Immediate vs Step-up Endoscopic Transluminal Necrosectomy in Necrotizing Pancreatitis: Systematic Review and
Dimo Dimitrov1, Yizhong Wu2, Bjorn Rodriguez3
1Boston Medical Center - Brighton, Department of Internal Medicine, Massachusetts, United States, Boston.
Endoscopy
|July 26, 2026
Summary
Immediate direct endoscopic necrosectomy (DEN) for walled-off necrosis (WON) shows higher clinical success and shorter hospital stays than step-up strategies. This suggests immediate DEN may be a beneficial option for select WON patients.
Area of Science:
- Gastroenterology
- Surgical Innovation
- Evidence-Based Medicine
Background:
- Walled-off necrosis (WON) management often involves direct endoscopic necrosectomy (DEN).
- Optimal timing for DEN in WON remains unclear, with step-up strategies deferring intervention versus immediate DEN for early source control.
- Randomized controlled trials (RCTs) are needed to compare these approaches.
Purpose of the Study:
- To systematically review and meta-analyze RCTs comparing immediate DEN versus step-up strategies for WON.
- To evaluate the impact of timing on clinical success, technical outcomes, and patient recovery.
Main Methods:
- Systematic review and random-effects meta-analysis of RCTs comparing immediate DEN and step-up strategies for WON.
- Searched major databases through April 26, 2026.
- Assessed certainty of evidence using GRADE methodology.
Main Results:
- Five RCTs with 269 patients (134 immediate DEN, 135 step-up) were analyzed.
- Immediate DEN demonstrated higher clinical success (OR 2.56) and shorter length of stay (MD -8.02 days) compared to step-up strategies.
- No significant differences were observed in technical success, necrosectomy sessions, total interventions, adverse events, or mortality.
Conclusions:
- Immediate DEN is associated with improved clinical success and reduced hospital stay for WON patients.
- These findings support the selective consideration of immediate DEN, acknowledging that timing should be individualized.
- Further research may refine patient selection for immediate intervention.
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