Total parenteral nutrition in pancreatic disease

Comparative effectiveness of elemental formula in the early enteral nutrition management of acute pancreatitis: a retrospective cohort study

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.

Acute Pancreatitis: Work-up and Management

Acute pancreatitis is still a common clinical entity that causes significant morbidity and mortality. The most common etiological associations include chronic al coholism, biliary tract disease, iatrogenic (e.g., endo scopic retrograde cholangiopancreatography-induced), hypertriglyceridemia, and idiopathic varieties. New radiological techniques such as dynamic pancreatog raphy appear to be useful in diagnosing and determin ing the extent of necrotizing pancreatitis. Biochem ical variables such as the C-reactive protein and the trypsinogen-activated peptide seem promising in de tecting severe disease within the first few days of hospi talization. Computed tomographic-guided percutane ous aspiration of phlegmonous pancreatitis may be helpful in differentiating infected from noninfected masses. Although current studies have not identified any pharmacological agent as efficacious in improving sur vival, emergency sphincterotomy and removal of im pacted gallstones in severe gallstone pancreatitis may be beneficial in this regard. Prolonged (i.e., 7 day) perito neal dialysis may reduce the severity of pancreatic sep sis. Surgical drainage of infected fluid collections such as abscesses is a well-accepted adjunct to medical therapy. Surgical necrosectomy for necrotizing pancreatitis, however, which is advocated in some aggressive surgi cal units, is not yet commonplace and its role needs to be determined in controlled studies.

Enteral versus parenteral nutrition for acute pancreatitis

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.

Successful long-term jejunostomy feedings in relapsing pancreatitis: a case report

Relapsing pancreatitis is characterized by repeated episodes of acute inflammation of the pancreas, with either a localized or a systemic organic response that may progress to chronic pancreatitis. Enteral jejunal feedings have been shown to be effective in the management of acute pancreatitis, but long-term use of jejunal feedings as treatment of relapsing pancreatitis has not been reported. We describe the case of a young patient treated with long-term jejunal feedings to induce remission and prevent recurrence of acute relapsing pancreatitis. An 18-year-old Hispanic man had well-documented recurrent episodes of acute pancreatitis. Multiple studies were performed as part of the diagnostic workup of the patient's relapsing pancreatitis, including endoscopic ultrasound, endoscopic retrograde cholangiopancreatography with biliary sphincterotomy, and laparoscopic cholecystectomy. Despite medical therapy, endoscopic and surgical procedures, the patient continued having episodes of pancreatitis on a monthly basis, with over 13 distinct documented episodes of pancreatitis during a 15-month period. A jejunostomy tube was inserted surgically, and long-term jejunal feedings were instituted, with excellent control of the patient's symptoms. There was only 1 episode of pancreatitis in the ensuing 24 months associated with the resumption of oral feedings and a weight gain of 20 pounds during this time period. Chronic jejunal feedings seem to be an effective alternative for treatment and prevention of acute relapsing pancreatitis. To our knowledge, this is the first report of long-term enteral feedings in acute relapsing pancreatitis.

Laparoscopic cystogastrostomy for the treatment of pancreatic pseudocysts in children

Pancreatic pseudocysts (PPSs) are common sequelae of pancreatitis and pancreatic trauma. The management is based upon the pseudocyst size and presence of symptoms. Those requiring intervention are often drained using several available options. The use of laparoscopic cystogastrostomy for large and recurrent PPSs has been described in adult patients as a less morbid alternative to open drainage procedures. This technique is considered a novel approach in children. We describe 2 children who had PPSs amenable to laparoscopic cystogastrostomy. The first was an 11-year-old girl who had blunt abdominal trauma from a bicycle handlebar. The second patient was a 7-year-old girl who developed idiopathic pancreatitis. Briefly, 2 ports were placed through the anterior abdominal and gastric walls, and into the lumen of the stomach. This intraluminal placement provided access to the posterior gastric wall. Using electrocautery diathermy, an incision was made through the posterior gastric wall and into the adjacent pseudocyst to obtain complete and unobstructed drainage. Both children tolerated the procedures well with resolution of their PPSs. The patients were each discharged on the fourth postoperative day and have been asymptomatic on 2 years follow-up. Laparoscopic cystogastrostomy is a safe and effective alternative to open cystogastrostomy for the minimally invasive management of PPSs in the pediatric population.

Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis

OBJECTIVE

To compare the safety and clinical outcomes of enteral and parenteral nutrition in patients with acute pancreatitis.

DATA SOURCES

Medline, Embase, Cochrane controlled trials register, and citation review of relevant primary and review articles.

STUDY SELECTION

Randomised controlled studies that compared enteral nutrition with parenteral nutrition in patients with acute pancreatitis. From 117 articles screened, six were identified as randomised controlled trials and were included for data extraction.

