Walled-Off Necrosis: Should We Debride Early Rather Than “Drain First”?: Endoscopy | September 2026

What Did the Study Find?

This meta-analysis included 5 randomised trials and 269 patients with walled-off pancreatic necrosis (WON), comparing immediate direct endoscopic necrosectomy (DEN) with drainage followed by step-up necrosectomy when required.

Immediate DEN achieved higher study-defined clinical success (OR 2.56).

Hospital stay was approximately 8 days shorter with immediate DEN.

Overall adverse events were not significantly increased.

Rates of bleeding, organ failure and mortality were similar.

Readmissions and the total number of procedures were also comparable.

However, definitions of clinical success varied across trials, and the overall evidence base remains small.

Why Does It Matter?

The conventional endoscopic strategy for WON is drain first, then necrosectomy only if needed. Earlier removal of solid necrotic material may provide faster source control in selected patients.

GastroAGI Takeaway

Immediate DEN may be better for selected WON—not for every WON. Patients with infected collections and substantial solid necrotic burden may particularly benefit from earlier debridement. These randomised data challenge a rigid step-up approach, but only 269 patients underpin the evidence; patient selection and expert-centre experience remain critical.