Immediate necrosectomy shows no clear advantage over on-demand treatment in meta-analysis

The optimal timing of endoscopic necrosectomy after endoscopic ultrasound (EUS)-guided drainage remains uncertain in necrotizing pancreatitis. A systematic review and meta-analysis in Surgical Endoscopy searched four databases through March 2026 and included four randomized trials comparing immediate necrosectomy, within 72 hours, with an on-demand approach. The trials enrolled 215 adults, including 192 (89.3%) with walled-off necrosis. Primary outcomes were technical success, clinical success, and the proportion undergoing necrosectomy.

Pooled random-effects analyses found no statistically significant differences in technical success (risk ratio [RR] 1.01, 95% CI 0.98–1.05) or clinical success (RR 1.17, 95% CI 0.98–1.40). Immediate treatment was associated with a higher proportion undergoing necrosectomy (RR 1.65, 95% CI 1.13–2.41). No significant differences were detected in hospital stay, costs, additional drainage, procedure- or disease-related adverse events, mortality, bleeding, stent migration, or pneumoperitoneum.

These findings do not establish a consistent advantage for routine immediate necrosectomy over an on-demand strategy. However, absence of statistically significant differences does not establish equivalence. Evidence certainty was low to very low, and the small number of trials and modest sample size limit conclusions about efficacy and safety. The magnitude and clinical significance of the increased proportion undergoing necrosectomy also remain uncertain.