Enteral nutrition within 48 hours of admission improves clinical outcomes of acute pancreatitis by reducing complications: a meta-analysis

Jie-Yao Li, Tao Yu, Guang-Cheng Chen, Yu-Hong Yuan, Wa Zhong, Li-Na Zhao, Qi-Kui Chen, Jie-Yao Li, Tao Yu, Guang-Cheng Chen, Yu-Hong Yuan, Wa Zhong, Li-Na Zhao, Qi-Kui Chen

Abstract

Background: Enteral nutrition is increasingly advocated in the treatment of acute pancreatitis, but its timing is still controversial. The aim of this meta-analysis was to find out the feasibility of early enteral nutrition within 48 hours of admission and its possible advantages.

Methods and findings: We searched PubMed, EMBASE Databases, Web of Science, the Cochrane library, and scholar.google.com for all the relevant articles about the effect of enteral nutrition initiated within 48 hours of admission on the clinical outcomes of acute pancreatitis from inception to December 2012. Eleven studies containing 775 patients with acute pancreatitis were analyzed. Results from a pooled analysis of all the studies demonstrated that early enteral nutrition was associated with significant reductions in all the infections as a whole (OR 0.38; 95%CI 0.21-0.68, P<0.05), in catheter-related septic complications (OR 0.26; 95%CI 0.11-0.58, P<0.05), in pancreatic infection (OR 0.49; 95%CI 0.31-0.78, P<0.05), in hyperglycemia (OR 0.24; 95%CI 0.11-0.52, P<0.05), in the length of hospitalization (mean difference -2.18; 95%CI -3.48-(-0.87); P<0.05), and in mortality (OR 0.31; 95%CI 0.14-0.71, P<0.05), but no difference was found in pulmonary complications (P>0.05). The stratified analysis based on the severity of disease revealed that, even in predicted severe or severe acute pancreatitis patients, early enteral nutrition still showed a protective power against all the infection complications as a whole, catheter-related septic complications, pancreatic infection complications, and organ failure that was only reported in the severe attack of the disease (all P<0.05).

Conclusion: Enteral nutrition within 48 hours of admission is feasible and improves the clinical outcomes in acute pancreatitis as well as in predicted severe or severe acute pancreatitis by reducing complications.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1. Flow chart of literature search…
Figure 1. Flow chart of literature search for meta-analysis.
Figure 2. Effect of early EN on…
Figure 2. Effect of early EN on all the infection complications of AP as a whole.
(A) Forest plot (Random-effect model) showing the effect of early EN on all the infection complications of AP as a whole and the sensitivity analysis subtotaling the plots by RCTs vs. retrospective studies. (B) Forest plot (Random-effect model) of the stratified study conducted based on the severity of AP.
Figure 3. Effect of early EN on…
Figure 3. Effect of early EN on catheter-related septic complications of AP.
(A) Forest plot (Fixed-effect model) showing the effect of early EN on catheter-related septic complications of AP and the sensitivity analysis subtotaling the plots by RCTs vs. retrospective studies. (B) Forest plot (Fixed-effect model) of the stratified study conducted based on the severity of AP.
Figure 4. Effect of early EN on…
Figure 4. Effect of early EN on pancreatic infection complications of AP.
(A) Forest plot (Fixed-effect model) showing the effect of early EN on pancreatic infection complications of AP and the sensitivity analysis subtotaling the plots by RCTs vs. retrospective studies. (B) Forest plot (Fixed-effect model) of a selection of five articles recruiting patients of pSAP or SAP.
Figure 5. Forest plot showing the effect…
Figure 5. Forest plot showing the effect of early EN on the incidence of hyperglycemia in AP.
Fixed-effect model was applied.
Figure 6. Forest plot showing the effect…
Figure 6. Forest plot showing the effect of early EN on the OF rate in AP.
All the patients with OF were classified as pSAP or SAP previously. Fixed-effect model was applied and the sensitivity analysis subtotaling the plots by RCTs vs. retrospective studies was conducted.
Figure 7. Forest plot showing the effect…
Figure 7. Forest plot showing the effect of early EN on the LOH in AP.
Fixed-effect model was applied and the sensitivity analysis subtotaling the plots by RCTs vs. retrospective studies was conducted.
Figure 8. Forest plot showing the effect…
Figure 8. Forest plot showing the effect of early EN on the mortality in AP.
Fixed-effect model was applied and sensitivity analysis subtotaling the plots by RCTs vs. retrospective studies was conducted.

