Immediate Versus On‐Demand Direct Endoscopic Necrosectomy for Necrotizing Pancreatitis: A Systematic Review and Meta‐Analysis

Abstract

ABSTRACT Background The optimal timing of direct endoscopic necrosectomy (DEN) for Necrotizing Pancreatitis (NP) remains unclear. This meta‐analysis aimed to evaluate the efficacy and safety of immediate DEN compared with on‐demand DEN. Methods PubMed, Embase, Web of Science, and Cochrane Library databases were systematically searched to identify studies. The primary outcome measure was clinical success. Results Seven studies (4 RCTs and 3 observational studies) comprising 616 patients were included. Immediate DEN did not demonstrate a statistically significant advantage in clinical success (OR: 1.92, 95% CI 1.01–3.63). No significant differences were found in technical success (OR: 1.62, 95% CI: 0.43–6.09), total number of DEN (standardized mean difference: 0.31, 95% CI: −0.21–0.84), need for additional percutaneous drainage (OR: 0.53, 95% CI: 0.27–1.03), need for salvage surgery (OR: 0.60, 95% CI: 0.28–1.27), procedure‐related adverse events were comparable between groups (OR: 0.81, 95% CI: 0.51–1.28), disease‐related adverse events (OR: 0.84, 95% CI: 0.34–2.13), mortality (OR: 1.11, 95% CI: 0.47–2.59). In RCT‐only analyses, these findings remained consistent. Immediate DEN lowered stent migration risk (OR: 0.31, 95% CI: 0.11–0.92), but lost significance in RCT‐only analysis. Conclusion This meta‐analysis found no overall superiority of immediate DEN over on‐demand DEN for patients with NP, highlighting the need to identify specific subgroups that benefit from an upfront necrosectomy strategy.