Objective: To investigate the indications and optimal time of surgery in fulminant acute pancreatitis (FAP). Methods: The clinical data of 32 FAP patients undergoing surgical treatment from August 2004 to August 2012 were retrospectively analyzed. Results: All the 32 FAP patients underwent surgical management for different reasons, which in 13 cases was due to the persistence of multiple organ dysfunction without any evidence of improvement after receiving 10- to 14-d full ICU care, in 8 cases was ascribed to no improvement but even rapid worsening of multiple organ functions after receiving 3- to 5-d full ICU care; and in 11 cases was attributed to sustained intra-abdominal pressure above 30 cmH2O (1 cmH2O=0.098 kPa) after a series of non-surgical procedures. The cure rate for the entire group of patients was 78.1% (25/32), and the mortality was 21.9% (7/32). Ninety patients were followed-up for 4 to 50 months, and 5 cases developed pancreatic pseudocyst, which were resolved by a second operation. Conclusion: Aggressive surgical intervention is justified in FAP patients with no evidence of improvement or even deterioration of multiple organ functions after full ICU care, or having sustained intra-abdominal hypertension without signs of relief after non-surgical treatment.