References

    1. Pezzilli R, Uomo G, Zerbi A, Gabbrielli A, Frulloni L, et al. (2008) Diagnosis and treatment of acute pancreatitis: the position statement of the Italian Association for the study of the pancreas. Dig Liver Dis 40: 803–808.
    1. Petrov MS, Shanbhag S, Chakraborty M, Phillips AP, Windsor JA (2010) Organ failure and infection of pancreatitis necrosis as determinants of mortality in patients with aucte pancreatitis. Gastroenterology 39: 813–820.
    1. Ammori BJ, Fitzgerald P, Hawkey P, McMahon MJ (2003) The early increase in intestinal permeability and systemic endotoxin exposure in patients with severe acute pancreatitis is not associated with systemic bacterial translocation: molecular investigation of microbial DNA in the blood. Pancreas 26: 18–22.
    1. Balzan S, de Almeida Quadros C, de Cleva R, Zilberstein B, Cecconello I (2007) Bacterial translocation: overview of mechanisms and clinical impact. J Gastroenterol Hepatol 22: 464–471.
    1. Foitzik T, Mithöfer K, Ferraro MJ, Fernández-del Castillo C, Lewandrowski KB, et al. (1994) Time course of bacterial infection of the pancreas and its relation to disease severity in a rodent model of acute necrotizing pancreatitis. Ann Surg Aug 220: 193–198.
    1. Sax HC, Warner BW, Talamini MA, Hamilton FN, Bell RH Jr, et al. (1987) Early total parenteral nutrition in acute pancreatitis: lack of beneficial effects. Am J Surg 153: 117–124.
    1. Al-Omran M, Albalawi ZH, Tashkandi MF, Al-Ansary LA (2010) Enteral versus parenteral nutrition for acute pancreatitis. Cochrane Database Syst Rev 20: CD002837.
    1. Feng Y, McDunn JE, Teitelbaum DH (2010) Decreased phospho-Akt signaling in a mouse model of total parenteral nutrition: a potential mechanism for the development of intestinal mucosal atrophy. Am J Physiol Gastrointest Liver Physiol 298: G833–G841.
    1. Chen J, Wang XP, Liu P, Wu K, Xu M, et al. (2004) Effects of continuous early enteral nutrition on the gut barrier function in dogs with acute necrotizing pancreatitis. Zhonghua Yi Xue Za Zhi 84: 1726–1731.
    1. Xu CF, Huang XX, Shen YZ, Wang XP, Gong L, et al. (2011) The effects of enteral nutrition versus total parenteral nutrition on gut barrier function in severe acute pancreatitis. Zhonghua Nei Ke Za Zhi 50: 370–373.
    1. Ong JP, Fock KM (2012) Nutritional support in acute pancreatitis. J Dig Dis 13: 445–452.
    1. Qin HL, Su ZD, Gao Q, Lin QT (2002) Early intrajejunal nutrition: bacterial translocation and gut barrier function of severe acute pancreatitis in dogs. Hepatobiliary Pancreat Dis Int 1: 150–154.
    1. Cao Y, Xu Y, Lu T, Gao F, Mo Z (2008) Meta-analysis of enteral nutrition versus total parenteral nutrition in patients with severe acute pancreatitis. Ann Nutr Metab 53: 268–275.
    1. Hajdú N, Belágyi T, Issekutz A, Bartek P, Gartner B, et al. (2012) Intravenous glutamine and early nasojejunal nutrition in severe acute pancreatitis – a prospective randomized clinical study. Magy Seb 65: 44–51.
    1. Hegazi R, Raina A, Graham T, Rolniak S, Centa P, et al. (2011) Early jejunal feeding initiation and clinical outcomes in patients with severe acute pancreatitis. JPEN J Parenter Enteral Nutr 35: 91–96.
    1. Casas M, Mora J, Fort E, Aracil C, Busquets D, et al. (2007) Total enteral nutrition vs. total parenteral nutrition in patients with severe acute pancreatitis. Rev Esp Enferm Dig 99: 264–269.
    1. Higgins J, Altman D (2008) Assessing risk of bias in included studies. Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.0. The Cochrane Collaboration. Available: ?. Accessed 2008.
    1. Bakker OJ, van Santvoort HC, van Brunschot S, Ahmed Ali U, Besselink MG, et al. (2011) Pancreatitis, very early compared with normal start of enteral feeding (PYTHON trial): design and rationale of a randomized controlled multicenter trial. Trials 12: 73.
    1. Petrov MS, Phillips A, Windsor JA (2012) Early nasogastric tube feeding versus nil-by-mouth in patients with mild and moderate acute pancreatitis: a randomized controlled trial. Gastroenterology 142: S94.
    1. Wu DC, Ding YB, Deng B, Xiao WM, Wu J, et al... (2008) Clinical case-control study of early enteral nutrition through three lumen gastrojejunal tube in severe acute pancreatitis. Parenteral & Enteral Nutrition 15: 285–287, 91.
    1. Petrov MS, Kukosh MV, Emelyanov NV (2006) A randomized controlled trial of enteral versus parenteral feeding in patients with predicted severe acute pancreatitis shows a significant reduction in mortality and in infected pancreatic complications with total enteral nutrition. Dig Surg 23: 336–344; discussion 344–345.
    1. Eckerwall GE, Axelsson JB, Andersson RG (2006) Early nasogastric feeding in predicted severe acute pancreatitis: a clinical, randomized study. Ann Surg 244: 959–965.
