What factors push you toward upfront necrosectomy rather than step-up drainage in a patient with symptomatic walled-off necrosis after four weeks?

The indications for intervention on walled-off pancreatic necrosis are typically signs that the fluid collection has become overtly infected (causing abdominal sepsis), significant mass effect on adjacent organs, gastric outlet obstruction, or resultant abdominal pain and anorexia. If the patient is...

A truly symptomatic case (fever, pain, or inability to eat due to compression) would lead me to favor upfront drainage. However, this remains an intriguing question that a well-designed RCT would need to answer definitively.