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Question: Among patients with necrotizing pancreatitis with infected necrosis, what are the differences in outcomes between a minimally invasive step-up approach and primary open necrosectomy? Conclusion: A minimally invasive step-up approach reduced complications or death by 43% compared with primary open necrosectomy, among patients with necrotizing pancreatitis and infected necrosis. Outcomes in Detail: primary Outcome Major complications or death 40% vs. 69% (RR 0.57; 95% CI 0.38-0.87; P=0.006; NNT=3) Secondary Outcomes Death 19% vs. 16% (RR 1.20; 95% CI 0.48-3.01; P=0.70) Major Complication New-onset multiple organ failure or systemic complications 12% vs. 42% (RR 0.28; 95% CI 0.11-0.67; P=0.001) Multiple organ failure 12% vs. 40% Multiple systemic complications 0% vs. 2% Intraabdominal bleeding requiring intervention 16% vs. 22% (RR 0.73; 95% CI 0.31-1.75; P=0.48) Enterocutaneous fistula or perforation requiring intervention 14% vs. 22% (RR 0.63; 95% CI 0.25-1.58; P=0.32) Pancreatic fistula 28% vs. 38% (RR 0.74; 95% CI 0.40-1.36; P=0.33) Incisional hernia 7% vs. 24% (RR 0.29; 95% CI 0.09-0.95; P=0.03) New-onset diabetes 16% vs. 38% (RR 0.43; 95% CI 0.20-0.94; P=0.02) Number of operations 53 vs. 91 (P=0.004) Number of drainage procedures 82 vs. 32 (P=0.004) #absite #generalsurgeryboards