DATA EXTRACTION

Six studies with 263 participants were analysed. Descriptive and outcome data were extracted. Main outcome measures were infections, complications other than infections, operative interventions, length of hospital stay, and mortality. The meta-analysis was performed with the random effects model.

DATA SYNTHESIS

Enteral nutrition was associated with a significantly lower incidence of infections (relative risk 0.45; 95% confidence interval 0.26 to 0.78, P = 0.004), reduced surgical interventions to control pancreatitis (0.48, 0.22 to 1.0, P = 0.05), and a reduced length of hospital stay (mean reduction 2.9 days, 1.6 days to 4.3 days, P < 0.001). There were no significant differences in mortality (relative risk 0.66, 0.32 to 1.37, P = 0.3) or non-infectious complications (0.61, 0.31 to 1.22, P = 0.16) between the two groups of patients.

CONCLUSIONS

Enteral nutrition should be the preferred route of nutritional support in patients with acute pancreatitis.

A rare manifestation of perforated diverticulitis: parastomal subcutaneous abscess

Perforation is a serious complication of diverticular disease. The sigmoid is the main affected anatomic site of perforated diverticulitis and sigmoid resection followed either by Hartmann procedure or primary anastomosis are the standard surgical approaches. Surgery, however, does not cure diverticular disease. About 50% of patients have residual diverticula. The morbidity of residual diverticula appears to be low [1]. However, adequate follow-up studies on recurrent diverticulitis after surgery are lacking. We report a rare case of recurrent perforated diverticulitis in the subcutaneous tissue in proximity of the colostomy after a Hartmann procedure for perforated diverticulitis of the sigmoid colon.

Management of severe acute pancreatitis

BACKGROUND

Acute pancreatitis is still associated with significant morbidity and mortality. Current management guidelines are sometimes equivocal, particularly in relation to the surgical treatment of severe disease. This review assesses available investigative and treatment strategies to allow the development of a formalized management approach.

METHODS

A literature review of diagnosis, staging and management of acute pancreatitis was performed.

RESULTS AND CONCLUSION

Recent evidence has helped to clarify the roles of computed tomography, endoscopic retrograde cholangiopancreatography, prophylactic antibiotics, enteral feeding and fine-needle aspiration for bacteriology in the management of acute pancreatitis. Despite a relative shortage of prospective randomized trials there has been a significant change in the surgical management of acute pancreatitis over the past 20 years. This change has been away from early aggressive surgical intervention towards more conservative management, except when infected necrosis is confirmed. A formalized approach, with appropriate use of the various non-surgical and surgical options, is feasible in the management of severe acute pancreatitis.

Enteral versus parenteral nutrition for acute pancreatitis

BACKGROUND

Acute pancreatitis creates a catabolic stress state promoting a systemic inflammatory response and nutritional deterioration. Adequate supply of nutrients plays an important role to ensure optimum recovery. Total parenteral nutrition (TPN) has been the standard practice for providing exogenous nutrients to patients with severe acute pancreatitis. However, recent data suggest that enteral nutrition (EN) is feasible. Thus, a comparison of EN and TPN in patients with acute pancreatitis needs to be made.

OBJECTIVES

To compare the effect of total parenteral nutrition (TPN) versus enteral nutrition (EN) on mortality, morbidity and length of hospital stay in patient with acute pancreatitis.

SEARCH STRATEGY

Trials were identified by computerized searches of The Cochrane Controlled Trials Register, MEDLINE, and EMBASE. Additional studies were identified and included where relevant by searching Scisearch, the bibliographies of review articles and identified trials, and personal files. The search was undertaken in August, 2000 and updated in September 2002. No language restrictions were applied.

SELECTION CRITERIA

Randomized clinical trials, in which nutrition support with TPN were compared to EN in patients with acute pancreatitis.

DATA COLLECTION AND ANALYSIS

Two reviewers independently abstracted data and assessed trial quality. Information was collected on death, length of hospital stay, systemic infection, local septic complications, and other local complications.

MAIN RESULTS

Two trials with a total of 70 participants were included. The relative risk (RR) for death with EN vs TPN was 0.56 (95% CI 0.05 to 5.62). Mean length of hospital stay was reduced with EN (WMD -2.20, 95% CI -3.62 to -0.78). RR for systemic infection with EN vs TPN was 0.61 (95% CI 0.29 to 1.28). In one trial, RR for local septic complications and other local complications with EN vs TPN was 0.56 (95% CI 0.12 to 2.68) and 0.16 (95% CI 0.01 to 2.86) respectively.

REVIEWER'S CONCLUSIONS

Although there is a trend towards reductions in the adverse outcomes of acute pancreatitis after administration of EN, clearly there are insufficient data to draw firm conclusions about the effectiveness and safety of EN versus TPN. Further trials are required with sufficient size to account for clinical heterogeneity and to measure all relevant outcomes.

