Between step-up and upfront intervention: Risk stratification as the missing link in timing endoscopic necrosectomy

Abstract

The management of walled-off pancreatic necrosis has shifted from surgical debridement to minimally invasive, step-up endoscopic strategies. While lumen-apposing metal stents enable effective drainage in many patients, a substantial proportion still requires direct endoscopic necrosectomy, where the optimal timing of intervention remains debated. Rather than a strict early-vs-delayed paradigm, timing increasingly reflects individualized clinical judgment. The study recently published by Lone et al highlights that clinical, biochemical, and radiologic factors, including necrosis extent, systemic inflammation, nutritional status, and anatomical complexity, can predict failure of passive drainage and the need for direct endoscopic necrosectomy. These findings support a risk-based approach in which patient stratification guides selective upfront or accelerated intervention. Risk stratification thus emerges as the missing link between waiting and acting, enabling more precise and personalized timing of necrosectomy in walled-off pancreatic necrosis management.

Keywords: Walled-off necrosis; Endoscopic necrosectomy; Risk stratification; Endoscopic step-up approach; Passive drainage failure; Personalized intervention

Core Tip: This article highlights the importance of the recently published study by Lone et al, which identifies key clinical, biochemical, and imaging predictors of passive drainage failure in patients with walled-off pancreatic necrosis. By demonstrating that factors such as necrosis extent, persistent inflammation, and poor nutritional reserve can predict the need for direct endoscopic necrosectomy, the study shifts the focus from a time-based step-up protocol toward a risk-based, individualized approach. These findings underscore that in walled-off pancreatic necrosis management, the key question is not when to intervene, but in whom waiting may be riskier than acting.