Comparative Outcomes of Endoscopic, Minimally Invasive Surgical, and Open Necrosectomy in Necrotizing Pancreatitis: Evidence From a Network Meta‐Analysis

BACKGROUND: The optimal interventional approach for necrotizing pancreatitis remains debated. We performed a systematic review with network meta-analysis and proportional meta-analysis to compare endoscopic trans-gastric necrosectomy (EN), minimally invasive surgical necrosectomy (MIN), and open necrosectomy (ON). METHODS: Databases were searched from inception through March 2026. Eligible studies included randomized and observational comparative studies enrolling adults with necrotizing pancreatitis requiring necrosectomy and comparing ON, MIN, and/or EN. Nine binary outcomes were assessed in a frequentist random-effects network meta-analysis. Separate proportional meta-analysis of single-arm studies pooled mortality, clinical success, complications, and need for additional surgery. Risk of bias was assessed using RoB 2 and ROBINS-I, and confidence in network estimates was assessed using CINeMA. RESULTS: Thirty-three studies were included. Nine comparative studies were included in the network meta-analysis, and 24 single-arm studies were analyzed separately. EN was associated with lower mortality, fewer complications, less new-onset multiple organ failure, less exocrine insufficiency, fewer new ICU admissions, and better overall treatment ranking than ON. EN also outperformed MIN for complications and new-onset multiple organ failure, whereas MIN was superior to ON for multiple organ failure, exocrine insufficiency, incisional hernia, and ICU admission. Bleeding, re-intervention, and new-onset diabetes did not differ significantly across techniques. In single-arm pooling, EN and MIN showed comparable mortality, clinical success, complications, and need for additional surgery. CONCLUSIONS: Endoscopic necrosectomy appears to offer the most favorable overall profile for necrotizing pancreatitis, whereas minimally invasive surgical approaches also improve several outcomes compared with open necrosectomy. Open surgery should likely remain reserved for selected rescue situations.