Enteral versus parenteral nutrition for acute pancreatitis

Background Acute pancreatitis creates a catabolic stress state promoting a systemic inflammatory response and nutritional deterioration. Adequate supply of nutrients plays an important role in recovery. Total parenteral nutrition (TPN) has been standard practice for providing exogenous nutrients to patients with severe acute pancreatitis. However, recent data suggest that enteral nutrition ( EN) is not only feasible, but safer and more effective. Therefore, we sought to update our systematic review to re-evaluate the level of evidence. Objectives To compare the effect of TPN versus EN on mortality, morbidity and length of hospital stay in patients with acute pancreatitis. Search strategy Trials were identified by computerized searches of The Cochrane Controlled Trials Register, MEDLINE, and EMBASE. Additional studies were identified by searching Scisearch, bibliographies of review articles and identified trials. The search was undertaken in August 2000 and updated in September 2002, October 2003, November 2004 and November 2008. No language restrictions were applied. Selection criteria Randomized clinical trials comparing TPN to EN in patients with acute pancreatitis. Data collection and analysis Two reviewers independently abstracted data and assessed trial quality. A standardized form was used to extract relevant data. Main results Eight trials with a total of 348 participants were included. Comparing EN to TPN for acute pancreatitis, the relative risk (RR) for death was 0.50 (95% CI 0.28 to 0.91), for multiple organ failure (MOF) was 0.55 ( 95% CI 0.37 to 0.81), for systemic infection was 0.39 ( 95% CI 0.23 to 0.65), for operative interventions was 0.44 ( 95% CI 0.29 to 0.67), for local septic complications was 0.74 ( 95% CI 0.40 to 1.35), and for other local complications was 0.70 ( 95% CI 0.43 to 1.13). Mean length of hospital stay was reduced by 2.37 days in EN vs TPN groups ( 95% CI -7.18 to 2.44). Furthermore, a subgroup analysis for EN vs TPN in patients with severe acute pancreatitis showed a RR for death of 0.18 ( 95% CI 0.06 to 0.58) and a RR for MOF of 0.46 ( 95% CI 0.16 to 1.29). Authors' conclusions In patients with acute pancreatitis, enteral nutrition significantly reduced mortality, multiple organ failure, systemic infections, and the need for operative interventions compared to those who received TPN. In addition, there was a trend towards a reduction in length of hospital stay. These data suggest that EN should be considered the standard of care for patients with acute pancreatitis requiring nutritional support.