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Hsieh PH, Yang TC, Kang EYN, Lee PC, Luo JC, Huang YH, Hou MC, Huang SP. Impact of nutritional support routes on mortality in acute pancreatitis: A network meta-analysis of randomized controlled trials. J Intern Med 2024; 295:759-773. [PMID: 38561603 DOI: 10.1111/joim.13782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND Nutritional administration in acute pancreatitis (AP) management has sparked widespread discussion, yet contradictory mortality results across meta-analyses necessitate clarification. The optimal nutritional route in AP remains uncertain. Therefore, this study aimed to compare mortality among nutritional administration routes in patients with AP using consistency model. METHODS This study searched four major databases for relevant randomized controlled trials (RCTs). Two authors independently extracted and checked data and quality. Network meta-analysis was conducted for estimating risk ratios (RRs) with 95% confidence interval (CI) based on random-effects model. Subgroup analyses accounted for AP severity and nutrition support initiation. RESULTS A meticulous search yielded 1185 references, with 30 records meeting inclusion criteria from 27 RCTs (n = 1594). Pooled analyses showed the mortality risk reduction associated with nasogastric (NG) (RR = 0.34; 95%CI: 0.16-0.73) and nasojejunal (NJ) feeding (RR = 0.46; 95%CI: 0.25-0.84) in comparison to nil per os. Similarly, NG (RR = 0.45; 95%CI: 0.24-0.83) and NJ (RR = 0.60; 95%CI: 0.40-0.90) feeding also showed lower mortality risk than total parenteral nutrition. Subgroup analyses, stratified by severity, supported these findings. Notably, the timing of nutritional support initiation emerged as a significant factor, with NJ feeding demonstrating notable mortality reduction within 24 and 48 h, particularly in severe cases. CONCLUSION For severe AP, both NG and NJ feeding appear optimal, with variations in initiation timings. NG feeding does not appear to merit recommendation within the initial 24 h, whereas NJ feeding is advisable within the corresponding timeframe following admission. These findings offer valuable insights for optimizing nutritional interventions in AP.
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Affiliation(s)
- Ping-Han Hsieh
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tsung-Chieh Yang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Enoch Yi-No Kang
- Evidence-Based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
| | - Pei-Chang Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiing-Chyuan Luo
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Healthcare and Services Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ming-Chih Hou
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Ping Huang
- Division of Gastroenterology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
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Liang XY, Wu XA, Tian Y, Gao H, Chen JJ, Feng QX. Effects of Early Versus Delayed Feeding in Patients With Acute Pancreatitis: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2024; 58:522-530. [PMID: 37428071 DOI: 10.1097/mcg.0000000000001886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 05/22/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND The aim of this study was to summarize the optimal strategy for early feeding in patients with acute pancreatitis. METHODS The search was undertaken in electronic databases, which compared early with delayed feeding in acute pancreatitis. The primary outcome was the length of hospital stay (LOHS). The second outcomes were intolerance of refeeding, mortality, and total cost of each patient. This meta-analysis followed the "Preferred Reporting Items for Systematic Reviews and Meta-analyses" guideline. Research is registered by PROSPERO, CRD42020192133. RESULTS A total of 20 trials involving 2168 patients were included, randomly assigned to the early feeding group (N = 1033) and delayed feeding group (N = 1135). The LOHS was significantly lower in the early feeding group than the delayed feeding group (mean difference: -2.35, 95% CI: -2.89 to -1.80; P < 0.0001), no matter the mild or severe subgroup ( Pint = 0.69). The secondary outcome of feeding intolerance and mortality were no significant difference (risk ratio: 0.96, 0.40 to 2.16, P = 0.87 and 0.91, 0.57 to 1.46, P = 0.69; respectively). Moreover, the hospitalization cost was significantly less in the early feeding group, resulting in an average savings of 50%. In patients with severe pancreatitis, early feeding after 24 hours may be beneficial ( Pint = 0.001). CONCLUSION Early oral feeding can significantly reduce the LOHS and hospitalization costs in patients with acute pancreatitis without increasing feeding intolerance or mortality. In patients with severe pancreatitis, early feeding after 24 hours may be beneficial.
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Affiliation(s)
- Xi-Ying Liang
- Department of Cardiology, The Second Affiliated Hospital of Xi'an Jiaotong University
- Pancreatic Disease Center, Xi'an Peoples Hospital
| | - Xin-An Wu
- Pancreatic Disease Center, Xi'an Peoples Hospital
| | - Ying Tian
- Pancreatic Disease Center, Xi'an Peoples Hospital
| | - Hang Gao
- Pancreatic Disease Center, Xi'an Peoples Hospital
| | | | - Quan-Xin Feng
- Pancreatic Disease Center, Xi'an Peoples Hospital
- Intensive Care Unit of Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaaxi, China
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Grover I, Gunjan D, Singh N, Gopi S, Sati HC, Sachdev V, Saraya A. Kitchen-based diet versus commercial polymeric formulation in acute pancreatitis: a pilot randomized comparative study. Eur J Clin Nutr 2024; 78:328-334. [PMID: 38243059 DOI: 10.1038/s41430-024-01400-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 12/14/2023] [Accepted: 01/02/2024] [Indexed: 01/21/2024]
Abstract
INTRODUCTION Nutrition plays an important role in management of acute pancreatitis (AP) and decreases its severity and infectious complications. Various formulations of enteral nutrition (EN) are available and are costly. For developing countries, cost and availability is a major issue and kitchen-based diet should be explored in patients with AP. AIM Comparison of kitchen-based diet with a commercially available polymeric formulation in terms of various outcomes in patients with AP within 14 days after the onset of pain. METHODS Sixty patients (39 male, mean age 36.1 ± 12.7 years) of moderately severe and severe AP of any etiology were randomized (30 in each group) to either kitchen-based diet or commercial polymeric formulation group. Outcome measures were refeeding pain, tolerability, infectious complications, mortality, total hospital/intensive care unit stay; and change in serum C-reactive protein (CRP), transferrin and pre albumin. RESULTS There was no significant difference in baseline demographic and biochemical parameters in both groups. No difference was observed in refeeding pain (7.1% vs 8%, p = 0.99), tolerability (28.6% vs 12%, p = 0.17), infectious complications (57.14% vs 36%, p = 0.12), mortality (31.7% vs 20%, p = 0.69), hospital stay (19.5 vs 23.5 days, p = 0.86), CRP (74.4 vs 59 mg/L, p = 0.97), transferrin levels (23.6 vs 25.6 mg/dL, p = 0.75) and pre albumin (9.45 vs 13.09 mg/dL, p = 0.68) in both groups. CONCLUSION Kitchen-based diet is comparable to commercial polymeric formulation for the early initiation of enteral nutrition in patients with severe or moderately severe acute pancreatitis. CLINICAL TRIAL REGISTRATION Trial registered with the Clinical Trials registry-India (CTRI/2018/01/011188).
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Affiliation(s)
- Indu Grover
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Namrata Singh
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Srikanth Gopi
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Hem Chandra Sati
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Vikas Sachdev
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India.
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De Lucia SS, Candelli M, Polito G, Maresca R, Mezza T, Schepis T, Pellegrino A, Zileri Dal Verme L, Nicoletti A, Franceschi F, Gasbarrini A, Nista EC. Nutrition in Acute Pancreatitis: From the Old Paradigm to the New Evidence. Nutrients 2023; 15:nu15081939. [PMID: 37111158 PMCID: PMC10144915 DOI: 10.3390/nu15081939] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 04/12/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
The nutritional management of acute pancreatitis (AP) patients has widely changed over time. The "pancreatic rest" was the cornerstone of the old paradigm, and nutritional support was not even included in AP management. Traditional management of AP was based on intestinal rest, with or without complete parenteral feeding. Recently, evidence-based data underlined the superiority of early oral or enteral feeding with significantly decreased multiple-organ failure, systemic infections, surgery need, and mortality rate. Despite the current recommendations, experts still debate the best route for enteral nutritional support and the best enteral formula. The aim of this work is to collect and analyze evidence over the nutritional aspects of AP management to investigate its impact. Moreover, the role of immunonutrition and probiotics in modulating inflammatory response and gut dysbiosis during AP was extensively studied. However, we have no significant data for their use in clinical practice. This is the first work to move beyond the mere opposition between the old and the new paradigm, including an analysis of several topics still under debate in order to provide a comprehensive overview of nutritional management of AP.
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Affiliation(s)
- Sara Sofia De Lucia
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Marcello Candelli
- Department of Emergency, Anesthesiological and Reanimation Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Giorgia Polito
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Rossella Maresca
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Teresa Mezza
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Tommaso Schepis
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Antonio Pellegrino
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Lorenzo Zileri Dal Verme
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Alberto Nicoletti
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Francesco Franceschi
- Department of Emergency, Anesthesiological and Reanimation Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Antonio Gasbarrini
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Enrico Celestino Nista
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
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Venkatesh K, Glenn H, Delaney A, Andersen CR, Sasson SC. Fire in the belly: A scoping review of the immunopathological mechanisms of acute pancreatitis. Front Immunol 2023; 13:1077414. [PMID: 36713404 PMCID: PMC9874226 DOI: 10.3389/fimmu.2022.1077414] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 12/21/2022] [Indexed: 01/13/2023] Open
Abstract
Introduction Acute pancreatitis (AP) is characterised by an inflammatory response that in its most severe form can cause a systemic dysregulated immune response and progression to acute multi-organ dysfunction. The pathobiology of the disease is unclear and as a result no targeted, disease-modifying therapies exist. We performed a scoping review of data pertaining to the human immunology of AP to summarise the current field and to identify future research opportunities. Methods A scoping review of all clinical studies of AP immunology was performed across multiple databases. Studies were included if they were human studies of AP with an immunological outcome or intervention. Results 205 studies met the inclusion criteria for the review. Severe AP is characterised by significant immune dysregulation compared to the milder form of the disease. Broadly, this immune dysfunction was categorised into: innate immune responses (including profound release of damage-associated molecular patterns and heightened activity of pattern recognition receptors), cytokine profile dysregulation (particularly IL-1, 6, 10 and TNF-α), lymphocyte abnormalities, paradoxical immunosuppression (including HLA-DR suppression and increased co-inhibitory molecule expression), and failure of the intestinal barrier function. Studies including interventions were also included. Several limitations in the existing literature have been identified; consolidation and consistency across studies is required if progress is to be made in our understanding of this disease. Conclusions AP, particularly the more severe spectrum of the disease, is characterised by a multifaceted immune response that drives tissue injury and contributes to the associated morbidity and mortality. Significant work is required to develop our understanding of the immunopathology of this disease if disease-modifying therapies are to be established.
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Affiliation(s)
- Karthik Venkatesh
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, St Leonards, NSW, Australia,The Kirby Institute, The University of New South Wales, Kensington, NSW, Australia,*Correspondence: Karthik Venkatesh,
| | - Hannah Glenn
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, St Leonards, NSW, Australia,Division of Critical Care, The George Institute for Global Health, Newtown, NSW, Australia
| | - Christopher R. Andersen
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, St Leonards, NSW, Australia,The Kirby Institute, The University of New South Wales, Kensington, NSW, Australia,Division of Critical Care, The George Institute for Global Health, Newtown, NSW, Australia
| | - Sarah C. Sasson
- The Kirby Institute, The University of New South Wales, Kensington, NSW, Australia,Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia
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Kanthasamy KA, Akshintala VS, Singh VK. Nutritional Management of Acute Pancreatitis. Gastroenterol Clin North Am 2021; 50:141-150. [PMID: 33518160 DOI: 10.1016/j.gtc.2020.10.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Acute pancreatitis (AP) remains among the most common gastrointestinal disorders leading to hospital admission. Optimizing nutritional support and maintaining gut function is instrumental in recovery of patients with AP. Enteral nutrition remains one of the only interventions with demonstrated mortality benefit in AP largely through preservation of gut function, serving to preserve the gut barrier as means to mitigate immune dysregulation and systemic inflammation inherent to AP. Practice variation remains in timing, route, and composition of nutritional support. This review highlights contemporary evidence regarding optimal nutritional support in AP and provides recommendations for management in line with current consensus opinions.
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Affiliation(s)
- Kavin A Kanthasamy
- Division of Gastroenterology, Johns Hopkins Medical Institutions, 1800 Orleans Street, Baltimore, MD 21287, USA.
| | | | - Vikesh K Singh
- 1830 East Monument Street, Room 428, Baltimore, MD 21205, USA
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Jegatheeswaran S, Geraghty J, Siriwardena AK. Multidisciplinary management of patients with post-inflammatory pancreatic necrosis. Hepatobiliary Pancreat Dis Int 2021; 20:1-3. [PMID: 33349603 DOI: 10.1016/j.hbpd.2020.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 11/16/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Santhalingam Jegatheeswaran
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
| | - Joe Geraghty
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; Department of Gastroenterology, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Ajith K Siriwardena
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK.
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Ghosh A, Biswas SK, Basu KS, Biswas SK. Early Feeding after Colorectal Surgery in Children: Is it Safe? J Indian Assoc Pediatr Surg 2020; 25:291-296. [PMID: 33343110 PMCID: PMC7732015 DOI: 10.4103/jiaps.jiaps_132_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/12/2019] [Accepted: 04/08/2020] [Indexed: 11/04/2022] Open
Abstract
Aim of the Study The aim of this study is to assess the role of early feeding after elective colorectal surgery in children and compare the outcome of feeding practice early versus traditional feeding. Study Design A randomized controlled, single-center study was conducted over a period of 3 years (November 2015-October 2018) at a tertiary care center. Materials and Methods Patients (n = 147), after colostomy closure (as elective colorectal surgery), were randomly selected for postoperative feeding initiation and were divided into two groups, namely the control (traditional feeding) group and study group (early feeding). In early group, feeding was initiated on the postoperative day 1 after the removal of nasogastric tube (removed after 16 h of surgery). Postoperative hospital stay and complications were compared among them. Statistical Analysis Used Data were tabulated and analyzed in Microsoft Excel 2010. Results Among 147 patients (boys[70] and girls [77]), the average age of colostomy closure was 4.36 years. Forty-five patients had early feeding and 102 traditional feeding. Average postoperative hospital stay was noted 5.62 ± 1.11 days for "Study group" and 8.1 ± 1.04 days for "Control group." Postoperative complications were found in 17 patients; 11 (7.5%) superficial surgical site infection (9 [8.8%] in control and 2 [4.4%] in study group) and 6 (4%) minor fecal fistulae (5 [4.9%] in control group and 1 [2.2%] in study group). None required any further surgical intervention. No mortality was reported. Conclusions Early feeding initiation after elective colorectal surgery is safe, and postoperative hospital stay is significantly reduced. It is definitely a step forward in the era of fast track surgery in pediatric population.
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Affiliation(s)
- Arindam Ghosh
- Department of Pediatric Surgery, N R S Medical College, Kolkata, West Bengal, India
| | - Somak Krishna Biswas
- Department of Pediatric Surgery, N R S Medical College, Kolkata, West Bengal, India
| | - Kalyani Saha Basu
- Department of Pediatric Surgery, N R S Medical College, Kolkata, West Bengal, India
| | - Sumitra Kumar Biswas
- Department of Pediatric Surgery, N R S Medical College, Kolkata, West Bengal, India
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Guo YB, Liu Y, Ma J, Cai Y, Jiang XM, Zhang H. Effect of early enteral nutrition support for the management of acute severe pancreatitis: A protocol of systematic review. Medicine (Baltimore) 2020; 99:e21569. [PMID: 32769901 PMCID: PMC7593012 DOI: 10.1097/md.0000000000021569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND This study aims to assess the effect of early enteral nutrition support (EENS) for the management of acute severe pancreatitis (ASP). METHODS This study will search Cochrane Library, PUBMED, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, CNKI, and WANGFANG from their inception to the present without language limitations. In addition, this study will also search clinical trial registry and reference lists of included trials. Eligible comparators will be standard care, medications, and any other interventions. Two authors will independently scan all citations, titles/abstracts, and full-text studies. The study methodological quality will be appraised using Cochrane risk of bias tool. If it is possible, we will pool out data and perform meta-analysis. Strength of evidence for each main outcome will be evaluated using the Grading of Recommendations Assessment, Development, and Evaluation. RESULTS This study will summarize the most recent evidence to assess the effect of EENS for the management of ASP. CONCLUSION The findings of this study will help to determine whether EENS is effective for patients with ASP. STUDY REGISTRATION INPLASY202070009.
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Affiliation(s)
- Yong-bo Guo
- Department of Critical Care Medicine, The Affiliated Hongqi Hospital of Mudanjiang Medical University
| | - Yan Liu
- Department of Critical Care Medicine, The Affiliated Hongqi Hospital of Mudanjiang Medical University
| | - Jing Ma
- Department of Critical Care Medicine, The Affiliated Hongqi Hospital of Mudanjiang Medical University
| | - Ying Cai
- Department of Critical Care Medicine, First Affiliated Hospital of Mudanjiang Medical University, Mudanjiang
| | - Xiao-ming Jiang
- Department of Critical Care Medicine, Beijing Mentougou District Hospital, Beijing, China
| | - Hong Zhang
- Department of Critical Care Medicine, The Affiliated Hongqi Hospital of Mudanjiang Medical University
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Mosko JD, Leiman DA, Ketwaroo GA, Gupta N. Development of Quality Measures for Acute Pancreatitis: A Model for Hospital-Based Measures in Gastroenterology. Clin Gastroenterol Hepatol 2020; 18:272-275.e5. [PMID: 31760190 DOI: 10.1016/j.cgh.2019.11.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jeffrey D Mosko
- Center for Therapeutic Endoscopy and Endoscopic Oncology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David A Leiman
- Division of Gastroenterology, Duke University, Durham, and Duke Clinical Research Institute, Durham, North Carolina
| | - Gyanprakash A Ketwaroo
- Department of Medicine, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas
| | - Neil Gupta
- Division of Gastroenterology and Nutrition, Loyola University Health System, Maywood, Illinois.
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Impact of Intravenous Fluids and Enteral Nutrition on the Severity of Gastrointestinal Dysfunction: A Systematic Review and Meta-analysis. ACTA ACUST UNITED AC 2020; 6:5-24. [PMID: 32104727 PMCID: PMC7029405 DOI: 10.2478/jccm-2020-0009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 01/30/2020] [Indexed: 12/11/2022]
Abstract
Introduction Gastrointestinal dysfunction (GDF) is one of the primary causes of morbidity and mortality in critically ill patients. Intensive care interventions, such as intravenous fluids and enteral feeding, can exacerbate GDF. There exists a paucity of high-quality literature on the interaction between these two modalities (intravenous fluids and enteral feeding) as a combined therapy on its impact on GDF. Aim To review the impact of intravenous fluids and enteral nutrition individually on determinants of gut function and implications in clinical practice. Methods Randomized controlled trials on intravenous fluids and enteral feeding on GDF were identified by a comprehensive database search of MEDLINE and EMBASE. Extraction of data was conducted for study characteristics, provision of fluids or feeding in both groups and quality of studies was assessed using the Cochrane criteria. A random-effects model was applied to estimate the impact of these interventions across the spectrum of GDF severity. Results Restricted/ goal-directed intravenous fluid therapy is likely to reduce ‘mild’ GDF such as vomiting (p = 0.03) compared to a standard/ liberal intravenous fluid regime. Enterally fed patients experienced increased episodes of vomiting (p = <0.01) but were less likely to develop an anastomotic leak (p = 0.03) and peritonitis (p = 0.03) compared to parenterally fed patients. Vomiting (p = <0.01) and anastomotic leak (p = 0.04) were significantly lower in the early enteral feeding group. Conclusions There is less emphasis on the combined approach of intravenous fluid resuscitation and enteral feeding in critically ill patients. Conservative fluid resuscitation and aggressive enteral feeding are presumably key factors contributing to severe life-threatening GDF. Future trials should evaluate the impact of cross-interaction between conservative and aggressive modes of these two interventions on the severity of GDF.
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Farkas N, Hanák L, Mikó A, Bajor J, Sarlós P, Czimmer J, Vincze Á, Gódi S, Pécsi D, Varjú P, Márta K, Hegyi PJ, Erőss B, Szakács Z, Takács T, Czakó L, Németh B, Illés D, Kui B, Darvasi E, Izbéki F, Halász A, Dunás-Varga V, Gajdán L, Hamvas J, Papp M, Földi I, Fehér KE, Varga M, Csefkó K, Török I, Hunor-Pál F, Mickevicius A, Maldonado ER, Sallinen V, Novák J, Ince AT, Galeev S, Bod B, Sümegi J, Pencik P, Szepes A, Szentesi A, Párniczky A, Hegyi P. A Multicenter, International Cohort Analysis of 1435 Cases to Support Clinical Trial Design in Acute Pancreatitis. Front Physiol 2019; 10:1092. [PMID: 31551798 PMCID: PMC6738025 DOI: 10.3389/fphys.2019.01092] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 08/07/2019] [Indexed: 12/12/2022] Open
Abstract
Background C-reactive protein level (CRP) and white blood cell count (WBC) have been variably used in clinical trials on acute pancreatitis (AP). We assessed their potential role. Methods First, we investigated studies which have used CRP or WBC, to describe their current role in trials on AP. Second, we extracted the data of 1435 episodes of AP from our registry. CRP and WBC on admission, within 24 h from the onset of pain and their highest values were analyzed. Descriptive statistical tools as Kruskal–Wallis, Mann–Whitney U, Levene’s F tests, Receiver Operating Characteristic (ROC) curve analysis and AUC (Area Under the Curve) with 95% confidence interval (CI) were performed. Results Our literature review showed extreme variability of CRP used as an inclusion criterion or as a primary outcome or both in past and current trials on AP. In our cohort, CRP levels on admission poorly predicted mortality and severe cases of AP; AUC: 0.669 (CI:0.569–0.770); AUC:0.681 (CI: 0.601–0.761), respectively. CRP levels measured within 24 h from the onset of pain failed to predict mortality or severity; AUC: 0.741 (CI:0.627–0.854); AUC:0.690 (CI:0.586–0.793), respectively. The highest CRP during hospitalization had equally poor predictive accuracy for mortality and severity AUC:0.656 (CI:0.544–0.768); AUC:0.705 (CI:0.640–0.769) respectively. CRP within 24 h from the onset of pain used as an inclusion criterion markedly increased the combined event rate of mortality and severe AP (13% for CRP > 25 mg/l and 28% for CRP > 200 mg/l). Conclusion CRP within 24 h from the onset of pain as an inclusion criterion elevates event rates and reduces the number of patients required in trials on AP.
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Affiliation(s)
- Nelli Farkas
- Institute of Bioanalysis, Medical School, University of Pécs, Pécs, Hungary.,Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Lilla Hanák
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Alexandra Mikó
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Department of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Judit Bajor
- Department of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Patrícia Sarlós
- Department of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - József Czimmer
- Department of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Áron Vincze
- Department of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Szilárd Gódi
- Department of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Dániel Pécsi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Department of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Varjú
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Department of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Katalin Márta
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Jenő Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Department of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Department of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Tamás Takács
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - László Czakó
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Balázs Németh
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Dóra Illés
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Balázs Kui
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Erika Darvasi
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Ferenc Izbéki
- Szent György University Teaching Hospital, Fejér County, Székesfehérvár, Hungary
| | - Adrienn Halász
- Szent György University Teaching Hospital, Fejér County, Székesfehérvár, Hungary
| | - Veronika Dunás-Varga
- Szent György University Teaching Hospital, Fejér County, Székesfehérvár, Hungary
| | - László Gajdán
- Szent György University Teaching Hospital, Fejér County, Székesfehérvár, Hungary
| | | | - Mária Papp
- Department of Internal Medicine, Division of Gastroenterology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Ildikó Földi
- Department of Internal Medicine, Division of Gastroenterology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Krisztina Eszter Fehér
- Department of Internal Medicine, Division of Gastroenterology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | | | | | - Imola Török
- County Emergency Clinical Hospital, University of Medicine, Pharmacy, Sciences and Technology of Targu Mures, Targu Mures, Romania
| | - Farkas Hunor-Pál
- County Emergency Clinical Hospital, University of Medicine, Pharmacy, Sciences and Technology of Targu Mures, Targu Mures, Romania
| | | | | | - Ville Sallinen
- Department of Transplantation and Liver Surgery, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
| | - János Novák
- Pándy Kálmán Hospital of County Békés, Gyula, Hungary
| | - Ali Tüzün Ince
- School of Medicine, Hospital of Bezmialem Vakif University, Istanbul, Turkey
| | - Shamil Galeev
- Saint Luke's Clinical Hospital, St. Petersburg, Russia
| | | | - János Sümegi
- Borsod-Abaúj-Zemplén County Hospital, University Teaching Hospital, Miskolc, Hungary
| | - Petr Pencik
- Centrum Péče o Zažívací Trakt, Vítkovická Nemocnice a.s., Ostrava, Czechia
| | - Attila Szepes
- Department of Gastroenterology, Bács-Kiskun County Hospital, Kecskemét, Hungary
| | - Andrea Szentesi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Andrea Párniczky
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Heim Pál National Institute of Pediatrics, Budapest, Hungary.,Clinical Medicine Doctoral School, University of Szeged, Szeged, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Department of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary.,First Department of Medicine, University of Szeged, Szeged, Hungary.,Momentum Gastroenterology Multidisciplinary Research Group, Hungarian Academy of Sciences, University of Szeged, Szeged, Hungary
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13
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Infection rate among nutritional therapies for acute pancreatitis: A systematic review with network meta-analysis of randomized controlled trials. PLoS One 2019; 14:e0219151. [PMID: 31291306 PMCID: PMC6620007 DOI: 10.1371/journal.pone.0219151] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 06/17/2019] [Indexed: 12/12/2022] Open
Abstract
Background Infection in acute pancreatitis (AP) is associated with nutritional therapies including naso-gastric (NG), naso-jejunal (NJ), and total parenteral nutrition (TPN). To examine infections among NG, NJ, TPN, and no nutritional support (NNS) in treating patients with AP. Methods The investigators completed comprehensive search in the Cochrane library, EMBASE, PubMed, Web of Science, and ClinicalTrials.gov without restriction on language and publication date before January 21, 2019. They also searched the reference lists of relevant studies for randomized controlled trials (RCTs) comparing NG, NJ, TPN, and NNS among patients with AP. Quantitative synthesis was conducted in a contrast-based network meta-analysis. To clarify effects, a network meta-analysis was conducted to calculate the surface under the cumulative ranking curve (SUCRA). Beside of overall infections, the event rates of infected pancreatic necrosis, bacteremia, line infection, pneumonia, urinary tract infection, and other types of infections were measured. Results The network meta-analysis of 16 RCTs showed that NJ had significantly lower overall infection rates compared with TPN (risk ratio: 0.59; 95% confidence interval: 0.38, 0.90); and NG had a larger effect size and higher rank probability compared with NJ, TPN, and NNS (mean rank = 1.7; SUCRA = 75.8). TPN was the least preferred (mean rank = 3.2; SUCRA = 26.6). Conclusions NG and NJ may be preferred therapies for treating patients with AP. Clinicians may consider NG as a first-line treatment for patients with AP (including severe AP) and even in patients receiving prophylactic antibiotics. In addition, we found that NNS should be avoided when treating patients with severe AP.
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14
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Abstract
OBJECTIVES Clinical trials on tube feedings (TFs) have not been sufficiently powered to change practice patterns in acute pancreatitis (AP). We aimed to describe the use, duration, and resource utilization of TF in AP patients at an expert US center. METHODS Of 423 AP patients prospectively enrolled at the University of Pittsburgh Medical Center from 2004 to 2014, 139 (33%) received TF. Data on TF were assessed in 100 (72%) of 139 patients with complete data available. RESULTS Patients on TF were more likely to be male, be obese, have alcohol etiology, and have moderately severe (34% vs 19%) or severe AP (62% vs. 3%) (P < 0.05). Tube feedings were started after a median of 5 days (interquartile range, 3-8 days) from admission and were administered for a median of 39 days (interquartile range, 19-58 days). A nasojejunal route (95%) with an oligomeric formula (92%) was the preferred TF strategy. Feeding tube complications led to at least 1 endoscopic tube replacement in 42% of patients and to an unexpected health care visit in 29% of those discharged on TF (16/55 patients). CONCLUSIONS Tube feedings form an important component in the management of patients with moderately severe and severe AP. Further studies should define the optimal utilization of TF and ways to reduce TF-related complications.
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15
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Shang Y, Guo C, Zhang D. Modified enhanced recovery after surgery protocols are beneficial for postoperative recovery for patients undergoing emergency surgery for obstructive colorectal cancer: A propensity score matching analysis. Medicine (Baltimore) 2018; 97:e12348. [PMID: 30278512 PMCID: PMC6181620 DOI: 10.1097/md.0000000000012348] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) is acknowledged to reduce perioperative stress in several surgical diseases. Here, we investigated whether modified ERAS is associated with beneficial effects in the setting of emergency colorectal surgery.We retrospectively evaluated the medical records of 839 consecutive patients with obstructive colorectal cancer undergoing surgical intervention at 4 institutes. Among them, 356 cases were managed with a multidisciplinary team approach to care (modified ERAS protocols), and the remaining 483 cases were treated based on traditional protocols. According to modified ERAS or traditional care, propensity score (PS) matching was performed to adjust biases in patient selection. The primary outcome was gastrointestinal function recovery. Secondary outcomes included postoperative complications and length of hospital stay.Modified ERAS was associated with postoperative gastrointestinal function recovery, including time to first flatus (P = .002), first defecation (P = .008), and prolonged ileus (P = .016). According to the Clavien-Dindo classification, fewer total episodes of grade II or higher postoperative complications were observed in patients cared for with modified ERAS than in patients with traditional care (P = .002). Median (interquartile range) postoperative hospital stay in the modified ERAS group was 6 (3-22) days versus 9 (7-27) days in the traditional care group (P < .001). Furthermore, the interval from operation to postoperative chemotherapy (d) was significantly shorter in the modified ERAS group (35.6 ± 11.5 vs 47.6 ± 23.8, P < .001).The modified ERAS was safe and associated with clinical benefits, including fast recovery of bowel function, reduced postoperative complications, and shorter hospital stay for patients with obstructive colorectal cancer.
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Affiliation(s)
- Yuanyuan Shang
- Department of Colorectal Surgery, Qingdao Municipal Hospital, Qingdao University, Qingdao
| | - Chunbao Guo
- Department of Pediatric General Surgery
- Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Dianliang Zhang
- Department of Colorectal Surgery, Qingdao Municipal Hospital, Qingdao University, Qingdao
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16
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Li W, Liu J, Zhao S, Li J. Safety and efficacy of total parenteral nutrition versus total enteral nutrition for patients with severe acute pancreatitis: a meta-analysis. J Int Med Res 2018; 46:3948-3958. [PMID: 29962261 PMCID: PMC6136006 DOI: 10.1177/0300060518782070] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Objective This study was performed to systematically compare the safety and efficacy of
total enteral nutrition (TEN) and total parenteral nutrition (TPN) for
patients with severe acute pancreatitis (SAP). Methods The PubMed database was searched up to January 2017, and nine studies were
retrieved. These studies were selected according to specific eligibility
criteria. The methodological quality of each trial was assessed, and the
study design, interventions, participant characteristics, and final results
were then analyzed by Review Manager 5.3 (The Nordic Cochrane Centre, The
Cochrane Collaboration, Copenhagen, Denmark). Results Nine relevant randomized controlled trials involving 500 patients (244
patients in the TEN group and 256 patients in the TPN group) were included
in the meta-analysis. Pooled analysis showed a significantly lower mortality
rate in the TEN than TPN group [odds ratio (OR), 0.31; 95% confidence
interval (CI), 0.18–0.54]. The duration of hospitalization was significantly
shorter in the TEN than TPN group (mean difference, −0.59; 95% CI,
−2.56–1.38). Compared with TPN, TEN had a lower risk of pancreatic infection
and related complications (OR, 0.41; 95% CI, 0.22–0.77), organ failure (OR,
0.17; 95% CI, 0.06–0.52), and surgical intervention (OR, 0.17; 95% CI,
0.05–0.62). Conclusions This meta-analysis indicates that TEN is safer and more effective than TPN
for patients with SAP. When both TEN and TPN have a role in the management
of SAP, TEN is the preferred option.
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Affiliation(s)
- Wen Li
- 2 Department of Surgical Intensive Care Unit, China-Japan Friendship Hospital, Yinghuadongjie, Chaoyang District, Beijing 100029, China
| | - Jixi Liu
- 1 Department of Gastroenterology, China-Japan Friendship Hospital, Yinghuadongjie, Chaoyang District, Beijing 100029, China
| | - Shuqiao Zhao
- 3 Department of Gastroenterology, The First Hospital of Shijiazhuang, Shijiazhuang, Hebei province 050011, China
| | - Jingtao Li
- 1 Department of Gastroenterology, China-Japan Friendship Hospital, Yinghuadongjie, Chaoyang District, Beijing 100029, China
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17
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Endo A, Shiraishi A, Fushimi K, Murata K, Otomo Y. Comparative effectiveness of elemental formula in the early enteral nutrition management of acute pancreatitis: a retrospective cohort study. Ann Intensive Care 2018; 8:69. [PMID: 29869095 PMCID: PMC5986693 DOI: 10.1186/s13613-018-0414-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 05/28/2018] [Indexed: 12/27/2022] Open
Abstract
Background Although enteral nutrition has become one of the standard therapies for patients with acute pancreatitis, the optimal formulae for enteral nutrition have been under debate. Elemental formula is assumed to be suitable in the treatment of patients with acute pancreatitis because it has less stimulating effects for exocrine secretions of the pancreas, simultaneously maintaining gut immunity; however, clinical studies corroborating this assumption have been scarce. Methods We conducted a retrospective cohort study using a Japanese national administrative database between 2010 and 2015. Patients with acute pancreatitis who received enteral feeding within 3 days of admission were identified and divided into two groups according to whether elemental formula was administered. We assessed the impact of elemental formula for the outcomes (primary, in-hospital mortality; secondary, development of sepsis, hospital-free days at 90 days, and total health-care costs) using a multivariate mixed-effect regression analysis and propensity score matching analysis adjusted by a well-validated case-mix adjustment model. Analysis for the subpopulation of patients with severe acute pancreatitis was also performed. Results Of 243,312 patients with acute pancreatitis, 948 patients were identified and classified into the elemental formula group (N = 382) and the control group (N = 566). No significant differences were observed for in-hospital mortality [10.2% in the elemental formula group vs. 11.0% in the control group; adjusted adds ratio (95% confidence interval; CI) = 0.94 (0.53–1.67)], sepsis development [5.0 vs. 7.1%; adjusted adds ratio (95% CI) = 0.66 (0.34–1.28)], mean hospital-free days [54 days vs. 51 days; adjusted difference (95% CI) = 2 days (− 2 to 5)], and mean total health-care costs [$29,360 vs. $34,214; adjusted difference (95% CI) = − $4250 (− 8643 to 141)]. Similar results were also observed in patients with severe acute pancreatitis. Conclusions The results of our retrospective cohort study using a large-scale national database did not demonstrate the benefit of elemental formula compared to semi-elemental and polymeric formulae in patients with acute pancreatitis. Further assessment of alternative nutritional strategy is expected. Electronic supplementary material The online version of this article (10.1186/s13613-018-0414-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Akira Endo
- Trauma and Acute Critical Care Medical Center, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.
| | - Atsushi Shiraishi
- Trauma and Acute Critical Care Medical Center, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.,Emergency and Trauma Center, Kameda Medical Center, 929 Higashicho, Kamogawa, Chiba, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Kiyoshi Murata
- Trauma and Acute Critical Care Medical Center, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.,The Shock Trauma and Emergency Medical Center, Matsudo City Hospital, 4005 Kamihongo, Matsudo, Chiba, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Medical Center, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
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18
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Vege SS, DiMagno MJ, Forsmark CE, Martel M, Barkun AN. Initial Medical Treatment of Acute Pancreatitis: American Gastroenterological Association Institute Technical Review. Gastroenterology 2018; 154:1103-1139. [PMID: 29421596 DOI: 10.1053/j.gastro.2018.01.031] [Citation(s) in RCA: 146] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Santhi Swaroop Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Matthew J DiMagno
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Chris E Forsmark
- Division of Gastroenterology, University of Florida, Gainesville, Florida
| | - Myriam Martel
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
| | - Alan N Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
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19
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Shang Q, Geng Q, Zhang X, Xu H, Guo C. The impact of early enteral nutrition on pediatric patients undergoing gastrointestinal anastomosis a propensity score matching analysis. Medicine (Baltimore) 2018; 97:e0045. [PMID: 29489656 PMCID: PMC5851715 DOI: 10.1097/md.0000000000010045] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 10/19/2017] [Accepted: 02/07/2018] [Indexed: 01/02/2023] Open
Abstract
This study was conducted to assess the clinical advantages of early enteral nutrition (EEN) in pediatric patients who underwent surgery with gastrointestinal (GI) anastomosis.EEN has been associated with clinical benefits in various aspect of surgical intervention, including GI function recovery and postoperative complications reduction. Evaluable data documenting clinical advantages with EEN for pediatric patients after surgery with GI anastomosis are limited.We retrospectively reviewed the medical records of 575 pediatric patients undergoing surgical intervention with GI anastomosis. Among them, 278 cases were managed with EEN and the remaining cases were set as late enteral nutrition (LEN) group. Propensity score (PS) matching was conducted to adjust biases in patient selection. Enteral feeding related complications were evaluated with symptoms, including serum electrolyte abnormalities, abdominal distention, abdominal cramps, and diarrhea. Clinical outcomes, including GI function recovery, postoperative complications, length of hospital stay, and postoperative follow-up, were assessed according to EEN or LEN.Following PS matching, the baseline variables of the 2 groups were more comparable. There were no differences in the incidence of enteral feeding-related complications. EEN was associated with postoperative GI function recovery, including time to first defecation (3.1 ± 1.4 days for EEN vs 3.8 ± 1.0 days for LEN, risk ratio [RR], 0.62; 95% confidence interval [CI] 0.43-1.08, P = .042). A lower total episodes of complication, including infectious complications and major complications were noted in patients with EEN than in patients with LEN (117 [45.9%] vs 137 [53.7%]; OR, 0.73, 95% CI 0.52-1.03, P = .046). Mean postoperative length of stay in the EEN group was 7.4 ± 1.8 days versus 9.2 ± 1.4 days in the LEN group (P = .007). Furthermore, the incidence of adhesive small bowel obstruction was lower for patients with laxative administration compared with control, but no significant difference was attained (P = .092)EEN was safe and associated with clinical benefits, including shorten hospital stay, and reduced overall postoperative complications on pediatric patients undergoing GI anastomosis.
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Affiliation(s)
- Qingjuan Shang
- Department of Pathology, Linyi People's Hospital, Linyi, Shandong province
| | - Qiankun Geng
- Department of Pediatric General Surgery, Children's Hospital
| | - Xuebing Zhang
- Department of Pediatric General Surgery, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Hongfang Xu
- Department of Pediatric General Surgery, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Chunbao Guo
- Department of Pathology, Linyi People's Hospital, Linyi, Shandong province
- Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital, Chongqing Medical University
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20
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Roberts KM, Nahikian-Nelms M, Ukleja A, Lara LF. Nutritional Aspects of Acute Pancreatitis. Gastroenterol Clin North Am 2018; 47:77-94. [PMID: 29413020 DOI: 10.1016/j.gtc.2017.10.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
The goal of nutritional support in acute pancreatitis is to reduce inflammation, prevent nutritional depletion, correct a negative nitrogen balance, and improve outcomes. Enteral nutrition (EN) in severe acute pancreatitis (SAP) should be preferred to parenteral nutrition. It maintains the integrity of the gut barrier, decreases intestinal permeability, downregulates the systemic inflammatory response, maintains intestinal microbiota equilibrium, and reduces the complications of the early phase of SAP, improving morbidity and possibly improving mortality, and it is less expensive. Further studies to understand optimal timing of nutrition, route of delivery of EN, and the type of nutrition and nutrients are necessary.
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Affiliation(s)
- Kristen M Roberts
- Division of Gastroenterology, Hepatology and Nutrition, School of Health and Rehabilitation Sciences, The Ohio State University, 453 West 10th Avenue, Columbus, OH 43210, USA
| | - Marcia Nahikian-Nelms
- School of Health and Rehabilitation Sciences, College of Medicine, The Ohio State University, 453 West 10th Avenue, Columbus, OH 43210, USA
| | - Andrew Ukleja
- Department of Gastroenterology, Digestive Disease Institute, 2950 Cleveland Clinic Florida, Weston FL 33331, USA
| | - Luis F Lara
- Division of Gastroenterology, Hepatology and Nutrition, Wexner Medical Center, The Ohio State University, 395 West 12th Avenue, 2nd Floor Office Tower, Columbus, OH 43210, USA.
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21
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Feinberg J, Nielsen EE, Korang SK, Halberg Engell K, Nielsen MS, Zhang K, Didriksen M, Lund L, Lindahl N, Hallum S, Liang N, Xiong W, Yang X, Brunsgaard P, Garioud A, Safi S, Lindschou J, Kondrup J, Gluud C, Jakobsen JC. Nutrition support in hospitalised adults at nutritional risk. Cochrane Database Syst Rev 2017; 5:CD011598. [PMID: 28524930 PMCID: PMC6481527 DOI: 10.1002/14651858.cd011598.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND The prevalence of disease-related malnutrition in Western European hospitals is estimated to be about 30%. There is no consensus whether poor nutritional status causes poorer clinical outcome or if it is merely associated with it. The intention with all forms of nutrition support is to increase uptake of essential nutrients and improve clinical outcome. Previous reviews have shown conflicting results with regard to the effects of nutrition support. OBJECTIVES To assess the benefits and harms of nutrition support versus no intervention, treatment as usual, or placebo in hospitalised adults at nutritional risk. SEARCH METHODS We searched Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE (Ovid SP), Embase (Ovid SP), LILACS (BIREME), and Science Citation Index Expanded (Web of Science). We also searched the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp); ClinicalTrials.gov; Turning Research Into Practice (TRIP); Google Scholar; and BIOSIS, as well as relevant bibliographies of review articles and personal files. All searches are current to February 2016. SELECTION CRITERIA We include randomised clinical trials, irrespective of publication type, publication date, and language, comparing nutrition support versus control in hospitalised adults at nutritional risk. We exclude trials assessing non-standard nutrition support. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane and the Cochrane Hepato-Biliary Group. We used trial domains to assess the risks of systematic error (bias). We conducted Trial Sequential Analyses to control for the risks of random errors. We considered a P value of 0.025 or less as statistically significant. We used GRADE methodology. Our primary outcomes were all-cause mortality, serious adverse events, and health-related quality of life. MAIN RESULTS We included 244 randomised clinical trials with 28,619 participants that met our inclusion criteria. We considered all trials to be at high risk of bias. Two trials accounted for one-third of all included participants. The included participants were heterogenous with regard to disease (20 different medical specialties). The experimental interventions were parenteral nutrition (86 trials); enteral nutrition (tube-feeding) (80 trials); oral nutrition support (55 trials); mixed experimental intervention (12 trials); general nutrition support (9 trials); and fortified food (2 trials). The control interventions were treatment as usual (122 trials); no intervention (107 trials); and placebo (15 trials). In 204/244 trials, the intervention lasted three days or more.We found no evidence of a difference between nutrition support and control for short-term mortality (end of intervention). The absolute risk was 8.3% across the control groups compared with 7.8% (7.1% to 8.5%) in the intervention groups, based on the risk ratio (RR) of 0.94 (95% confidence interval (CI) 0.86 to 1.03, P = 0.16, 21,758 participants, 114 trials, low quality of evidence). We found no evidence of a difference between nutrition support and control for long-term mortality (maximum follow-up). The absolute risk was 13.2% in the control group compared with 12.2% (11.6% to 13%) following nutritional interventions based on a RR of 0.93 (95% CI 0.88 to 0.99, P = 0.03, 23,170 participants, 127 trials, low quality of evidence). Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.We found no evidence of a difference between nutrition support and control for short-term serious adverse events. The absolute risk was 9.9% in the control groups versus 9.2% (8.5% to 10%), with nutrition based on the RR of 0.93 (95% CI 0.86 to 1.01, P = 0.07, 22,087 participants, 123 trials, low quality of evidence). At long-term follow-up, the reduction in the risk of serious adverse events was 1.5%, from 15.2% in control groups to 13.8% (12.9% to 14.7%) following nutritional support (RR 0.91, 95% CI 0.85 to 0.97, P = 0.004, 23,413 participants, 137 trials, low quality of evidence). However, the Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.Trial Sequential Analysis of enteral nutrition alone showed that enteral nutrition might reduce serious adverse events at maximum follow-up in people with different diseases. We could find no beneficial effect of oral nutrition support or parenteral nutrition support on all-cause mortality and serious adverse events in any subgroup.Only 16 trials assessed health-related quality of life. We performed a meta-analysis of two trials reporting EuroQoL utility score at long-term follow-up and found very low quality of evidence for effects of nutritional support on quality of life (mean difference (MD) -0.01, 95% CI -0.03 to 0.01; 3961 participants, two trials). Trial Sequential Analyses showed that we did not have enough information to confirm or reject clinically relevant intervention effects on quality of life.Nutrition support may increase weight at short-term follow-up (MD 1.32 kg, 95% CI 0.65 to 2.00, 5445 participants, 68 trials, very low quality of evidence). AUTHORS' CONCLUSIONS There is low-quality evidence for the effects of nutrition support on mortality and serious adverse events. Based on the results of our review, it does not appear to lead to a risk ratio reduction of approximately 10% or more in either all-cause mortality or serious adverse events at short-term and long-term follow-up.There is very low-quality evidence for an increase in weight with nutrition support at the end of treatment in hospitalised adults determined to be at nutritional risk. The effects of nutrition support on all remaining outcomes are unclear.Despite the clinically heterogenous population and the high risk of bias of all included trials, our analyses showed limited signs of statistical heterogeneity. Further trials may be warranted, assessing enteral nutrition (tube-feeding) for different patient groups. Future trials ought to be conducted with low risks of systematic errors and low risks of random errors, and they also ought to assess health-related quality of life.
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Affiliation(s)
- Joshua Feinberg
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Emil Eik Nielsen
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Steven Kwasi Korang
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Kirstine Halberg Engell
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Marie Skøtt Nielsen
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Kang Zhang
- Beijing University of Chinese MedicineCentre for Evidence‐Based Chinese MedicineBeijingChina
| | - Maria Didriksen
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Lisbeth Lund
- Danish Committee for Health Education5. sal, Classensgade 71CopenhagenDenmark2100
| | - Niklas Lindahl
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Sara Hallum
- Cochrane Colorectal Cancer Group23 Bispebjerg BakkeBispebjerg HospitalCopenhagenDenmarkDK 2400 NV
| | - Ning Liang
- Beijing University of Chinese MedicineCentre for Evidence‐Based Chinese MedicineBeijingChina
| | - Wenjing Xiong
- Beijing University of Chinese MedicineCentre for Evidence‐Based Chinese MedicineBeijingChina
| | - Xuemei Yang
- Fujian University of Traditional Chinese MedicineResearch Base of TCM syndromeNo。1,Qiu Yang RoadShangjie town,Minhou CountyFuzhouFujian ProvinceChina350122
| | - Pernille Brunsgaard
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Alexandre Garioud
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Sanam Safi
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Jane Lindschou
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Jens Kondrup
- Rigshospitalet University HospitalClinical Nutrition UnitAmager Boulevard 127, 2th9 BlegdamsvejKøbenhavn ØDenmark2100
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
- Holbaek HospitalDepartment of CardiologyHolbaekDenmark4300
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Affiliation(s)
- Timothy O Lipman
- Department of Veterans Affairs Medical Center, Gastroenterology-Hepatology-Nutrition Section, Washington, DC 20422, USA.
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Stimac D, Poropat G, Hauser G, Licul V, Franjic N, Valkovic Zujic P, Milic S. Early nasojejunal tube feeding versus nil-by-mouth in acute pancreatitis: A randomized clinical trial. Pancreatology 2016; 16:523-8. [PMID: 27107634 DOI: 10.1016/j.pan.2016.04.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 03/28/2016] [Accepted: 04/02/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES There is substantial evidence of superiority of enteral nutrition (EN) to parenteral nutrition in acute pancreatitis (AP) treatment, but few studies evaluated its effectiveness compared to no intervention. The objective of our trial was to compare the effects of EN to a nil-by-mouth (NBM) regimen in patients with AP. METHODS Patients with AP were randomized to receive either EN via a nasojejunal tube initiated within 24 h of admission or no nutritional support. Systemic inflammatory response syndrome (SIRS) was assessed as the primary outcome. Secondary outcomes included mortality, organ failure, local complications, infected pancreatic necrosis, surgical interventions, length of hospital stay, adverse events and inflammatory response intensity. Outcomes were compared using Student's t-test and Mann-Whitney U test as appropriate. RESULTS 214 patients were randomized in total, 107 to each group. SIRS occurrence was similar between groups, with 48 (45%) versus 51 (48%), respectively (RR 0.94; 95% CI 0.71-1.26). No significant reduction of persistent organ failure (RR 0.81; 95% CI 0.52-1.27) and mortality (RR 0.59; 95% CI 0.28-1.23) was present in the EN group. There were no significant differences in other outcomes between the groups. When analyzing the occurrence of SIRS and mortality in subgroup of patients with severe disease no significant differences were noted. CONCLUSION Our results showed no significant reduction of persistent organ failure and mortality in patients with AP receiving early EN compared to patients treated with no nutritional support (NCT01965873).
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Affiliation(s)
- D Stimac
- Department of Gastroenterology, Faculty of Medicine Rijeka, University Hospital Rijeka, Rijeka, Croatia
| | - G Poropat
- Department of Gastroenterology, Faculty of Medicine Rijeka, University Hospital Rijeka, Rijeka, Croatia.
| | - G Hauser
- Department of Gastroenterology, Faculty of Medicine Rijeka, University Hospital Rijeka, Rijeka, Croatia
| | - V Licul
- Department of Gastroenterology, Faculty of Medicine Rijeka, University Hospital Rijeka, Rijeka, Croatia
| | - N Franjic
- Department of Gastroenterology, Faculty of Medicine Rijeka, University Hospital Rijeka, Rijeka, Croatia
| | - P Valkovic Zujic
- Department of Radiology, Faculty of Medicine Rijeka, University Hospital Rijeka, Rijeka, Croatia
| | - S Milic
- Department of Gastroenterology, Faculty of Medicine Rijeka, University Hospital Rijeka, Rijeka, Croatia
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Horibe M, Nishizawa T, Suzuki H, Minami K, Yahagi N, Iwasaki E, Kanai T. Timing of oral refeeding in acute pancreatitis: A systematic review and meta-analysis. United European Gastroenterol J 2015; 4:725-732. [PMID: 28408989 DOI: 10.1177/2050640615612368] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 09/21/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND AIM The optimal timing of oral refeeding in acute pancreatitis is unclear. This study aimed to perform a systematic review with meta-analysis of randomized controlled trials (RCTs) that compared early oral refeeding with standard oral refeeding in acute pancreatitis. METHODS PubMed, the Cochrane library, and the Igaku-Chuo-Zasshi database were searched in order to identify RCTs eligible for inclusion in the systematic review. The weighted mean differences (WMDs) or odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. RESULTS Five eligible RCTs were included. Compared with standard oral refeeding, early oral refeeding significantly decreased the length of hospital stay (WMD: -2.22, 95%CI: -3.37 to -1.08, p = 0.0001). Although there was heterogeneity (I2 = 56%, p = 0.06), subgroup analysis of the refeeding criteria (immediate group and hungry group) eliminated the heterogeneity. There was no significant difference between the early refeeding group and standard refeeding groups with respect abdominal pain and distension (OR 1.14; 95%CI 0.65-1.99 and OR 1.53; 95%CI 0.81-2.90). CONCLUSIONS Compared with standard oral refeeding, early oral refeeding safely reduced the length of hospital stay in patients with acute pancreatitis.
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Affiliation(s)
- Masayasu Horibe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine
| | - Toshihiro Nishizawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine.,Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School Of Medicine
| | - Hidekazu Suzuki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine
| | - Kazuhiro Minami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School Of Medicine
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine
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Mansfield C, Beths T. Management of acute pancreatitis in dogs: a critical appraisal with focus on feeding and analgesia. J Small Anim Pract 2015; 56:27-39. [PMID: 25586804 DOI: 10.1111/jsap.12296] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 05/22/2014] [Accepted: 05/26/2014] [Indexed: 12/31/2022]
Abstract
Knowledge about acute pancreatitis has increased recently in both the medical and veterinary fields. Despite this expansion of knowledge, there are very few studies on treatment interventions in naturally occurring disease in dogs. As a result, treatment recommendations are largely extrapolated from experimental rodent models or general critical care principles. General treatment principles involve replacing fluid losses, maintaining hydrostatic pressure, controlling nausea and providing pain relief. Specific interventions recently advocated in human medicine include the use of neurokinin-1 antagonists for analgesia and early interventional feeding. The premise for early feeding is to improve the health of the intestinal tract, as unhealthy enterocytes are thought to perpetuate systemic inflammation. The evidence for early interventional feeding is not supported by robust clinical trials to date, but in humans there is evidence that it reduces hospitalisation time and in dogs it is well tolerated. This article summarises the major areas of management of acute pancreatitis in dogs and examines the level of evidence for each recommendation.
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Affiliation(s)
- C Mansfield
- Faculty of Veterinary and Agricultural Sciences, The University of Melbourne, 250 Princes Highway, Werribee, Victoria 3030, Australia
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26
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When to initialize enteral nutrition in patients with severe acute pancreatitis? A retrospective review in a single institution experience (2003-2013). Pancreas 2015; 44:507-11. [PMID: 25723878 DOI: 10.1097/mpa.0000000000000293] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The present retrospective study aimed to analyze the optimal time to initiate enteral nutrition (EN) in patients with severe acute pancreatitis at a single Chinese institution (China Medical University Hospital). METHODS A total of 1196 patients with severe acute pancreatitis were admitted in the intensive care unit between November 2003 and June 2013; 1092 patients were selected and were divided into the early and delayed EN groups, according to their initial timing of EN. RESULTS Five hundred sixty-six patients were administered with the delayed EN, and 526 with the early EN. Both groups had similar severity of pancreatic necrosis, but organ failure developed in 81% patients of the delayed EN group and 21% in the early EN group (P < 0.01). The numbers of septic necrosis and morbidity were significantly higher in the delayed EN group than in the early EN (P < 0.01). CONCLUSIONS The early EN had significant benefits over the delayed EN in the decrease of organ failure and mortality; our findings suggested that the first 48 hours of administration in the intensive care unit was the optimal time to start EN.
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Lei QC, Wang XY, Xia XF, Zheng HZ, Bi JC, Tian F, Li N. The role of omega-3 fatty acids in acute pancreatitis: a meta-analysis of randomized controlled trials. Nutrients 2015; 7:2261-73. [PMID: 25835048 PMCID: PMC4425143 DOI: 10.3390/nu7042261] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 02/23/2015] [Accepted: 03/17/2015] [Indexed: 12/19/2022] Open
Abstract
To determine whether treatment with omega-3 fatty acids (ω-3 FA) provides benefits to patients with acute pancreatitis (AP). The Cochrane Library, PubMed, Embase, Web of Science, and Chinese Biomedical Literature Database were searched. Data analysis was performed using Revman 5.2 software. A total of eight randomized controlled trials (RCTs) were included. Overall, ω-3 FA treatment resulted in a significantly reduced risk of mortality (RR 0.35; 95% CI 0.16 to 0.75, p < 0.05), infectious complications (RR 0.54; 95% CI 0.34 to 0.85, p < 0.05) and length of hospital stay (MD -6.50; 95% CI -9.54 to -3.46, p < 0.05), but not length of ICU stay (MD -1.98; 95% CI -6.92 to 2.96, p > 0.05). In subgroup analysis, only patients who received ω-3 FA parenterally had some statistically significant benefits in terms of mortality (risk ratio (RR) 0.37; 95% confidence interval (CI) 0.16 to 0.86, p < 0.05), infectious complications (RR 0.5; 95% CI 0.28 to 0.9, p < 0.05) and length of hospital stay (mean difference (MD) -8.13; 95% CI -10.39 to -5.87, p < 0.001). The administration of ω-3 FA may be beneficial for decreasing mortality, infectious complications, and length of hospital stay in AP, especially when used parenterally. Large and rigorously designed RCTs are required to elucidate the efficacy of parenteral or enteral ω-3 FA treatment in AP.
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Affiliation(s)
- Qiu Cheng Lei
- Graduate School, Southern Medical University, Guangzhou 510515, China.
- Department of General Surgery, Jinling Hospital, Clinical College of Southern Medical University, Nanjing 210002, China.
| | - Xin Ying Wang
- Graduate School, Southern Medical University, Guangzhou 510515, China.
- Department of General Surgery, Jinling Hospital, Clinical College of Southern Medical University, Nanjing 210002, China.
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, China.
| | - Xian Feng Xia
- Department of Surgery, Prince of Wales Hospital, Faculty of Medicine, the Chinese University of Hong Kong, Hong Kong 999077, China.
| | - Hua Zhen Zheng
- Key Laboratory for Medical Molecular Diagnostics of Guangdong Province, Guangdong Medical College, Dongguan 523808, China.
| | - Jing Cheng Bi
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, China.
| | - Feng Tian
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, China.
| | - Ning Li
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, China.
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Abstract
BACKGROUND Acute pancreatitis is a common and potentially lethal disease with increasing incidence. Severe cases are characterised by high mortality, and despite improvements in intensive care management, no specific treatment relevantly improves clinical outcomes of the disease. Meta-analyses suggest that enteral nutrition is more effective than conventional treatment consisting of discontinuation of oral intake with use of total parenteral nutrition. However, no systematic review has compared different enteral nutrition formulations for the treatment of patients with acute pancreatitis. OBJECTIVES To assess the beneficial and harmful effects of different enteral nutrition formulations in patients with acute pancreatitis. SEARCH METHODS We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Specialised Register of Clinical Trials, the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 7), MEDLINE (from inception to 20 August 2013), EMBASE (from inception to 2013, week 33) and Science Citation Index-Expanded (from 1990 to August 2013); we conducted full-text searches and applied no restrictions by language or publication status. SELECTION CRITERIA We considered randomised clinical trials assessing enteral nutrition in patients with acute pancreatitis. We allowed concomitant interventions if they were received equally by all treatment groups within a trial. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and extracted data. We performed the analysis using Review Manager 5 (Review Manager 2013) and both fixed-effect and random-effects models. We expressed results as risk ratios (RRs) for dichotomous data, and as mean differences (MDs) for continuous data, both with 95% confidence intervals (CIs). Analysis was based on an intention-to-treat principle. MAIN RESULTS We included 15 trials (1376 participants) in this review. We downgraded the quality of evidence for many of our outcomes on the basis of high risk of bias. Low-quality evidence suggests that immunonutrition decreases all-cause mortality (RR 0.49, 95% CI 0.29 to 0.80). The effect of immunonutrition on other outcomes from a subset of the included trials was uncertain. Subgrouping trials by type of enteral nutrition did not explain any variation in effect. We found mainly very low-quality evidence for the effects of probiotics on the main outcomes. One eligible trial in this comparison reported a higher rate of serious adverse events leading to increased organ failure and mortality due to low numbers of events and low risk of bias. When we excluded this study as a post hoc sensitivity analysis, risks of mortality (RR 0.30, 95% CI 0.10 to 0.84), organ failure (RR 0.74, 95% CI 0.59 to 0.92) and local septic complications (RR 0.40, 95% CI 0.22 to 0.72) were lower with probiotics. In one trial assessing immunonutrition with probiotics and fibres, no deaths occurred, but hospital stay was shorter with immunonutrition (MD -5.20 days, 95% CI -8.73 to -1.67). No deaths were reported following semi-elemental enteral nutrition (EN), and the effect on length of hospital stay was small (MD 0.30 days, 95% CI -0.82 to 1.42). Fibre-enriched formulations reduced the number of other local complications (RR 0.52, 95% CI 0.32 to 0.87) and length of hospital stay (MD -9.28 days, 95% CI -13.21 to -5.35) but did not significantly affect all-cause mortality (RR 0.23, 95% CI 0.03 to 1.84) and other outcomes. Very low-quality evidence from the subgroup of trials comparing EN versus no intervention showed a decrease in all-cause mortality with EN (RR 0.50, 95% CI 0.29 to 0.86). AUTHORS' CONCLUSIONS We found evidence of low or very low quality for the effects of immunonutrition on efficacy and safety outcomes. The role of supplementation of enteral nutrition with potential immunomodulatory agents remains in question, and further research is required in this area. Studies assessing probiotics yielded inconsistent and almost contrary results, especially regarding safety and adverse events, and their findings do not support the routine use of EN enriched with probiotics in routine clinical practice. However, further research should be carried out to try to determine the potential efficacy or harms of probiotics. Lack of trials reporting on other types of EN assessed and lack of firm evidence regarding their effects suggest that additional randomised clinical trials are needed. The quality of evidence for the effects of any kind of EN on mortality was low, and further studies are likely to have an impact on the finding of improved survival with EN versus no nutritional support. Evidence remains insufficient to support the use of a specific EN formulation.
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Affiliation(s)
- Goran Poropat
- Department of Gastroenterology, Clinical Hospital Centre Rijeka, Kresimirova 42, Rijeka, Croatia, 51000
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29
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Wu LM, Sankaran SJ, Plank LD, Windsor JA, Petrov MS. Meta-analysis of gut barrier dysfunction in patients with acute pancreatitis. Br J Surg 2014; 101:1644-56. [PMID: 25334028 DOI: 10.1002/bjs.9665] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 07/05/2014] [Accepted: 09/05/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND The gut is implicated in the pathogenesis of acute pancreatitis but there is discrepancy between individual studies regarding the prevalence of gut barrier dysfunction in patients with acute pancreatitis. The aim of this study was to determine the prevalence of gut barrier dysfunction in acute pancreatitis, the effect of different co-variables, and changes in gut barrier function associated with the use of various therapeutic modalities. METHODS A literature search was performed using PRISMA and MOOSE guidelines. Summary estimates were presented as pooled prevalence of gut barrier dysfunction and the associated 95 per cent c.i. RESULTS A total of 44 prospective clinical studies were included in the systematic review, of which 18 studies were subjected to meta-analysis. The pooled prevalence of gut barrier dysfunction was 59 (95 per cent c.i. 48 to 70) per cent; the prevalence was not significantly affected by disease severity, timing of assessment after hospital admission or type of test used, but showed a statistically significant association with age. Overall, nine of 13 randomized clinical trials reported a significant improvement in gut barrier function following intervention compared with the control group, but only three of six studies that used standard enteral nutrition reported a statistically significant improvement in gut barrier function after intervention. CONCLUSION Gut barrier dysfunction is present in three of five patients with acute pancreatitis, and the prevalence is affected by patient age but not by disease severity. Clinical studies are needed to evaluate the effect of enteral nutrition on gut function in acute pancreatitis.
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Affiliation(s)
- L M Wu
- Department of Surgery, University of Auckland, Auckland, New Zealand
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Oláh A, Romics Jr L. Enteral nutrition in acute pancreatitis: A review of the current evidence. World J Gastroenterol 2014; 20:16123-16131. [PMID: 25473164 PMCID: PMC4239498 DOI: 10.3748/wjg.v20.i43.16123] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 07/22/2014] [Indexed: 02/06/2023] Open
Abstract
The use of enteral feeding as part of the management of acute pancreatitis dates back almost two decades. This review describes the indications for and limitations of enteral feeding for the treatment of acute pancreatitis using up-to-date evidence-based data. A systematic review was carried out to analyse current data on the use of enteral nutrition in the management of acute pancreatitis. Relevant literature was analysed from the viewpoints of enteral vs parenteral feeding, early vs delayed enteral nutrition, nasogastric vs nasojejunal feeding, and early oral diet and immunonutrition, particularly glutamine and probiotic supplementation. Finally, current applicable guidelines and the effects of these guidelines on clinical practice are discussed. The latest meta-analyses suggest that enteral nutrition significantly reduces the mortality rate of severe acute pancreatitis compared to parenteral feeding. To maintain gut barrier function and prevent early bacterial translocation, enteral feeding should be commenced within the first 24 h of hospital admission. Also, the safety of nasogastric feeding, which eases the administration of enteral nutrients in the clinical setting, is likely equal to nasojejunal feeding. Furthermore, an early low-fat oral diet is potentially beneficial in patients with mild pancreatitis. Despite the initial encouraging results, the current evidence does not support the use of immunoenhanced nutrients or probiotics in patients with acute pancreatitis.
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Affiliation(s)
- Ronald L. Koretz
- Olive View–UCLA Medical Center, David Geffen–UCLA School of Medicine, Sylmar and Los Angeles, California
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Bakker OJ, van Brunschot S, Farre A, Johnson CD, Kalfarentzos F, Louie BE, Oláh A, O'Keefe SJ, Petrov MS, Powell JJ, Besselink MG, van Santvoort HC, Rovers MM, Gooszen HG. Timing of enteral nutrition in acute pancreatitis: meta-analysis of individuals using a single-arm of randomised trials. Pancreatology 2014; 14:340-6. [PMID: 25128270 DOI: 10.1016/j.pan.2014.07.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Revised: 06/02/2014] [Accepted: 07/14/2014] [Indexed: 12/11/2022]
Abstract
INTRODUCTION In acute pancreatitis, enteral nutrition (EN) reduces the rate of complications, such as infected pancreatic necrosis, organ failure, and mortality, as compared to parenteral nutrition (PN). Starting EN within 24 h of admission might further reduce complications. METHODS A literature search for trials of EN in acute pancreatitis was performed. Authors of eligible trials were requested to provide the data of all patients in the EN-arm of their trials. A meta-analysis of individual patient data was performed. The cohort of patients with EN was divided into patients receiving EN within 24 h or after 24 h of admission. Multivariable logistic regression, adjusting for predicted disease severity and trial, was used to study the effect of timing of EN on a composite endpoint of infected pancreatic necrosis, organ failure, or mortality. RESULTS Observational data from 165 individuals from 8 randomised trials were obtained; 100 patients with EN within 24 h and 65 patients with EN after 24 h of admission. In the multivariable model, EN started within 24 h of admission compared to EN started after 24 h of admission, reduced the composite endpoint from 45% to 19% (adjusted odds ratio [OR] of 0.44; 95% confidence interval [CI] 0.20-0.96). Within the composite endpoint, organ failure was reduced from 42% to 16% (adjusted OR 0.42; 95% CI 0.19-0.94). CONCLUSIONS In this meta-analysis of observational data from individuals with acute pancreatitis, starting EN within 24 h after hospital admission, compared with after 24 h, was associated with a reduction in complications.
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Affiliation(s)
- Olaf J Bakker
- Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Sandra van Brunschot
- Dept. of Operation Theatres and Department of Health Evidence, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Antoni Farre
- Dept. of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Colin D Johnson
- Dept. of Surgery, Southampton General Hospital, University of Southampton, UK
| | - Fotis Kalfarentzos
- Dept. of Surgery, Nutritional and Metabolic Unit, University of Patras, Patras, Greece
| | - Brian E Louie
- Dept. of Thoracic Surgery, Swedish Cancer Instititute and Medical Center, Seattle, WA, USA
| | - Attila Oláh
- Dept. of Surgery, Petz Aladár Teaching Hospital, Györ, Hungary
| | - Stephen J O'Keefe
- Physicians Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh, PA, USA
| | - Maxim S Petrov
- Dept. of Surgery, University of Auckland, Auckland, New Zealand
| | - James J Powell
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Marc G Besselink
- Dept. of Surgery, Amsterdam Medical Center, Amsterdam, The Netherlands
| | | | - Maroeska M Rovers
- Dept. of Operation Theatres and Department of Health Evidence, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Hein G Gooszen
- Dept. of Operation Theatres and Department of Health Evidence, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Early enteral nutrition with polymeric feeds was associated with chylous ascites in patients with severe acute pancreatitis. Pancreas 2014; 43:553-8. [PMID: 24632544 DOI: 10.1097/mpa.0000000000000067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Chylous ascites (CA) may be involved in the pathological process of severe acute pancreatitis (SAP), but the underlying mechanisms remain unknown. This study investigated the incidence of CA in patients with SAP and its relationship with enteral nutrition (EN). METHODS A retrospective review of 85 patients with SAP admitted to our hospital was performed. Patients starting EN within 72 hours after the onset of SAP were classified as the early EN (EEN) group, and others, as the later EN group. The incidences of CA and prognosis in the EEN and later EN groups were examined with nutrition preparation of polymeric formula or semielemental feed. RESULTS Thirteen (15.29%) of 85 patients were identified with CA. A higher incidence of CA was observed in EEN patients who received polymeric formula (9 of 33, P < 0.05). All patients with CA were successfully treated with a modified medium-chain triglyceride diet. Consequently, there were no differences in intensive care unit stay and in mortality rates in patients with or without CA. CONCLUSIONS There was a higher incidence of CA associated with early enteral feeding of polymeric formula in patients with SAP. Future studies are warranted to confirm our findings and evaluate better enteral feeding options to avoid CA.
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Nutrition, inflammation, and acute pancreatitis. ISRN INFLAMMATION 2013; 2013:341410. [PMID: 24490104 PMCID: PMC3893749 DOI: 10.1155/2013/341410] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 10/30/2013] [Indexed: 12/14/2022]
Abstract
Acute pancreatitis is acute inflammatory disease of the pancreas. Nutrition has a number of anti-inflammatory effects that could affect outcomes of patients with pancreatitis. Further, it is the most promising nonspecific treatment modality in acute pancreatitis to date. This paper summarizes the best available evidence regarding the use of nutrition with a view of optimising clinical management of patients with acute pancreatitis.
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Fujita T, Daiko H, Nishimura M. Early enteral nutrition reduces the rate of life-threatening complications after thoracic esophagectomy in patients with esophageal cancer. ACTA ACUST UNITED AC 2012; 48:79-84. [PMID: 22377820 DOI: 10.1159/000336574] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Accepted: 01/15/2012] [Indexed: 12/15/2022]
Abstract
BACKGROUND Early postoperative enteral nutrition has been suggested to improve the nutritional status of patients after esophageal surgery. However, whether enteral nutrition decreases rates of surgical complications and increases the completion rate of the clinical management pathway is unclear. METHODS We analyzed 154 patients who were randomly assigned to either an enteral or parenteral nutrition group after undergoing esophagectomy, compared the incidence of surgical complications, and evaluated the completion rate of the clinical pathway. In these 2 patient groups, perioperative management was performed through identical clinical pathways, except for nutrition. RESULTS The overall rate of surgical complications of any type did not differ between patients who received early enteral nutrition and those who did not (p = 0.50); however, the rate of life-threatening surgical complications was significantly lower in patients who received early enteral nutrition (p = 0.02). The rate of non-life-threatening surgical complications did not differ between the groups (p = 0.98). In patients who received enteral nutrition, the completion rate of the clinical pathway was higher (p = 0.03), and the postoperative hospital stay was shorter (p = 0.04). CONCLUSIONS Early enteral nutrition reduces the incidence of life-threatening surgical complications and improves the completion rate of the clinical pathway for thoracic esophagectomy.
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Affiliation(s)
- T Fujita
- Division of Esophageal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
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Miranda CJ, Babu BI, Siriwardena AK. Recombinant human activated protein C as a disease modifier in severe acute pancreatitis: systematic review of current evidence. Pancreatology 2012; 12:119-23. [PMID: 22487521 DOI: 10.1016/j.pan.2012.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The severity of organ failure caused by acute pancreatitis (AP) is the most important determinant of mortality in the disease. Recombinant human activated protein C (Drotrecogin Alfa; Xigris, APC, rhAPC) is the first drug to show a decrease in all-cause mortality due to multiple organ failure caused by sepsis. As the systemic inflammatory response syndrome (SIRS) that causes organ failure in early AP is similar to that caused by severe sepsis, the use of rhAPC in the management of AP has been investigated in experimental and clinical studies which are collated in this review. METHODS A literature review of published material identified from MEDLINE and EMBASE databases, for the period from January 1985 to January 2011, reporting rhAPC usage in AP. RESULTS 3 of 4 experimental studies reported an improvement in outcome in animals with AP given rhAPC. The clinical randomized trial showed no improvement in outcome in the treatment arm. CONCLUSION The experimental evidence of disease amelioration in AP following intervention with rhAPC has not translated to the small clinical RCT. Given that there were only 16 patients in the treatment arm, further clinical evaluation is justified.
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Affiliation(s)
- Charles J Miranda
- Hepatobiliary Surgery Unit, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
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Evaluation of early enteral feeding through nasogastric and nasojejunal tube in severe acute pancreatitis: a noninferiority randomized controlled trial. Pancreas 2012; 41:153-9. [PMID: 21775915 DOI: 10.1097/mpa.0b013e318221c4a8] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE This study aimed to determine the noninferiority of early enteral feeding through nasogastric (NG) compared to nasojejunal (NJ) route on infectious complications in patients with severe acute pancreatitis (SAP). METHODS Patients with SAP were fed via NG (candidate) or NJ (comparative) route. The primary outcome was the occurrence of any infectious complication in blood, pancreatic tissue, bile, or tracheal aspirate. Secondary end points were pain in refeeding, duration of hospital stay, intestinal permeability assessed by lactulose/mannitol excretion, and endotoxemia assessed by endotoxin core antibody types immunoglobulin G and M. RESULTS Seventy-eight patients were randomized to feeding by either the NG or the NJ route. During the hospital stay, the presence of any infectious complication in the NG and NJ groups was 23.1% and 35.9% (significantly different), respectively. The effect size of the difference of infectious complications was -12.8 (95% confidence interval, -29.6 to 4.0). The upper limit of the 95% confidence interval was 4.0 and was within the 5% limit set for noninferiority. The value of 8.0 for the number needed to treat implies that 8 patients should be treated with NG compared with the NJ group to prevent 1 patient from any of the infectious complications. CONCLUSIONS Early enteral feeding through NG was not inferior to NJ in patients with SAP. Infectious complications were within the noninferiority limit. Pain in refeeding, intestinal permeability, and endotoxemia were comparable in both groups.
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Hegazi R, Raina A, Graham T, Rolniak S, Centa P, Kandil H, O'Keefe SJ. Early jejunal feeding initiation and clinical outcomes in patients with severe acute pancreatitis. JPEN J Parenter Enteral Nutr 2011; 35:91-6. [PMID: 21224435 DOI: 10.1177/0148607110376196] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Compared with parenteral nutrition, enteral nutrition reduces infectious complications and mortality in patients with severe acute pancreatitis (SAP). This study used clinical outcomes to investigate the association between time to initiation of distal jejunal feeding (DJF) and time to achievement of goal enteral feeding with clinical outcomes. METHODS A retrospective chart review was performed on all patients with SAP admitted to the medical intensive care unit (ICU) during a 1-year period. Collected data included demographic information, body mass index (BMI; kg/m(2)), Acute Physiology and Chronic Health Evaluation (APACHE) II scores at admission, time of onset of DJF, time to goal feeding, ICU length of stay, and mortality. RESULTS Time to starting DJF was longer in nonsurvivors (n = 4) than in survivors (n = 12) (17 vs 7 days, P < .05). All nonsurvivors had BMI >30 kg/m(2) (50% had BMI > 50 kg/m(2)). ICU length of stay was significantly associated with achievement of goal feeding. Three patients never reached goal feeding and spent 45.3 ± 19.6 days in the ICU; 7 patients reached goal feeding within 3 days of initiating DJF and spent 18 ± 1.7 days in the ICU; and 4 patients reached goal feeding within 3 days and spent 10.5 ± 3.5 days in the ICU. APACHE II scores were not significantly different among the 3 groups (16.7 ± 1.5, 12 ± 0.7, and 16.2 ± 1.2, respectively, P > .05). CONCLUSIONS Early initiation of DJF in the ICU was associated with reduced mortality in this cohort of patients with SAP. Early achievement of jejunal feeding goal early was associated with a shorter ICU length of stay, irrespective of the severity of SAP.
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Affiliation(s)
- Refaat Hegazi
- University of Pittsburgh, Pittsburgh, PA 15261, USA.
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Mansfield C, James F, Steiner J, Suchodolski J, Robertson I, Hosgood G. A Pilot Study to Assess Tolerability of Early Enteral Nutrition via Esophagostomy Tube Feeding in Dogs with Severe Acute Pancreatitis. J Vet Intern Med 2011; 25:419-25. [DOI: 10.1111/j.1939-1676.2011.0703.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Abstract
MOTIVATION The American Society of Parenteral and Enteral Nutrition (ASPEN) guidelines advise use of enteral nutrition (EN) for critically ill hospital patients requiring nutritional support, but no studies have comprehensively estimated economic benefits from adherence to this recommendation. METHODS We systematically reviewed studies comparing EN to alternative nutritional support therapies among adult, critically ill patients. We reviewed 1200 abstracts, selected 243 for further review, and included 48 studies in our analysis. Most retained studies compared EN and parenteral nutrition (PN). Using meta-analysis, we estimated the absolute impact of EN on adverse event risk and its impact on treatment duration and length of stay. These estimates were converted to population economic impacts by assuming 10% of PN patients are suitable candidates for EN. RESULTS Compared to PN, EN reduces the risk of major, potentially life-threatening infections (RR = 0.58, 95% confidence interval [CI] 0.44 to 0.77), the risk of major, potentially life-threatening non-infection events (RR = 0.73, CI 0.59 to 0.91), and suggests a reduction in mortality, although this result did not achieve statistical significance (RR = 0.70, CI 0.45 to 1.09). EN also reduces inpatient length of stay, time in the ICU, and length of nutritional treatment. Compared to PN, EN savings from reduced adverse event risks average nearly $1500 per patient; savings from reduced hospital length of stay amount to nearly $2500 per patient. Shifting 10% of parenterally treated adult patients in the U.S. to EN would save $35 million annually due to reduced adverse events and another $57 million due to shorter hospital stays. CONCLUSION The evidence of both clinical and economic gains from EN is consistent with ASPEN guidelines recommending use of EN in critically ill hospital patients when possible.
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Affiliation(s)
- Michael J Cangelosi
- Center for Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA 02111, USA
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Williamson JML, Williamson RCN. Alcohol and the pancreas. Br J Hosp Med (Lond) 2010; 71:556-61. [PMID: 21085071 DOI: 10.12968/hmed.2010.71.10.78938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- J M L Williamson
- Department of Surgery, The Great Western Hospital, Swindon, Wiltshire SN3 6BB
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Abstract
Introduction. In patients with acute pancreatitis (AP), nutritional support is required if normal food cannot be tolerated within several days. Enteral nutrition is preferred over parenteral nutrition. We reviewed the literature about enteral nutrition in AP. Methods. A MEDLINE search of the English language literature between 1999-2009. Results. Nasogastric tube feeding appears to be safe and well tolerated in the majority of patients with severe AP, rendering the concept of pancreatic rest less probable. Enteral nutrition has a beneficial influence on the outcome of AP and should probably be initiated as early as possible (within 48 hours). Supplementation of enteral formulas with glutamine or prebiotics and probiotics cannot routinely be recommended. Conclusions. Nutrition therapy in patients with AP emerged from supportive adjunctive therapy to a proactive primary intervention. Large multicentre studies are needed to confirm the safety and effectiveness of nasogastric feeding and to investigate the role of early nutrition support.
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Oláh A, Romics L. Evidence-based use of enteral nutrition in acute pancreatitis. Langenbecks Arch Surg 2010; 395:309-16. [PMID: 20309576 DOI: 10.1007/s00423-010-0631-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Accepted: 03/02/2010] [Indexed: 02/06/2023]
Abstract
PURPOSE A systematic review was carried out to analyze current evidence-based data on the use of enteral nutrition in the management of acute pancreatitis. METHODS Literature search was performed on "Pubmed" and "Medline" databases to identify articles investigating the role and potential effect of enteral nutrition on the outcome of patients with acute pancreatitis. Relevant data were analyzed from the viewpoints of possible benefits and complications, route and timing of administration, and composition of nutrients. RESULTS Thirty-two prospective randomized controlled trials and 15 meta-analyses of those were identified and included in this overview. Strong evidence suggests that enteral nutrition significantly reduces mortality rate of severe acute pancreatitis. While both nasogastric and nasojejunal feeding appear to be safe in severe pancreatitis, early low-fat oral diet is possibly beneficial in patients with mild pancreatitis. Since maintenance of the gut barrier function is one of the crucial effects of enteral nutrition, enteral feeding should be commenced within the first 24 h after hospital admission, in order to prevent early bacterial translocation. However, it seems that neither immunonoenhanced nutrients nor probiotic supplementation are able to reduce mortality further, and--therefore--cannot be recommended for patients with acute pancreatitis. CONCLUSION Although enteral nutrition is undoubtedly a key component of the management of acute pancreatitis, the exact role of that is needed to be defined yet. In particular, conflicting data from studies on nutrient compositions will require further clarification in the future.
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Affiliation(s)
- Attila Oláh
- Department of Surgery, Petz Aladár Teaching Hospital, 9002, Gyor, P.O. Box 92, Hungary.
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Abstract
OBJECTIVE This study was designed to evaluate the effects of total enteral nutrition and total parenteral nutrition in prevention of pancreatic necrotic infection in severe acute pancreatitis. METHODS One hundred seven patients were enrolled in the study between 2003 and 2007. In the first week of hospitalization, they were randomized to feeding by either total parenteral nutrition (54 patients) or total enteral nutrition (53 patients). All patients were concomitantly administered with sufficient prophylactic antibiotics. Computed tomographic scan and C-reactive protein level indicated a similar clinical severity in both groups. RESULTS Eighty percent of the patients developed organ failure in the group with total parenteral nutrition, which was higher than that in the group with total enteral nutrition (21%). Eighty percent and 22% (P < 0.05) of the patients in the total parenteral nutrition and total enteral nutrition groups, respectively, underwent surgical intervention. The incidence of pancreatic septic necroses in the group with total enteral nutrition (23%) was lower than that in the group with total parenteral nutrition (72%, P < 0.05). Mortality in the total parenteral nutrition group (43%) was higher than in the total enteral nutrition group (11%, P < 0.05). CONCLUSION Total enteral nutrition is better than total parenteral nutrition in the prevention of pancreatic necrotic infection in severe acute pancreatitis.
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Al‐Omran M, AlBalawi ZH, Tashkandi MF, Al‐Ansary LA. Enteral versus parenteral nutrition for acute pancreatitis. Cochrane Database Syst Rev 2010; 2010:CD002837. [PMID: 20091534 PMCID: PMC7120370 DOI: 10.1002/14651858.cd002837.pub2] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute pancreatitis creates a catabolic stress state promoting a systemic inflammatory response and nutritional deterioration. Adequate supply of nutrients plays an important role in recovery. Total parenteral nutrition (TPN) has been standard practice for providing exogenous nutrients to patients with severe acute pancreatitis. However, recent data suggest that enteral nutrition (EN) is not only feasible, but safer and more effective.Therefore, we sought to update our systematic review to re-evaluate the level of evidence. OBJECTIVES To compare the effect of TPN versus EN on mortality, morbidity and length of hospital stay in patients with acute pancreatitis. SEARCH STRATEGY Trials were identified by computerized searches of The Cochrane Controlled Trials Register, MEDLINE, and EMBASE. Additional studies were identified by searching Scisearch, bibliographies of review articles and identified trials. The search was undertaken in August 2000 and updated in September 2002, October 2003, November 2004 and November 2008. No language restrictions were applied. SELECTION CRITERIA Randomized clinical trials comparing TPN to EN in patients with acute pancreatitis. DATA COLLECTION AND ANALYSIS Two reviewers independently abstracted data and assessed trial quality. A standardized form was used to extract relevant data. MAIN RESULTS Eight trials with a total of 348 participants were included. Comparing EN to TPN for acute pancreatitis, the relative risk (RR) for death was 0.50 (95% CI 0.28 to 0.91), for multiple organ failure (MOF) was 0.55 (95% CI 0.37 to 0.81), for systemic infection was 0.39 (95% CI 0.23 to 0.65), for operative interventions was 0.44 (95% CI 0.29 to 0.67), for local septic complications was 0.74 (95% CI 0.40 to 1.35), and for other local complications was 0.70 (95% CI 0.43 to 1.13). Mean length of hospital stay was reduced by 2.37 days in EN vs TPN groups (95% CI -7.18 to 2.44). Furthermore, a subgroup analysis for EN vs TPN in patients with severe acute pancreatitis showed a RR for death of 0.18 (95% CI 0.06 to 0.58) and a RR for MOF of 0.46 (95% CI 0.16 to 1.29). AUTHORS' CONCLUSIONS In patients with acute pancreatitis, enteral nutrition significantly reduced mortality, multiple organ failure, systemic infections, and the need for operative interventions compared to those who received TPN. In addition, there was a trend towards a reduction in length of hospital stay. These data suggest that EN should be considered the standard of care for patients with acute pancreatitis requiring nutritional support.
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Affiliation(s)
- Mohammed Al‐Omran
- College of Medicine, King Saud UniversityDepartment of Surgery and Peripheral Vascular Disease Research ChairP.O.Box 7805(37)RiyadhSaudi Arabia11472
| | - Zaina H AlBalawi
- College of Medicine, King Saud UniversitySheikh Abdullah S. Bahamdan Research Chair for Evidence‐Based Health Care and Knowledge TranslationP.O. Box 68639RiyadhCentralSaudi Arabia11537
| | - Mariam F Tashkandi
- LKSKI St. Michael's HospitalApplied Health Research Centre10 Queens Quay ‐ 1211TorontoOntarioCanadaM5J2R9
| | - Lubna A Al‐Ansary
- College of Medicine, King Saud UniversityDepartment of Family & Community Medicine, Holder of "Shaikh Abdullah S. Bahamdan" Research Chair for Evidence‐Based Health Care and Knowledge TranslationP.O.Box 2925RiyadhSaudi Arabia11461
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Petrov MS, Loveday BPT, Pylypchuk RD, McIlroy K, Phillips ARJ, Windsor JA. Systematic review and meta-analysis of enteral nutrition formulations in acute pancreatitis. Br J Surg 2009; 96:1243-52. [PMID: 19847860 DOI: 10.1002/bjs.6862] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Although the benefits of enteral nutrition in acute pancreatitis are well established, the optimal composition of enteral feeding is largely unknown. The aim of the study was to compare the tolerance and safety of enteral nutrition formulations in patients with acute pancreatitis. METHODS Electronic databases (Scopus, MEDLINE, Cochrane Controlled Clinical Trials Register) and the proceedings of major pancreatology conferences were searched. RESULTS Twenty randomized controlled trials, including 1070 patients, met the inclusion criteria. None of the following was associated with a significant difference in feeding intolerance: the use of (semi)elemental versus polymeric formulation (relative risk (RR) 0.62 (95 per cent confidence interval (c.i.) 0.10 to 3.97); P = 0.611); supplementation of enteral nutrition with probiotics (RR 0.69 (95 per cent c.i. 0.43 to 1.09); P = 0.110); or immunonutrition (RR 1.60 (95 per cent c.i. 0.31 to 8.29); P = 0.583). The risk of infectious complications and death did not differ significantly in any of the comparisons. CONCLUSION The use of polymeric, compared with (semi)elemental, formulation does not lead to a significantly higher risk of feeding intolerance, infectious complications or death in patients with acute pancreatitis. Neither the supplementation of enteral nutrition with probiotics nor the use of immunonutrition significantly improves the clinical outcomes.
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Affiliation(s)
- M S Petrov
- Department of Surgery, School of Medicine, University of Auckland, Auckland, New Zealand.
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Lu HG, Shi YB, Zhao LM, Bai C, Wang X. Role of enteral ebselen and ethylhydroxyethyl cellulose in pancreatitis-associated multiple-organ dysfunction in humans. ACTA ACUST UNITED AC 2009. [DOI: 10.1080/17471060701486209] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Affiliation(s)
- Ronald L. Koretz
- From the Department of Medicine, UCLA School of Medicine, Sylmar, California
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Gianotti L, Meier R, Lobo DN, Bassi C, Dejong CHC, Ockenga J, Irtun O, MacFie J. ESPEN Guidelines on Parenteral Nutrition: pancreas. Clin Nutr 2009; 28:428-35. [PMID: 19464771 DOI: 10.1016/j.clnu.2009.04.003] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Accepted: 04/01/2009] [Indexed: 12/13/2022]
Abstract
Assessment of the severity of acute pancreatitis (AP), together with the patient's nutritional status is crucial in the decision making process that determines the need for artificial nutrition. Both should be done on admission and at frequent intervals thereafter. The indication for nutritional support in AP is actual or anticipated inadequate oral intake for 5-7 days. This period may be shorter in those with pre-existing malnutrition. Substrate metabolism in severe AP is similar to that in severe sepsis or trauma. Parenteral amino acids, glucose and lipid infusion do not affect pancreatic secretion and function. If lipids are administered, serum triglycerides must be monitored regularly. The use of intravenous lipids as part of parenteral nutrition (PN) is safe and feasible when hypertriglyceridemia is avoided. PN is indicated only in those patients who are unable to tolerate targeted requirements by the enteral route. As rates of EN tolerance increase then volumes of PN should be decreased. When PN is administered, particular attention should be given to avoid overfeeding. When PN is indicated, a parenteral glutamine supplementation should be considered. In chronic pancreatitis PN may, on rare occasions, be indicated in patients with gastric outlet obstruction secondary to duodenal stenosis or those with complex fistulation, and in occasional malnourished patients prior to surgery.
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Affiliation(s)
- L Gianotti
- Department of Surgery, Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
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