Early versus late direct endoscopic necrosectomy for pancreatic walled-off necrosis: a grade‑assessed systematic review with trial sequential evidence
In brief
Early endoscopic necrosectomy cuts need for percutaneous drainage by about half
A systematic review of eight studies (745 patients) found that early and late direct endoscopic necrosectomy achieve similar clinical and technical success, mortality, and complication rates. However, early necrosectomy halved the likelihood of requiring additional percutaneous drainage, though the overall evidence quality was very low, underscoring the need for better trials.
- Journal
- Surgical endoscopy (Q1)
- Published
- 11 August 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Mostafa Adel T Mahmoud, Islam Mohamed, Alshayma Alalawneh, EzzElDien A Ibrahim, Omar Alkasabrah, Abdelrahman Awad, et al.
- PMID
- 42581200
- DOI
- 10.1007/s00464-026-13227-0
Why clinicians should know about it
- Picked for Gastroenterology (top studies of the week, 16 August 2026): Early vs late DEN show comparable efficacy, safety
- Picked for Epidemiology (top studies of the week, 16 August 2026).
- Picked for Surgery (top studies of the week, 16 August 2026): Early vs late DEN for pancreatic WON, systematic review
Abstract
BACKGROUND: The optimal timing of direct endoscopic necrosectomy (DEN) for pancreatic walled-off necrosis (WON) remains uncertain, with practice varying from early intervention to a delayed approach. This systematic review and meta-analysis aims to compare the clinical efficacy and safety of early versus late DEN. METHODS: We systematically searched Cochrane, PubMed, Scopus, and Web of Science until October 28, 2025, for studies comparing early and late DEN. The primary outcomes were clinical success, technical success, the number of necrosectomy sessions, the need for percutaneous drainage, mortality, and procedure-related adverse events. Pooled estimates were calculated using random- or fixed-effects models and reported as risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CI). Trial sequential analysis (TSA) was performed, and the certainty of evidence was evaluated. PROSPERO ID: CRD420251176766. RESULTS: Eight studies were included, comprising three randomized controlled trials (RCTs) and five cohort studies, involving 745 patients. No significant differences were observed in clinical success (RR 1.04, 95% CI 0.99 to 1.09), technical success (RR 1.01, 95% CI 0.98 to 1.04), number of necrosectomy sessions (MD 0.35, 95% CI -0.50 to 1.19), mortality (RR 1.17, 95% CI 0.61 to 2.27), or overall adverse events (RR 0.91, 95% CI 0.68 to 1.22). TSA indicated firm evidence of no difference for clinical and technical success. In RCTs alone, early DEN was associated with a reduced need for percutaneous drainage (RR 0.44, 0.20 to 0.96). The certainty of evidence was rated as very low for most outcomes. CONCLUSIONS: Early and late DEN show comparable efficacy and safety. Early DEN may reduce the need for adjunctive percutaneous drainage. However, the low certainty of evidence necessitates further high-quality RCTs to confirm these safety and efficiency findings.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.