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Comparison of minimal access retroperitoneal pancreatic necrosectomy (MARPN) versus open necrosectomy in the treatment of infected or nonresolving pancreatic necrosis.Infected pancreatic necrosis may lead to progressive organ failure and death. Minimal access techniques have been developed in an attempt to reduce the high mortality of open necrosectomy.This was a retrospective analysis on a prospective data base comprising 189 consecutive patients undergoing MARPN or open necrosectomy (August 1997 to September 2008). Outcome measures included total and postoperative ICU and hospital stays, organ dysfunction, complications and mortality using an intention to treat analysis.Overall 137 patients underwent MARPN versus open necrosectomy in 52. Median (range) age of the patients was 57.5 (18–85) years; 118 (62%) were male. A total of 131 (69%) patients were tertiary referrals, with a median time to transfer from index hospital of 19 (2–76) days. Etiology was gallstones or alcohol in 129 cases (68%); 98 of 168 (58%) patients had a positive culture at the first procedure. Of the 137 patients, 34 (31%) had postoperative organ failure in the MARPN group, and 39 of 52 (56%) in the open group (P < 0.0001); 59/137 (43%) versus 40/52 (77%), respectively, required postoperative ICU support (P < 0.0001). Of the 137 patients 75 (55%) had complications in the MARPN group and 42 of 52 (81%) in the open group (P = 0.001). There were 26 (19%) deaths in the MARPN group and 20 (38%) following open procedure (P = 0.009). Age (P < 0.0001), preoperative multiorgan failure (P < 0.0001), and surgical procedure (MARPN, P = 0.016) were independent predictors of mortality.This study has shown significant benefits for a minimal access approach including fewer complications and deaths compared with open necrosectomy.