Early Versus Delayed Enteral Feeding in Predicted Severe Acute Gallstone Pancreatitis: A Retrospective Study

Abstract

BackgroundThe optimal timing of enteral nutrition (EN) initiation in predicted severe acute gallstone pancreatitis (SAGP) and its influence on disease outcomes are not well known.MethodsWe conducted a retrospective study of patients with predicted SAGP treated with endoscopic retrograde cholangiopancreatography and EN. The patients were classified into two groups according to the timing of EN initiation after admission: within 48 h, and more than 48 h. The primary outcome was in-hospital mortality. The secondary outcomes were length of hospital stay, need for intensive care admission, need for surgical intervention, improvements in blood test results after 7-10 days of EN, incidence of pancreatic necrosis and infection, and hospital care costs. The microbiological profiles of infectious complications were also evaluated.ResultsOf the 98 patients, 31 and 67 started EN within 48 h, and more than 48 h after admission, respectively. Early EN was associated with a decrease in in-hospital mortality (0 vs. 11.9%; p=0.045), length of hospital stay (median:18 vs. 27 days; p=0.001), need for intensive care admission (3.2% vs. 20.9%; p=0.032), and hospital care costs (median:9,289 vs. 13,518 US$; p=0.007), compared to delayed EN. Moreover, early EN for 7-10 days had more beneficial effects on blood test results than delayed EN, including total protein (p=0.03) and CRP (p=0.006) levels. However, the need for surgical intervention and incidence of pancreatic necrosis did not differ between the two groups. In our study, Gram-negative bacteria were the main responsible pathogens (50.5%). Infection with multidrug-resistant organisms (MDRO) was found in 19.4% of the patients. The most common MDRO was MDR Enterococcus faecium. Early EN was not superior in reducing incidence of infected pancreatic necrosis, bacteremia, polymicrobial infection, or MDROs.ConclusionsIn patients with predicted SAGP, early EN is associated with a decrease in in-hospital mortality, length of hospital stay, need of intensive care admission, and hospital care costs, compared to delayed EN. There are no significant benefits of early EN in reducing the rate of infection-related complications. Further studies with larger sample sizes are warranted.

Nutrition therapy in critically ill patients with severe acute pancreatitis

“…Wereszczynska-Siemiatkowska's retrospective analysis confirmed that EN started after 48 h was associated with worse clinical outcomes (higher mortality and incidence of organ dysfunction) compared with EN started within 48 h. 18 Another study also showed that EN initiation within 48 h was associated with decreased in-hospital mortality and length of hospital stay compared with delayed EN (>48 h) in predicted severe acute gallstone pancreatitis. 19 In 2010, a retrospective investigation performed by Hegazi and colleagues found that the time to start jejunal feeding was much longer in nonsurvivors than in survivors (17 vs 7 days). 20 Because of the retrospective nature of the study, "survivor bias" can not be ruled out, because survivors may simply better tolerate EN feeding.…”