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Research Article
A Meta-Analysis of Enteral Nutrition and Total Parenteral
Nutrition in Patients with Acute Pancreatitis
Heming Quan, Xingpeng Wang, and Chuanyong Guo
Department of Gastroenterology, Tenth Peoples Hospital, Tongji University, Shanghai 200072, China
Correspondence should be addressed to Chuanyong Guo, guochuanyong@hotmail.com
Received 20 February 2011; Accepted 28 March 2011
Academic Editor: Michel Kahaleh
Copyright 2011 Heming Quan et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objective. To analyze the eect of total parenteral nutrition (TPN) and enteral nutrition (EN) in patients with acute pancreatitis.
Methods. Randomized controlled trials of TPN and EN in patients with acute pancreatitis were searched in NCBI and CBM
databases and The Cochrane Controlled Trials Register. Six studies were enrolled into the analysis, and the details about the
trial designs, characters of the subjects, results of the studies were reviewed by two independent authors and analyzed by STATA
11.0 software. Results. Compared with TPN, EN was associated with a significantly lower incidence of pancreatic infection
complications (RR = 0.556, 95% CI 0.4360.709, P = .000), MOF (RR = 0.395, 95% CI 0.2720.573, P = .003), surgical
interventions (RR = 0.556, 95% CI 0.4360.709, P = .000), and mortality (RR = 0.426, 95% CI 0.2380.764, P = .167). There
was no statistic significance in non-pancreatitis-related complications (RR = 0.853, 95% CI 0.4901.483, P = .017). However,
EN had a significantly higher incidence of non-infection-related complications (RR = 2.697, 95% CI 1.9473.735, P = .994).
Conclusion. EN could be the preferred nutrition feeding method in patients with acute pancreatitis.
1. Introduction
Acute pancreatitis is an inflammatory process that presents
dierent severity degrees, ranging from a mild self-limited
disease, with interstitial edema in the pancreas, to a severe
disease with extensive necrosis [1]. Severe AP with its related
systemic inflammatory response (SIR) causes increased
metabolic demands and may progress to multiorgan disease
(MOD). Cigarette smoking is an independent risk factor
for AP (95% confidence interval 1.48 to 3.09) and total
exposure correlates with overall risk [2]. Recurrent attacks
of alcoholic AP, however, were not associated with cigarette
smoking [3] but occurred less frequently in those who
had repeated 6-month counselling sessions (to encourage
sobriety) compared with a single session (8% versus 21%,
P = .042) [4]. These data reinforce the common sense
approach of encouraging drinking cessation.
The clinical course of an attack of AP varies from a short
period of hospitalization with supportive care to prolonged
hospitalization and admittance to an intensive care unit
(ICU) because of the development of systemic inflammatory
response syndrome (SIRS), multiorgan failure (MOF), and
2
Many high-quality studies have demonstrated that EN
results in clinically relevant and statistically significant risk
reduction of infectious complications, pancreatic infections,
and mortality in patients with predicted severe acute pancreatitis. EN has also been shown to be beneficial as an
adjunct to the management of severe acute pancreatitis by
obviating the systemic inflammatory response syndrome
and in modifying the course of the disease. On the other
hand, TPN has a deleterious eect on the intestinal barrier
function. Studies performed on animals and human beings
show that TPN may worsen intestinal atrophy and intestinal
and systemic immunity, and thereby it may also contribute
to impair the intestinal mucosa permeability and facilitate
bacterial translocation [1]. The protective role of EN,
compared with parenteral nutritional (PN), in maintaining
the integrity of the gut barrier has been demonstrated in a
rat model of acute pancreatitis. The EN group was found
to have significantly less bacterial translocation and a lower
blood endotoxin level than the PN group.
Data of randomized controlled trials have compared the
eect of TEN and TPN. But the results are always not the
same and the eect of therapeutics is still not identified
because of the small sample sizes. Here, we conducted metaanalysis comparing enteral nutrition with parenteral nutrition to determine the incidence of complications associated
with these dierent routes of nutritional support [18].
