2004 MacLean-Mueller prize enteral or parenteral nutrition for severe pancreatitis: a randomized controlled trial and health technology assessment

Abstract

Background: The optimal route of nutrition in severe pancreatitis is controversial. Parenteral nutrition (PN) is preferred, but enteral nutrition (EN) promises to attenuate inflammation and prevent sepsis. We hypothesized that EN was at least equivalent to PN in reducing inflammation, providing effective nutrition and being cost-effective.

Methods: We conducted a randomized controlled trial comparing PN to EN in pancreatitis in an academic, multi-institutional, tertiary care health system. We screened 728 consecutive patients. Twenty-eight patients with a Ranson's score greater than 2 who did not tolerate clear fluids 4 days after admission were randomized: 18 to PN and 10 to EN. Both groups were provided daily 105 kJ (25 kcal)/kg and 1.5 g/kg of protein, respectively, until they could tolerate a regular diet.

Results: C-reactive protein in EN patients was reduced by 50% 5 days faster than PN patients (Wilcoxon test, p = 0.09). Both groups received a similar number of kilojoules and achieved near normal prealbumin and 24-hour urinary nitrogen values. Neither regimen caused a change in cholecystokinin levels. Overall mortality was 4.9% (3 patients in the PN group). In 5 patients (4 PN, 1 EN) there were infected pancreatic collections. Nine EN patients dislodged the nasojejunal tube. EN had an average cost of dollar 1375 per patient compared with dollar 2608 for PN (p = 0.08). After sensitivity analysis, EN cost dollar 957 compared with dollar 2608 for PN (p = 0.03).

Conclusions: EN or PN is safe and provides adequate nutrition in severe pancreatitis. EN shows a trend toward faster attenuation of inflammation, with fewer septic complications and is the dominant therapy in terms of cost-effectiveness. This study favours EN for nutritional support in severe pancreatitis.

Figures

FIG. 1. Therapeutic intervention. After randomization, patients are to receive, daily, either parenteral nutrition (PN) or enteral nutrition (EN) at 105 kJ/kg and 1.5 g protein/kg. Failures are denoted by PN cholestasis, intolerance of nasojejunal tube and inability to deliver adequate energy. Nutrition is tapered as oral intake is increased. CHO = carbohyrdates, DAT = diet as tolerated, FF = full fluids, EGD = esophagogastroduodenoscopy, NJ = nasojejunal tube, PICC = percutaneous intravenous central catheter, PPN = peripheral parenteral nutrition, VHP = very high protein.

FIG. 2. Overall results: the progress of the 728 patients assessed for eligibility and screened to reach the 28 patients randomized and followed up in the study. EN = enteral nutrition, ERCP = endoscopic retrograde cholangiopancreatography, PN = parenteral nutrition.