Immediate versus step-up endoscopic transluminal necrosectomy in necrotizing pancreatitis: systematic review and...

Direct endoscopic necrosectomy (DEN) is commonly performed for walled-off necrosis (WON), yet its 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.

Major databases were searched through to 26 April 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 the Hartung-Knapp adjustment. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE).

5 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 the step-up strategy (odds ratio [OR] 2.56, 95%CI 1.03 to 6.37; P = 0.046; I ² = 0%). A post hoc sensitivity analysis including the ACCELERATE trial yielded a similar estimate (OR 2.59, 95%CI 1.33 to 5.04; P = 0.02; I ² = 0%). Immediate DEN was associated with a shorter length of stay (mean difference -8.02 days, 95%CI -15.00 to -1.05; P = 0.03; I ² = 42%). Technical success, necrosectomy sessions, total interventions, adverse events, bleeding, organ failure, mortality, and readmission did not differ significantly.

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 the timing remains individualized.