3. Results
Of 138 articles screened, 9 RCTs comparing EN and TPN
were identified. Only 6 RCTs [20, 2226] fulfilled the criteria
in the meta-analysis. 6 RCTs were included because: (1) an
Acute Physiology and Chronic Health Evaluation (APACHE
II) score 8; (2) trial group received TEN and control
group received TPN; (3) eective ends include one of
pancreatitis-related complications, non-pancreatitis-related
complications, non-infection-related complications, surgery
intervention, multiple-organ failure (MOF), and mortality.
Five of the six studies are high-quality studies [21]. Random
generation: two studies were opaque envelopes, one study
was odd/even numbers, and two studies were computerized
3
Table 1
(a) Study characteristics of the included trials
Authors
Years
Country
Age (EN/PN)
Louie [23]
Petrov [25]
Gunilla [24]
Casas [26]
Doley [20]
Wu [22]
2005
2006
2006
2007
2009
2010
UK
Russia
Sweden
Spain
India
China
10/18
35/34
24/26
11/11
25/25
53/54
11.8/12.7
12/12.5
10/9
>8
>8
14/16
65.3/59.0
51/52
71/68
61.2/55.6
38.4/41.1
52/54
Gender (EN/PN)
Male
Female
6/9
4/9
27/24
8/10
10/14
14/12
8/8
3/3
32/21
30/24
Authors
Years
Louie
Petrov
Gunilla
Casas
Doley
Wu
2005
2006
2006
2007
2009
2010
Others
3/7
8/6
7/5
6/0
4/4
Years
Louie
2005
Petrov
Gunilla
Casas
Doley
Wu
2006
2006
2007
2009
2010
Randomized method
3-center, computer-generated assignment placed in sealed, opaque
envelopes
Computerized random number generation
Single-center, sealed, numbered envelopes
Computerized random number generation
Odd/even numbers
Not mentioned
Blind
Exit/lost to followup
Jadad scores
No
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
3
3
3
3
2
Authors
Years
No. Patients
(EN/PN)
Louie
Petrov
Gunilla
Casas
Doley
Wu
2005
2006
2006
2007
2009
2010
10/18
35/34
24/26
11/11
25/25
53/54
Pancreatitis-related
complications
(EN/PN)
3/9
14/32
9/4
1/5
16/15
12/39
Non-pancreatitisrelated complications
(EN/PN)
0/3
4/11
12/7
Non-infection-related
complications
(EN/PN)
6/4
15/6
17/7
41/15
Hospital stay
(EN/PN)
30.2/30.7
42/36
27/16
Surgery intervention
(EN/PN)
0/3
21/21
12/43
(b)
Authors
Years
MOF (EN/PN)
Mortality (EN/PN)
Louie
Petrov
Gunilla
Casas
Doley
Wu
2005
2006
2006
2007
2009
2010
7/13
7/17
1/1
0/2
8/35
0/3
1/0
0/2
5/4
6/23
random number generation. Blind: all patients were randomized to receive either enteral or parenteral feeding, so
none of the studies was blind. Baseline characteristics: all
of the six studies reported the baseline characteristics of
the two groups, four of which performed statistics analysis.
The results indicated that the baseline demographic and
clinical characteristics of the two groups were similar. No
significant dierences were found between the two groups
of patients. Loss of followup: all patients in the six studies
were hospitalized and followed up during the study. No
patients were failed to be followed up. Intention-to-treat
analysis and compliance analysis are almost coincident.
These characteristics are presented in Figure 1.
3.1. Pancreatitis-Related Complications. All studies reported
pancreatitis-related complications, including pancreatic
infection, pancreatic abscess, and pancreatic necrosis, not
including infections out of pancreas. By M-H analysis, there
was a significantly lower risk of infection in patients who
received enteral nutrition compared to those who received
parenteral nutrition (relative risk of 0.556, 95% confidence
interval 0.436 to 0.709, P = .000, Figure 2). The test result
for heterogeneity between the studies was not significant
(P = .13006252).
