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

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.