Immediate vs On-Demand Endoscopic Necrosectomy in Infected Walled-Off Pancreatic Necrosis: A Randomized Controlled...

Area of Science:

• Gastroenterology
• Interventional Endoscopy
• Pancreatic Diseases

Background:

• Infected walled-off pancreatic necrosis (WON) is a serious complication of pancreatitis.
• Endoscopic drainage is a standard treatment for WON.
• The optimal timing for necrosectomy in WON remains debated, lacking high-quality comparative evidence.

Purpose of the Study:

• To compare the efficacy and safety of immediate versus on-demand endoscopic necrosectomy in patients with infected WON.
• To evaluate the number of reinterventions required for clinical success.
• To assess secondary outcomes including adverse events, hospital stay, and mortality.

Main Methods:

• A single-center, prospective, randomized controlled superiority trial was conducted.
• Patients with infected WON were randomized to immediate or on-demand endoscopic necrosectomy after EUS-guided drainage.
• Clinical success was defined by reduced collection diameter and symptom resolution; primary outcome was reinterventions.

Main Results:

• Clinical success rates were similar (92% immediate vs. 88% on-demand).
• The on-demand group required fewer necrosectomy sessions (median 1 vs. 2) and 44% resolved without necrosectomy.
• Adverse events were less frequent in the on-demand group (24% vs. 40%), with no moderate-to-severe events compared to 16% in the immediate group.

Conclusions:

• Immediate endoscopic necrosectomy is not superior to an on-demand strategy for infected WON.
• The on-demand approach is associated with a reduced number of necrosectomy sessions.
• An on-demand strategy for WON management may lead to fewer procedure-related adverse events.