Immediate or On-Demand Endoscopic Necrosectomy for Necrotizing Pancreatitis: A Randomized Controlled Trial
Tomotaka Saito1, Toshio Fujisawa2, Takeshi Ogura3
1Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
Gastroenterology
|February 20, 2026
Summary
Immediate direct endoscopic necrosectomy (DEN) after endoscopic ultrasound (EUS)-guided drainage speeds up recovery for necrotizing pancreatitis patients. This approach offers faster clinical success without increasing adverse events compared to a step-up strategy.
Area of Science:
- Gastroenterology
- Interventional Endoscopy
- Pancreatic Diseases
Background:
- Necrotizing pancreatitis requires timely intervention.
- Endoscopic ultrasound (EUS)-guided transmural drainage is a key treatment modality.
- Optimal timing for direct endoscopic necrosectomy (DEN) post-drainage is unclear.
Purpose of the Study:
- To compare immediate DEN versus a drainage-oriented step-up approach for symptomatic necrotizing pancreatitis.
- To evaluate the impact of immediate DEN on time to clinical success.
Main Methods:
- A multicenter, open-label, superiority randomized trial (WONDER-01).
- Patients received EUS-guided drainage, then randomized to immediate DEN or step-up approach.
- Primary endpoint: time to clinical success (collection size ≤3 cm, improved inflammatory markers).
Main Results:
- Immediate DEN shortened time to clinical success (median 29 vs 44 days, P=.009).
- Adverse event rates were similar between groups (24% vs 22%, P=.79).
- Technical success and mortality rates showed no significant differences.
Conclusions:
- Immediate DEN following EUS-guided drainage accelerates clinical success in necrotizing pancreatitis.
- This strategy is safe and does not increase adverse outcomes.
- Immediate DEN necessitates more necrosectomy procedures compared to the step-up approach.
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