Immediate vs Step-up Endoscopic Transluminal Necrosectomy in Necrotizing Pancreatitis: Systematic Review and Meta-analysis of Randomized Controlled Trials

Why clinicians should know about it

• Picked for Gastroenterology (top studies of the week, 2 August 2026): Immediate DEN improves success and LOS in necrotizing pancreatitis

Abstract

Background Direct endoscopic necrosectomy (DEN) is commonly performed for walled-off necrosis (WON), yet optimal timing remains uncertain. Step-up strategies defer necrosectomy until clinical deterioration, whereas immediate DEN may provide earlier source control but risks unnecessary intervention. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing immediate versus step-up DEN. Methods Major databases were searched through April 26, 2026, for RCTs comparing immediate versus step-up DEN. The primary outcome was clinical success. Secondary outcomes included technical success, necrosectomy sessions, total interventions, length of stay, adverse events, bleeding, organ failure, mortality, recurrence, and readmission. Random-effects meta-analysis was performed using Hartung-Knapp adjustment. Certainty of evidence was assessed using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Results Five randomized trials, including 269 patients (134 immediate DEN; 135 step-up strategy), were analyzed. In four trials reporting standalone study-defined clinical success, immediate DEN was associated with higher success than step-up strategy (OR 2.56, 95% CI 1.03-6.37; p=0.046; I²=0%). A post hoc sensitivity analysis including ACCELERATE yielded a similar estimate (OR 2.59, 95% CI 1.33-5.04; p=0.017; I² = 0%). Immediate DEN was associated with shorter length of stay (MD -8.02 days, 95% CI -15.00 to -1.05; p=0.033; I²=42%). Technical success, necrosectomy sessions, total interventions, adverse events, bleeding, organ failure, mortality, and readmission did not differ significantly. Conclusions Immediate DEN was associated with higher clinical success and shorter hospital stay compared with a step-up strategy. These findings support selective consideration of immediate DEN in appropriate patients with WON, while timing remains individualized.

Abstract as published, via PubMed.