The use of upfront direct endoscopic necrosectomy (DEN) at the index drainage of pancreatic walled-off necrosis (WON) remains controversial when compared with on-demand necrosectomy, particularly in patients presenting with severe sepsis. Moreover, the exact role of SOFA score in selecting candidates for upfront DEN has not been established yet. The aim of our study was to assess the upfront endoscopic necrosectomy for infected  WON  based on  SOFA score>2 in choosing upfront DEN. 

A retrospective analysis of a prospectively collected database was conducted on patients who underwent endoscopic drainage and necrosectomy for symptomatic pancreatic WON at one tertiary referral center between September 2023 and September 2025. Patients were divided into: Group 1 included patients with upfront DEN and infection with SOFA score> 2 and group 2 with step-up therapy with infections and SOFA score< 2 or no infection. QNI classification was used for initial characterization of WON. The choice of LAMS or plastic stent was performed by the endoscopist according to the WON features. Infection resolution was defined by clinical improvement (absence of fever and septic signs) and biochemical response (reduction of CRP  < 2 mg/dl or normalization of procalcitonin). Radiological improvement was recorded when available, but was not required for defining infection clearance.  Clinical success was based on radiological WON resolution < 30 mm at the 3-month imaging follow-up.

The distribution of patients into group 1 (n=11) and group 2 (n=49) was similar for age, sex, and size of WON (120.45 ± 36.95 mm vs 103 ± 40 mm), ≥ 3 quadrants involvement (54.5% vs 30.6%, p=0.169) or necrosis ≥ 30% (81.8% vs 49%, p= 0.091). Infected WON were significantly more common in the group 1 compared with the group 2 (100% vs 16.3%, p<0.001).

LAMS were used similarly in the two groups (6/11, 55% in Group 1 vs 26/49, 53% in Group 2, p= 1.00). The mean number of DEN sessions (2.64 ± 1.57 vs 2.04 ± 1.51, p=0.270), the need for > 3 DEN (36.4% vs 22.4%, p = 0.563) or additional percutaneous, surgical, or ERCP procedures did not differ significantly (3/11 vs 10/49, p=0.690).

Clinical success was 100% and 81,6% (p=0,15), while time to infection resolution was 13.9 days in Group 1 and 10.9 days in Group 2 (p=0,054). Complication rates (18.2% vs 16.32%, p=0.847) and overall mortality at 3 months (0% vs 8.2%, p=1.00) were similar between groups.

Selection based on high SOFA score for upfront DEN in WON assures similar outcome to lower SOFA scores patients, without influencing the outcome, the number of DEN or additional procedures, complications or mortality.