3.2. Non-Pancreatitis-Related Complications. All studies
reported non-pancreatitis-related complications, including
pneumonia, urinary system infection, and central venous
catheter infection. By M-H analysis, there was no statistic
significance in non-pancreatitis-related complications in
patients who received enteral nutrition compared to those
who received parenteral nutrition (relative risk of 0.853,
95% confidence interval 0.490 to 1.483, P = .017, Figure 3).
The test result for heterogeneity between the studies was not
significant (P = .826279278).
Study
ID
RR (95% CI)
Weight
Petrov 2006
Gunilla E 2006
Doley 2009
Xing-Mao Wu 2010
Casas 2007
Louie 2005
Overall (I-squared
= 79.3%, P =.000)
10
Figure 2
Study
ID
RR (95% CI)
Weight
Study
ID
RR (95% CI)
Petrov 2006
Petrov 2006
0.35 (0.12, 1)
54.98
Gunilla E 2006
32.38
Gunilla E 2006
Xing-Mao Wu 2010
Louie 2005
12.65
Casas 2007
Overall (I-squared =
75.4%, P = .017)
0.1
100
Louie 2005
Overall (I-squared =
74.6%, P = .003)
10
26.68
1.45
53.64
3.87
0.1
Figure 3
Weight
14.36
100
10
Figure 5
Study
%
%
Study
ID
Petrov 2006
Gunilla E 2006
Xing-Mao Wu 2010
63.49
5.22
100
Overall (I-squared =
0%, P = .994)
Overall (I-squared
94.6%, P =.000)
0.1
10
10
Figure 6
Figure 4
31.3
Casas 2007
Weight
Xing-Mao Wu 2010
1 (0.79, 1.27)
Doley 2009
Louie 2005
0.1
RR (95% CI)
4. Discussion
This meta-analysis shows that EN, compared with PN, has
important beneficial eects in patients with predicted severe
acute pancreatitis, notably, clinically relevant, and statistically significant risk reduction in pancreatitis-related complications, non-pancreatitis-related complications, multipleorgan failure (MOF), surgery intervention, and mortality.
But PN is superior to EN in non-infection-related complications. There is no dierence between EN and PN in hospital
stay. The literatures included in this meta-analysis, except
for Wu, are all high-quality randomized controlled trials
with Jadad score more than three and summarizing the best
available evidence-based data. The statistic characterizations
of the population and the inclusion/exclusion criteria of
Author
Year
EN regimen
A semielemental product with low fat content was infused at 25 mL/h and
increased by 10 mL/h every 6 hours, until the target rate was achieved
Semielemental nutrition was commenced at a rate of 25 mL/h and increased
by 10 mL/h every 6 h, until the desired caloric intake was reached
Semielemental nutrition rate was 25 mL/hr and gradually increased daily up
to 100 mL/hr if tolerated and needed. The aim was to reach full nutrition
within 72 hours
Polymeric diet infusion rate was 25 mL/h with increases of 25 mL/4 h until
requirements were reached
Louie
2005
Petrov
2006
Gunilla
2006
Casas
2007
Doley
2009
Not mentioned
Within 72 h
Wu
2010
Within 24 h
Study
ID
Gunilla E 2006
Doley 2009
Xing-Mao Wu 2010
Casas 2007
Louie 2005
Overall (I-squared =
1.46
38.2%, P = .167)
0.1
10
Figure 7
Initial time
Lasting time
Within 24 h
10 days
Within 48 h
More than 7
days
Within 24 h
10 days
Within 72 h
More than 10
days
More than 14
days
16 days
5. Disadvantages
We did not perform sensitivity analysis because there is
only on paper with the Jadad score less than two. But there
are still many disadvantages in this meta-analysis. First,
the population included in the study is small. Second, in
Gunillas study, the nutritional support way was nasogastric
feeding tube. One new meta-analysis compared nasogastric
feeding tube and nasojejunal feeding tube and showed that
there was no dierence between the two ways in mortality,
hospital stay, infection-related complications, and costs [41].
