher number of patients with >50% necrosis required surgery compared to PCD alone group while Significantly higher percentage of patients with <30% necrosis could be managed conservatively.
CT scan in Acute Pancreatitis

CT Abdomen	Conservative (n=14)	PCD alone (n=29)	PCD followed by surgery (n=27)	Conservative Vs PCD P [OR]	PCD Vs PCD followed by surgery P [OR]
Maximum extent of necrosis during the stay <30 % (n=12) 30-50 % (n=17) > 50% (n=41)	5(42) 3(18) 6(15)	3(25) 12(71) 14(34)	4(33) 2(11) 21(51)	0.04[0.2] 0.2[2.5] 0. 7[1.2]	0.6[1.5] 0.003[0.1] 0.02[3.7]
Site of necrosis Head Region ± Body, tail* (n=36) Only Body ± tail (n=34)	5(14) 9(26)	18(50) 11(32)	13(36) 14(42)	0.1[2.9]	0.3[0.5]
Disease specific Mortality	1(7)	2(7)	11(40)	0.9[0.9]	0.003[9.3]

* complete necrosis - conservative group (n=1); PCD alone group (n= 3); PCD followed by surgery (n=6)