Review: enteral or parenteral nutrition reduces risk for mortality in acute pancreatitis.

Abstract

Question In patients with acute pancreatitis, how do enteral and parenteral nutrition compare with no supplementary nutrition? Review scope Studies selected compared standard enteral or parenteral nutrition with no supplementary nutrition, or enteral nutrition with parenteral nutrition in patients with acute pancreatitis. Outcomes were infectious complications and mortality. Review methods MEDLINE, EMBASE/Excerpta Medica, Cochrane Central Register of Controlled Trials, and reference lists were searched to January 2008 for randomized controlled trials (RCTs). 15 RCTs (n =617) met the selection criteria. Main results Meta-analysis showed that parenteral nutrition reduced mortality but not infectious complications compared with no supplementary nutrition (Table). Enteral nutrition reduced infectious complications but not mortality compared with parenteral nutrition (Table). Indirect adjusted meta-analysis showed that enteral nutrition reduced mortality (relative risk [RR] 0.2, 95% CI 0.07 to 0.7) but not infectious complications (RR 0.6, CI 0.07 to 4.3) compared with no supplementary nutrition. Conclusion Enteral or parenteral nutrition reduces risk for mortality compared with no supplementary nutrition in acute pancreatitis. Comparisons of enteral nutrition (EN), parenteral nutritional (PN), and no supplementary nutrition (NSN) in acute pancreatitis* Outcomes Number of trials (n) Comparisons Weighted event rates RRR (95% CI) NNT (CI) Infectious complications 10 (430) EN vs PN 16% vs 39% 59% (43 to 70) 5 (4 to 6) Mortality 9 (404) EN vs PN 9.6% vs 16% 40% (14 to 68) Not significant 3 (113) PN vs NSN 8.2% vs 23% 64% (3 to 87) 7 (6 to 147) RRI (CI) NNH Infectious complications 2 (98) PN vs NSN 22% vs 16% 36% (82 to 940) Not significant *Abbreviations defined in Glossary. RRR, RRI, NNT, NNH, and CI calculated from control event rates and relative risks in article using a random-effects model. Commentary Over the past decade, there has been a paradigm shift in the nutritional management of patients with acute pancreatitis. Avoiding pancreatic stimulation with parenteral nutrition was considered the mainstay of treatment, but accumulating evidence shows that enteral feeding is associated with less morbidity and lower cost (1). Practice guidelines now recommend nasojejunal feeding with a semi-elemental or elemental formula as the preferred method of nutritional support (1). In the systematic review by Petrov and colleagues, enteral or parenteral feeding was associated with reduced mortality compared with no supplementary nutrition. Many of the studies analyzed, however, had small numbers of patients, few events (infections or deaths), brief follow-up, and heterogeneous patient populations (mild and severe pancreatitis). Further, 2 studies were >20 years old and do not reflect the improved outcomes that are attributed to better intensive medical care. Despite these limitations, the meta-analysis supports the role of feeding in patients with pancreatitis. The review also confirms previous analyses showing that enteral nutrition is superior to parenteral nutrition because of lower rates of complications (infection and hyperglycemia) and lower cost. The meta-analysis also highlights the need for larger RCTs to address current questions about nutritional support. These questions include the tolerability of enteral feeding, optimal timing of starting nutritional support, and whether delivery of an elemental formula to the jejunum (as opposed to simple nasogastric feeding) is necessary. An ongoing multicenter study sponsored by the National Institutes of Health is evaluating patient tolerance, safety, and efficacy of nasogastric compared with nasojejunal feeding in patients with severe acute pancreatitis (2). Until such studies are completed, this and other meta-analyses and practice guidelines recommend preferential use of nasojejunal feeding using an elemental or semi-elemental formula in patients with acute pancreatitis who are unable to eat for 5 to 7 days.