Third, the total number of patients enrolled was limited (n =
335), which may lead to wide CI. Fourth, it is possible that
studies with negative results, which showed no trend in favor
of either intervention, may remain unpublished, leading to
publication bias.
7
Taken together, this meta-analysis confirmed previous
reports in the literature, especially those from recent years.
This study demonstrated that enteral nutritional support
is safe and eective when compared to parenteral support.
Compared with TPN, EN was associated with a significantly
lower incidence of pancreatic infection complications (RR =
0.556, 95% CI 0.4360.709, P = .000), MOF (RR = 0.395,
95% CI 0.2720.573, P = .003), surgical interventions (RR =
0.556, 95% CI 0.4360.709, P = .000), and mortality (RR =
0.426, 95% CI 0.2380.764, P = .167). There was no statistic
significance in non-pancreatitis-related complications (RR
= 0.853, 95% CI 0.4901.483, P = .017). However, EN
had a significantly higher incidence of non-infection-related
complications (RR = 2.697, 95% CI 1.9473.735, P = .994).
There was no significant dierence in hospital stay between
patients with TPN and EN. However, a deficiency of this
study is its retrospective nature and relatively small sample
size. Therefore, studies with larger sample sizes should be
done to better define the role of enteral nutritional support
in the treatment of severe acute pancreatitis.
Acknowledgment
This work was funded by grants from Shanghai Shen
Kang Hospital Management Centermunicipal hospital joint research projects leading-edge technology (no.
SHDC12010111).
References
[1] J. T. Modena, L. B. Cevasco, C. A. Basto, A. O. Vicuna, and
M. P. Ramrez, Total enteral nutrition as prophylactic therapy
for pancreatic necrosis infection in severe acute pancreatitis,
Pancreatology, vol. 6, no. 1-2, pp. 5864, 2006.
[2] B. Lindkvist, S. Appelros, J. Manjer, G. Berglund, and A.
Borgstrom, A prospective cohort study of smoking in acute
pancreatitis, Pancreatology, vol. 8, no. 1, pp. 6370, 2008.
[3] H. Pelli, R. Lappalainen-Lehto, A. Piironen, J. Sand, and I.
Nordback, Risk factors for recurrent acute alcohol-associated
pancreatitis: a prospective analysis, Scandinavian Journal of
Gastroenterology, vol. 43, no. 5, pp. 614621, 2008.
[4] I. Nordback, H. Pelli, R. Lappalainen-Lehto, S. Jarvinen, S.
Raty, and J. Sand, The recurrence of acute alcohol-associated
pancreatitis can be reduced: a randomized controlled trial,
Gastroenterology, vol. 136, no. 3, pp. 848855, 2009.
[5] M. C. Winsler, C. Hall., N. J. M. London, and J. P. Neoptolemus, Relationship of diagnostic serum amylase to aetiology
and prognosis in acute pancreatitis, Gut, vol. 33, pp. 982986,
1992.
[6] E. L. Bradley, Indications for surgery in necrotizing
pancreatitisa millineal review, Journal of the Pancreas, vol.
1, no. 1, pp. 13, 2000.
[7] S. W. Ashley, A. Perez, E. A. Pierce et al., Necrotizing
pancreatitis, Annals of Surgery, vol. 234, no. 4, pp. 572580,
2001.
[8] M. W. Buchler, B. Gloor, C. A. Muller, H. Friess, C. A.
Seiler, and W. Uhl, Acute necrotizing pancreatitis: treatment
strategy according to th status of infection, Annals of Surgery,
vol. 232, no. 5, pp. 619622, 2000.
8
[9] J. Slavin, P. Ghaneh, R. Sutton et al., Management of
necrotizing pancreatitis, World Journal of Gastroenterology,
vol. 7, no. 4, pp. 476481, 2001.
