Aim. To analyze management of severe acute destructive pancreatitis and to determine the main tactical, anatomical and pathophysiological factors determining risks of adverse outcomes. Material and methods. 3581 patients with acute pancreatitis were enrolled. Retrospectively, 239 patients were assigned to severe pancreatic necrosis; invasive surgical techniques were applied in 210 cases. Twenty-nine patients with pancreatic necrosis underwent endoscopic papillosphincterotomy with main pancreatic duct stenting. Results. Overall mortality in patients with severe pancreatic necrosis was 32.3%, in case of minimally invasive techniques – 29.6%, conventional approach – 34.1%. There were similar outcomes regardless surgical technique in patients with pancreatic necrosis (p > 0.05), although introduction of main statements of national recommendations for treatment of pancreatic necrosis (regardless severity) reduced mortality from 25.4% to 9.5% (p < 0.001). Advanced parapancreatitis was accompanied by mortality near 36.5%. Stenting of main pancreatic duct was followed by death of 3 out of 29 patients with pancreatic necrosis (10.3%). Conclusion. Indications and choice of surgical approach according to national recommendations are not accompanied by improved postoperative mortality in patients with severe pancreatic necrosis and multiple organ failure. However, according to analysis on the whole, there is reduced postoperative mortality regardless severity of disease if these recommendations are sustained. Widespread involvement of retroperitoneal structures is adverse prognostic factor. Early endoscopic intraduodenal drainage in effective to prevent parapancreatic tissues.