    1. Gupta R, Patel K, Calder PC, Yaqoob P, Primrose JN, et al. (2003) A randomised clinical trial to assess the effect of total enteral and total parenteral nutritional support on metabolic, inflammatory and oxidative markers in patients with predicted severe acute pancreatitis (APACHE II> or = 6). Pancreatology 3: 406–413.
    1. Oláh A, Pardavi G, Belágyi T, Nagy A, Issekutz A, et al. (2002) Early nasojejunal feeding in acute pancreatitis is associated with a lower complication rate. Nutrition 18: 259–262.
    1. Qin HL, Zheng JJ, Tong DN, Chen WX, Fan XB, et al. (2008) Effect of Lactobacillus Plantarum enteral feeding on the gut permeability and septic complications in the patients with acute pancreatitis. Eur J Clin Nutr 62: 923–930.
    1. Bakker OJ, van Santvoort HC, Besselink MG, Fischer K, Pollen TL, et al. (2009) Timing of enteral nutrition in patients with predicted severe acute pancreatitis: an early start is associated with a reduction in bacteremia. Gastroenterology 136: A75–A76.
    1. McClave SA, Greene LM, Snider HL, Makk LJ, Cheadle WG, et al. (1997) Comparison of the safety of early enteral vs. parenteral nutrition in mild acute pancreatitis. JPEN J Parenter Enteral Nutr 21: 14–20.
    1. Kalfarentzos F, Kehagias J, Mead N, Kokkinis K, Gogos CA (1997) Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial. Br J Surg 84: 1665–1669.
    1. Oláh A, Pardavi G, Varga GY, Rácz I (1996) Effect of early jejunal feeding on septic complications in acute pancreatitis. A prospect randomized study. Nutrition 12: 580.
    1. Vieira JP, Araújo GF, Azevedo JR, Goldenberg A, Linhares MM (2010) Parenteral nutrition versus enteral nutrition in severe acute pancreatitis. Acta Cir Bras 25: 449–454.
    1. Mirtallo JM, Forbes A, McClave SA, Jensen GL, Waitzberg DL, et al. (2012) International Consensus Guideline Committee Pancreatitis Task Force. International consensus guidelines for nutrition therapy in pancreatitis. JPEN J Parenter Enteral Nutr 36: 284–291.
    1. Bordejé Laguna L, Lorencio Cárdenas C (2011) Acosta Escribano J; Metabolism and Nutrition Working Group of the Spanish Society of Intensive Care Medicine and Coronary units (2011) Guidelines for specialized nutritional and metabolic support in the critically ill-Patient: update. Consensus SEMICYUC-SENPE: severe acute pancreatitis. Nutr Hosp 26 Suppl 232–36.
    1. ASPEN Board of Directors, the Clinical Guidelines Task Force (2002) Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr 26 Suppl 11SA–138SA.
    1. Abou-Assi S, Craig K, O'Keefe SJ (2002) Hypocaloric fejunal feeding is better than total parenteral nutrition in acute pancreatitis: results of a randomized comparative study. Am J Gastroenterol 97: 2255–2262.
    1. Fritz S, Hackert T, Hartwig W, Rossmanith F, Strobel O, et al. (2010) Bacterial translocation and infected pancreatic necrosis in acute necrotizing pancreatitis derives from small bowel rather than from colon. Am J Surg 200: 111–117.
    1. Pupelis G, Selga G, Austrums E, Kaminski A (2001) Jejunal feeding, even when instituted late, improves outcomes in patients with severe pancreatitis and peritonitis. Nutrition 17: 91–94.
    1. Koh YY, Jeon WK, Cho YK, Kim HJ, Chung WG, et al. (2012) The effect of intestinal permeability and endotoxemia on the prognosis of acute pancreatitis. Gut Liver 6: 505–511.
    1. Capurso G, Zerboni G, Signoretti M, Valente R, Stigliano S, et al. (2012) Role of the gut barrier in acute pancreatitis. J Clin Gastroentereol 46 Suppl: S46–S51
    1. Qin HL, Su ZD, Hu LG, Ding ZX, Lin QT (2002) Effect of early intrajejunal nutrition on pancreatic pathological features and gut barrier function in dogs with acute pancreatitis. Clin Nutr 21: 469–473.
    1. Ammori BJ (2003) Role of the gut in the course of severe acute pancreatitis. Pancreas 26: 122–129.
    1. Petrov MS, Pylypchuk RD, Uchugina AF (2009) A systematic review on the timing of artificial nutrition in acute pancreatitis. Br J Nutr 101: 787–793.
    1. Elder AS, Saccone GT, Dixon DL (2012) Lung injury in acute pancreatitis: mechanisms underlying augmented secondary injury. Pancreatology 12: 49–56.
    1. Yubero S, Manso MA, Ramudo L, Vicente S, De Dios I (2012) Dexamethasone down-regulates the inflammatory mediators but fails to reduce the tissue injury in the lung of acute pancreatitis rat models. Pulm Pharmacol Ther 25: 319–324.
    1. Mikaeili H, Yazdchi M, Barazandeh F, Ansarin K (2012) Euglycemic state reduces the incidence of rritical illness polyneuropathy and duration of ventilator dependency in medical intensive care unit. Bratisl Lek Listy 113: 616–619.
    1. Jacobi J, Bircher N, Krinsley J, Agus M, Braithwaite SS, et al. (2012) Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med 40: 3251–3276.

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren