Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: Results of a randomized prospective trial

Kalfarentzos, Fotis; Kehagias, J.; Mead, Nancy; Kokkinis, K.; Gogos, Charalambos

doi:10.1002/bjs.1800841207

Cited by 441 publications

(165 citation statements)

References 25 publications

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“…No problems 166 (36) 172 (37) Slight problems 93 (20) 90 (19) Moderate problems 114 (24) 99 (21) Severe problems 65 (20) 80 (17) Extreme problems 29 (6) 32 (7)…”

Section: Results: Cost-effectivenessmentioning

confidence: 99%

“…Adams et al 15 Borzotta et al 16 Cerra et al 17 Dunham et al 18 Gianotti et al 19 Hadfield et al 14 Kalfarentzos et al 20 Kudsk et al 21 Radrizzani et al 12 Rapp et al 22 Reynolds et al 23 Woodcock et al 24 Rayes et al 25 Overall Gianotti et al 19 Kalfarentzos et al 20 Radrizzani et al 12 Rayes et al 25 Overall …”

Section: Primarymentioning

confidence: 99%

“…No problems 242 (43) 239 (44) Slight problems 158 (29) 142 (26) Moderate problems 111 (20) 114 (21) Severe problems 28 (5) 35 (6) Extreme problems 19 (3) 14 (3) a In total, 185 (25%) and 183 (25%) patients had incomplete 90-day questionnaires in the parenteral and enteral groups, respectively. Results are presented for the samples with complete information; the number of complete responses/eligible patients at 90 days were as follows: parenteral group 558/743 (75%), enteral group 544/727 (75%).…”

Section: Pain/discomfortmentioning

confidence: 99%

“…This shows that the base-case results are robust to alternative assumptions. Moderate problems 95 (20) 95 (20) Severe problems 30 (6) 41 (9) Extreme problems 15 (3) 11 (2) a Totals of 209 (31%) and 185 (28%) patients had incomplete 12-month questionnaires in the PN and EN group, respectively. Results are presented for the samples with complete information; the number of complete responses/eligible patients at 12 months are as follows: PN: 467/676 (69%), EN: 473/658 (72%).…”

Section: Table 32mentioning

confidence: 99%

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A multicentre, randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of early nutritional support via the parenteral versus the enteral route in critically ill patients (CALORIES)

Harvey

Parrott

Harrison

et al. 2016

Health Technol Assess

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BackgroundMalnutrition is a common problem in critically ill patients in UK NHS critical care units. Early nutritional support is therefore recommended to address deficiencies in nutritional state and related disorders in metabolism. However, evidence is conflicting regarding the optimum route (parenteral or enteral) of delivery.ObjectivesTo estimate the effect of early nutritional support via the parenteral route compared with the enteral route on mortality at 30 days and on incremental cost-effectiveness at 1 year. Secondary objectives were to compare the route of early nutritional support on duration of organ support; infectious and non-infectious complications; critical care unit and acute hospital length of stay; all-cause mortality at critical care unit and acute hospital discharge, at 90 days and 1 year; survival to 90 days and 1 year; nutritional and health-related quality of life, resource use and costs at 90 days and 1 year; and estimated lifetime incremental cost-effectiveness.DesignA pragmatic, open, multicentre, parallel-group randomised controlled trial with an integrated economic evaluation.SettingAdult general critical care units in 33 NHS hospitals in England.Participants2400 eligible patients.InterventionsFive days of early nutritional support delivered via the parenteral (n = 1200) and enteral (n = 1200) route.Main outcome measuresAll-cause mortality at 30 days after randomisation and incremental net benefit (INB) (at £20,000 per quality-adjusted life-year) at 1 year.ResultsBy 30 days, 393 of 1188 (33.1%) patients assigned to receive early nutritional support via the parenteral route and 409 of 1195 (34.2%) assigned to the enteral route had died [p = 0.57; absolute risk reduction 1.15%, 95% confidence interval (CI) −2.65 to 4.94; relative risk 0.97 (0.86 to 1.08)]. At 1 year, INB for the parenteral route compared with the enteral route was negative at −£1320 (95% CI −£3709 to £1069). The probability that early nutritional support via the parenteral route is more cost-effective – given the data – is < 20%. The proportion of patients in the parenteral group who experienced episodes of hypoglycaemia (p = 0.006) and of vomiting (p < 0.001) was significantly lower than in the enteral group. There were no significant differences in the 15 other secondary outcomes and no significant interactions with pre-specified subgroups.LimitationsBlinding of nutritional support was deemed to be impractical and, although the primary outcome was objective, some secondary outcomes, although defined and objectively assessed, may have been more vulnerable to observer bias.ConclusionsThere was no significant difference in all-cause mortality at 30 days for early nutritional support via the parenteral route compared with the enteral route among adults admitted to critical care units in England. On average, costs were higher for the parenteral route, which, combined with similar survival and quality of life, resulted in negative INBs at 1 year.Future workNutritional support is a complex combination of timing, dose, duration, delivery and type, all of which may affect outcomes and costs. Conflicting evidence remains regarding optimum provision to critically ill patients. There is a need to utilise rigorous consensus methods to establish future priorities for basic and clinical research in this area.Trial registrationCurrent Controlled Trials ISRCTN17386141.FundingThis project was funded by the NIHR Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 28. See the NIHR Journals Library website for further project information.

