Endoscopic Versus Surgical Management for Infected Necrotizing Pancreatitis and Walled-Off Necrosis: A Systematic Review of Randomized Controlled Trials

<i>Background and Objectives</i>: Infected necrotizing pancreatitis and walled-off necrosis are associated with substantial morbidity and mortality. The evolution from open necrosectomy to minimally invasive and endoscopic strategies has improved outcomes, yet complex cases may require multimodal approaches. <i>Materials and Methods</i>: A systematic literature search was performed across PubMed, Web of Science, and Google Scholar from inception to 15 July 2024, following PRISMA 2020 guidelines. Only RCTs directly comparing endoscopic and surgical necrosectomy were included. We analyzed RCTs enrolling adults with infected necrotizing pancreatitis or symptomatic/infected walled-off necrosis, irrespective of etiology, comparing endoscopic step-up strategies with surgical or minimally invasive step-up approaches. Outcomes assessed included mortality, complications, hospital stay, long-term pancreatic function, and quality of life. <i>Results</i>: Six RCTs comprising 1045 patients were identified. Endoscopic necrosectomy demonstrated comparable mortality to surgical or minimally invasive step-up approaches (8-18% vs. 6-15%) but significantly reduced rates of pancreatic fistula (8% vs. 34%, <i>p</i> < 0.01), new-onset organ failure, and, in several studies, shortened hospital stay. Median timing of intervention ranged from 4 to 6 weeks after pancreatitis onset, although some trials reported earlier or delayed drainage, highlighting variability in clinical practice. Long-term endocrine and exocrine pancreatic function, as well as quality of life, were largely similar between techniques, although early recovery and physical functioning scores favored endoscopy in selected studies. <i>Conclusions</i>: Endoscopic necrosectomy offers a safer peri-procedural profile compared with surgical approaches, but complex or anatomically unfavorable necrosis may still require surgical intervention. Individualized multimodal management, informed by evolving evidence, represents the cornerstone of modern care for patients with infected necrotizing pancreatitis and walled-off necrosis.