A step-up approach or open necrosectomy for necrotizing pancreatitis was evaluated in a randomized trial involving 88 patients with necrotizing pancreatitis and suspected or confirmed infected necrotic tissue. The study compared primary open necrosectomy with a minimally invasive step-up approach, which included percutaneous drainage followed by minimally invasive retroperitoneal necrosectomy if necessary. The primary endpoint was a composite of major complications or death. The step-up approach significantly reduced the rate of this composite endpoint, with 69% of patients in the open necrosectomy group and 40% in the step-up group experiencing it (risk ratio 0.57; 95% CI 0.38 to 0.87; P=0.006). The step-up approach also reduced the incidence of new-onset multiple-organ failure (12% vs. 40%), incisional hernias (7% vs. 24%), and new-onset diabetes (16% vs. 38%). The mortality rate did not differ significantly between the groups (19% vs. 16%). The step-up approach was associated with lower healthcare resource utilization and costs, with a 12% reduction in total costs. The study suggests that the minimally invasive step-up approach is more effective than open necrosectomy in reducing complications, mortality, and healthcare costs in patients with necrotizing pancreatitis and infected necrotic tissue. The results support the use of a step-up approach as a preferred treatment strategy for these patients.A step-up approach or open necrosectomy for necrotizing pancreatitis was evaluated in a randomized trial involving 88 patients with necrotizing pancreatitis and suspected or confirmed infected necrotic tissue. The study compared primary open necrosectomy with a minimally invasive step-up approach, which included percutaneous drainage followed by minimally invasive retroperitoneal necrosectomy if necessary. The primary endpoint was a composite of major complications or death. The step-up approach significantly reduced the rate of this composite endpoint, with 69% of patients in the open necrosectomy group and 40% in the step-up group experiencing it (risk ratio 0.57; 95% CI 0.38 to 0.87; P=0.006). The step-up approach also reduced the incidence of new-onset multiple-organ failure (12% vs. 40%), incisional hernias (7% vs. 24%), and new-onset diabetes (16% vs. 38%). The mortality rate did not differ significantly between the groups (19% vs. 16%). The step-up approach was associated with lower healthcare resource utilization and costs, with a 12% reduction in total costs. The study suggests that the minimally invasive step-up approach is more effective than open necrosectomy in reducing complications, mortality, and healthcare costs in patients with necrotizing pancreatitis and infected necrotic tissue. The results support the use of a step-up approach as a preferred treatment strategy for these patients.