Nasogastric or nasojejunal feeding in predicted severe acute pancreatitis: a meta-analysis

Abstract

IntroductionEnteral feeding can be given either through the nasogastric or the nasojejunal route. Studies have shown that nasojejunal tube placement is cumbersome and that nasogastric feeding is an effective means of providing enteral nutrition. However, the concern that nasogastric feeding increases the chance of aspiration pneumonitis and exacerbates acute pancreatitis by stimulating pancreatic secretion has prevented it being established as a standard of care. We aimed to evaluate the differences in safety and tolerance between nasogastric and nasojejunal feeding by assessing the impact of the two approaches on the incidence of mortality, tracheal aspiration, diarrhea, exacerbation of pain, and meeting the energy balance in patients with severe acute pancreatitis.MethodWe searched the electronic databases of the Cochrane Central Register of Controlled Trials, PubMed, and EMBASE. We included prospective randomized controlled trials comparing nasogastric and nasojejunal feeding in patients with predicted severe acute pancreatitis. Two reviewers assessed the quality of each study and collected data independently. Disagreements were resolved by discussion among the two reviewers and any of the other authors of the paper. We performed a meta-analysis and reported summary estimates of outcomes as Risk Ratio (RR) with 95% confidence intervals (CIs).ResultsWe included three randomized controlled trials involving a total of 157 patients. The demographics of the patients in the nasogastric and nasojejunal feeding groups were comparable. There were no significant differences in the incidence of mortality (RR = 0.69, 95% CI: 0.37 to 1.29, P = 0.25); tracheal aspiration (RR = 0.46, 95% CI: 0.14 to 1.53, P = 0.20); diarrhea (RR = 1.43, 95% CI: 0.59 to 3.45, P = 0.43); exacerbation of pain (RR = 0.94, 95% CI: 0.32 to 2.70, P = 0.90); and meeting energy balance (RR = 1.00, 95% CI: 0.92 to 1.09, P = 0.97) between the two groups. Nasogastric feeding was not inferior to nasojejunal feeding.ConclusionsNasogastric feeding is safe and well tolerated compared with nasojejunal feeding. Study limitations included a small total sample size among others. More high-quality large-scale randomized controlled trials are needed to validate the use of nasogastric feeding instead of nasojejunal feeding.

Placement of feeding tubes using fluoroscopy guidance and over-the-wire technique: A technical review

“…With the increasing use of nasojejunal tubes, which have been associated with a lower risk of aspiration pneumonitis compared to nasogastric tubes, [22][23][24] imaging guidance is often required in order to place the tip of the feeding tubes beyond the pylorus or even into the proximal jejunum. Fluoroscopy is available in most institutions and is well-suited for such purpose because most commercially available feeding tubes appear radio-opaque on X-ray.…”

Nutritional Management in Acute Pancreatitis

“…Parenteral nutrition could be started in 24-48 hours after resuscitation and stable hemodynamics. 14 In mild acute pancreatitis study, partenteral nutrition for 5-7 days have no positive effect so that it is not recommended, except in malnourished patients. Substrate metabolism in severe acute pancreatitis was similar to severe sepsis patients.…”

“…There were no data for other amino acid administration in acute pancreatitis patients, such as BCAA, EAA, and arginine. 14 Glucose should fulfill 50-70% of total calorie needs. Glucose was also prevent gluconeogenesis, but hyperglycemia as side effect should be prevented.…”

“…A developed hypothesis told that nasogastric tube will stimulate 14 This was investigated by O'keefe et al Per oral liquid polymeric diet compared to placebo showed an Polymeric enteral formula administration into duodenum also stimulate amilase, trypsin, and lipase, otherwise elemental formula only slightly increase lipase. Studies also compared secretory response in nutritional administration at duodenum, mid-jejunal (40-60 cm distal ligamentum treitz) and distal jejunum (100-120 cm distal ligamentum treitz).…”

Significant Publications for Pharmacy Nutrition Support Practice in 2013

“…40 A separate 2013 meta-analysis pooled 3 RCTs that supported the safety of early jejunal feeding and also suggests the need for additional study. 41 The authors of these guidelines acknowledge that additional evidence is currently being accumulated in a large multicenter trial sponsored by the National Institutes of Health. Currently, results of this trial are not available and it is hoped that this large trial will provide clarity regarding gastric versus jejunal feeding for these patients.…”