[10] R. Flint, J. Windsor, and M. Bonham, Trends in the
management of severe acute pancreatitis: interventions and
outcome, ANZ Journal of Surgery, vol. 74, no. 5, pp. 335342,
2004.
[11] D. Karsenti, P. Bourlier, E. Dorval et al., Morbidity and
mortality of acute pancreatitis. Prospective study in a French
university hospital, Presse Medicale, vol. 31, no. 16, pp. 727
734, 2002.
[12] D. Fenton-Lee and C. W. Imrie, Pancreatic necrosis: assessment of outcome related to quality of life and cost of
management, British Journal of Surgery, vol. 80, no. 12, pp.
15791582, 1993.
[13] B.W. M. Spanier, M. J. Bruno, and E. M. H. MathusVliegen, Enteral nutrition and acute pancreatitis: a review,
Gastroenterology Research and Practice, vol. 2011, pp. 1155
1153, 2010.
[14] R. F. Meier and C. Beglinger, Nutrition in pancreatic
diseases, Best Practice and Research: Clinical Gastroenterology,
vol. 20, no. 3, pp. 507529, 2006.
[15] R. Meier, J. Ockenga, M. Pertkiewicz et al., ESPEN guidelines
on enteral nutrition: pancreas, Clinical Nutrition, vol. 25, no.
2, pp. 275284, 2006.
[16] S. J. OKeefe and S. A. McClave, Feeding the injured
pancreas, Gastroenterology, vol. 129, no. 3, pp. 11291130,
2005.
[17] Y. Cao, Y. Xu, T. Lu, F. Gao, and Z. Mo, Meta-analysis of
enteral nutrition versus total parenteral nutrition in patients
with severe acute pancreatitis, Annals of Nutrition and
Metabolism, vol. 53, no. 3-4, pp. 268275, 2009.
[18] M. S. Petrov, H. C. Van Santvoort, M. G. H. Besselink, G. J.
M. G. Van Der Heijden, J. A. Windsor, and H. G. Gooszen,
Enteral nutrition and the risk of mortality and infectious
complications in patients with severe acute pancreatitis: a
meta-analysis of randomized trials, Archives of Surgery, vol.
143, no. 11, pp. 11111117, 2008.
[19] M. Al-Omran, A. Groof, and D. Wilke, Enteral versus
parenteral nutrition for acute pancreatitis, Cochrane Database
of Systematic Reviews, no. 1, Article ID CD002837, 2003.
[20] R. P. Doley, T. D. Yadav, J. D. Wig et al., Enteral nutrition in
severe acute pancreatitis, Journal of the Pancreas, vol. 10, no.
2, pp. 157162, 2009.
[21] P. E. Marik and G. P. Zaloga, Meta-analysis of parenteralnutrition versus enteral nutrition in patients with acute
pancreatitis, British Medical Journal, vol. 328, no. 7453, pp.
14071410, 2004.
[22] X. M. Wu, K. Q. Ji, H. Y. Wang, G. F. Li, B. Zang, and W.
M. Chen, Total enteral nutrition in prevention of pancreatic
necrotic infection in severe acute pancreatitis, Pancreas, vol.
39, no. 2, pp. 248251, 2010.
[23] B. E. Louie, T. Noseworthy, D. Hailey, L. M. Gramlich, P.
Jacobs, and G. L. Warnock, 2004 MacLean-Mueller Prize
Enteral or parenteral nutrition for severe pancreatitis: a randomized controlled trial and health technology assessment,
Canadian Journal of Surgery, vol. 48, no. 4, pp. 298306, 2005.
[24] G. E. Eckerwall, J. B. Axelsson, and R. G. Andersson, Early
nasogastric feeding in predicted severe acute pancreatitis: a
clinical, randomized study, Annals of Surgery, vol. 244, no. 6,
pp. 959965, 2006.