Immediate Necrosectomy Accelerates Recovery in Walled-Off Necrosis : Gastroenterology | Jul 2026

Introduction:

Endoscopic ultrasound (EUS)-guided drainage has become the preferred minimally invasive treatment for symptomatic necrotizing pancreatitis. However, the optimal timing of direct endoscopic necrosectomy (DEN) following drainage remains uncertain. While the conventional step-up approach reserves necrosectomy for patients who fail to improve after drainage alone, some experts advocate earlier intervention to accelerate resolution of infected or symptomatic necrosis.

Problem Statement:

Although the step-up strategy minimizes procedural interventions, delayed necrosectomy may prolong inflammation, hospital stay, and recovery. Whether immediate DEN following EUS-guided drainage improves clinical outcomes without increasing complications has not been established in prospective randomized trials.

Summary:

The WONDER-01 trial is the first randomized study to directly compare immediate DEN with a drainage-oriented step-up strategy in patients undergoing endoscopic treatment for symptomatic necrotizing pancreatitis. The study demonstrated that immediate necrosectomy significantly shortened the time to clinical success, resulting in faster reduction of necrotic collections and earlier resolution of systemic inflammation. Patients receiving immediate DEN achieved recovery approximately two weeks earlier than those managed with the conventional step-up approach. Importantly, this benefit was achieved without an increase in procedure-related adverse events, mortality, or technical failure. As expected, all patients in the immediate intervention arm underwent necrosectomy, whereas less than half of patients in the step-up group ultimately required the procedure, highlighting the trade-off between faster recovery and greater procedural utilization. The findings suggest that early removal of necrotic debris may accelerate disease resolution in appropriately selected patients while maintaining a favorable safety profile. However, because many patients managed with drainage alone avoided necrosectomy altogether, treatment decisions should remain individualized. Overall, this landmark trial provides evidence that immediate DEN after EUS-guided drainage can shorten recovery time without compromising safety. The results challenge the traditional step-up paradigm and support consideration of earlier necrosectomy in selected patients with symptomatic walled-off necrosis, while emphasizing the need to balance procedural burden against potential clinical benefit.