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“…No problems 166 (36) 172 (37) Slight problems 93 (20) 90 (19) Moderate problems 114 (24) 99 (21) Severe problems 65 (20) 80 (17) Extreme problems 29 (6) 32 (7)…”

Section: Results: Cost-effectivenessmentioning

confidence: 99%

Section: Primarymentioning

confidence: 99%

Section: Pain/discomfortmentioning

confidence: 99%

Section: Table 32mentioning

confidence: 99%

See 2 more Smart Citations

A multicentre, randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of early nutritional support via the parenteral versus the enteral route in critically ill patients (CALORIES)

Harvey

Parrott

Harrison

et al. 2016

Health Technol Assess

View full text Add to dashboard Cite

show abstract

“…Studies of 100% WHP and pancreatitis are characterized in Table 2 [ 6,9,[27][28][29][30][31][32] . In a prospective pilot study conducted by Tiengou et al [27] , patients with severe acute pancreatitis who required nasojejunal nutrition were randomized to receive a 100% WHP semi-elemental diet (n = 15) or a standard polymeric formula (n = 15) for seven days.…”

Section: Pancreatitismentioning

confidence: 99%

Nutritional and health benefits of semi-elemental diets: A comprehensive summary of the literature

Alexander¹,

Bylsma²,

Elkayam³

et al. 2016

WJGPT

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AIM:To critically review and summarize the literature on nutritional and health outcomes of semi-elemental formulations on various nutritionally vulnerable patient populations who are unable to achieve adequate nutrition from standard oral diets. METHODS:We conducted a comprehensive literature search of Pubmed and Embase databases. We manually screened articles that examined nutritional and health outcomes (e.g. , growth, disease activity, gastrointestinal impairment, mortality, and economic impact) among various patient groups receiving semi-elemental diets. This review focused on full-text articles of randomized controlled clinical trials and other intervention studies, but pertinent abstracts and case studies were also included. Results pertaining primarily to tolerance, digestion, and absorption were summarized for each patient population in this systematic review.

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Enteral Nutrition Prevents Bacterial Translocation but Does Not Improve Survival During Acute Pancreatitis

Kotani

Usami²,

Nomura³

et al. 1999

Arch Surg

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To evaluate the effect of enteral nutrition (EN) in attenuating bacterial and/or endotoxin translocation, maintaining immune responsiveness, and improving outcome in early acute pancreatitis (AP) in Wistar male rats. Design: Acute pancreatitis was induced in rats receiving total parenteral nutrition (TPN) (AP/TPN group) (n=34) and EN (AP/EN group) (n=35) by pressure injection of 1% deoxycholate into the biliopancreatic duct (0.6 mg/kg of body weight). Rats in the sham/ TPN and sham/EN groups (n=10 each) underwent laparotomy without induction of AP. Catheters for TPN and EN were placed into the external jugular vein and jejunum, respectively. Rats were infused with Ringer lactate solution for 48 hours followed by TPN in the AP/TPN and sham/TPN groups, and EN in the AP/EN and sham/EN groups until day 7. The fluid volume and energy (calories) intake were similar in all groups. Setting: Medical school research laboratory. Main Outcome Measures: Survival, blood endotoxin level, villus height, 5-bromo-2'-deoxyuridine (BrdU) uptake in the jejunum and ileum, bacterial culture of mes-enteric lymph nodes, and CD4/CD8 ratio of T cells in mesenteric lymph nodes, spleen, and peripheral blood. Results: There was no difference in survival and pancreatic healing between the AP/TPN and AP/EN groups. Colony-forming units of the mesenteric lymph nodes and the endotoxin level were significantly lower in the AP/EN group than in the AP/TPN group (PϽ.05). Villus height and BrdU intake was significantly higher in the AP/EN group than in the AP/TPN group (PϽ.05). The CD4/CD8 ratio of T cells in spleen and peripheral blood was higher in the AP/EN group than in the AP/TPN group (PϽ.05), whereas there was no difference in mesenteric lymph nodes.

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Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: Results of a randomized prospective trial

Abstract: This study suggests that early enteral nutrition should be used preferentially in patients with severe acute pancreatitis.

Cited by 441 publications

References 25 publications

A multicentre, randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of early nutritional support via the parenteral versus the enteral route in critically ill patients (CALORIES)

A multicentre, randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of early nutritional support via the parenteral versus the enteral route in critically ill patients (CALORIES)

Nutritional and health benefits of semi-elemental diets: A comprehensive summary of the literature

Enteral Nutrition Prevents Bacterial Translocation but Does Not Improve Survival During Acute Pancreatitis

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