Nutrition support during acute pancreatitis

Studies have shown that protein catabolism increases by 80% and energy expenditure by 20% in acute pancreatitis, indicating that nutritional requirements are elevated. Other studies have associated the resolution of negative nitrogen balance by nutrition support with improved outcome. Consequently, the need for effective nutrition is one cornerstone of management of acute pancreatitis. Concerns that feeding may exacerbate the disease process by stimulating the synthesis of proteolytic enzymes in the acinar cell and perpetuating autolysis has led to the widespread use of total parenteral nutrition (TPN) and bowel rest. Unfortunately, the use of TPN in clinical practice has been associated with major metabolic and infective complications, possibly because 1). patients with acute pancreatitis are intolerant of glucose due to coexistent pancreatic endocrine dysfunction and 2). the disease causes immune suppression. This has led to the search for alternatives. Based on physiologic studies, infusion of nutrients into the distal jejunum bypasses the stimulatory effect of feeding on pancreatic secretion. Many controlled trials have compared TPN with jejunal feeding. No study has shown that jejunal feeding exacerbates the disease. Further, jejunal feeding is associated with fewer infectious and metabolic complications. These observations and the fact that enteral feeding is one-tenth the cost of TPN has resulted in the general acceptance of jejunal feeding as the preferred mode for maintaining nutrition in patients with acute pancreatitis.

Hypocaloric jejunal feeding is better than total parenteral nutrition in acute pancreatitis: results of a randomized comparative study

OBJECTIVES

The aims of this study were to define the indications for, and to evaluate the cost-effectiveness of, nutritional support in patients with acute pancreatitis.

METHODS

All admissions during the 12-month period from January through December 2000, were entered into a common management protocol consisting of an initial 48-h fast with i.v. fluids and analgesics. After 48 h, those patients who were improving were restarted on oral feeding (group O). The remaining patients were randomized to receive nasojejunal (group EN) or parenteral feeding (group TPN). The randomization study was continued until 50 patients had been accrued. Outcomes in the three groups were compared with respect to length of hospital stay, duration of feeding, complications, and hospital costs.

RESULTS

A total of 156 admissions were evaluated in the first 12 months. Of these, 87% patients had mild disease, 10% moderate, and 3% severe; 62% were related to alcohol abuse, 18% gallstones, and 8% idiosyncratic drug reactions. Of the patients, 75% improved on 48 h bowel rest and i.v. fluids, and were discharged within 4 days. The remainder were randomized to jejunal elemental (n = 26) or parenteral (n = 27) feeding. Duration of feeding was shorter with EN (6.7 vs 10.8 days, p < 0.05) and nutrition costs were lower, representing an average cost saving of $2362.00 per patient fed. EN was less effective in meeting estimated nutritional requirements (54 vs 88%, p < 0.0001), but metabolic (p < 0.003) and septic complications (p = 0.01) were lower. Subgroup analysis of patients with severe disease showed similar findings.

CONCLUSION

Despite concerns that metabolic expenditure is increased and that food-stimulated pancreatic secretion might exacerbate the disease process, hypocaloric enteral feeding seems to be safer and less expensive than parenteral feeding and bowel rest in patients with acute pancreatitis.

Enteral and parenteral nutrition in acute pancreatitis

In the last 5 years naso-enteric feeding has increasingly been used in clinical practice in patients with severe acute pancreatitis. Randomized clinical studies in both mild and severe forms of the disease have demonstrated not only the feasibility but also the safety of this approach. The majority of patients have been fed by variously placed nasojejunal tubes with varied problems in maintaining both location and patency. Most have been surprised to find that it is possible to feed the patients in this way with the potential of improving gut barrier function and immune response, at reduced cost and greater safety than with parenteral nutrition. The current evidence points to nasojejunal feeding being preferable to parenteral feeding, but evidence has yet to be produced to prove beyond reasonable doubt that such feeding is an improvement on conservative management without feeding. Finally, the most recent development has indicated that fine-bore nasogastric feeding may well be a realistic alternative to nasojejunal feeding even in the more severe forms of this disease. A small percentage of patients may still need parenteral nutrition.

Nutritional management of acute pancreatitis

Most patients with acute pancreatitis have mild to moderate disease and require no specialized nutritional support. Twenty percent to 30% have severe cases, resulting in a catabolic hypermetabolic state, and these patients may require early aggressive nutritional support. Traditionally, this support has been in the form of total parenteral nutrition. However, recent data suggest that enteral nutrition infused into the jejunum is feasible, well tolerated, associated with fewer complications, and significantly less expensive than parenteral nutrition. The pathophysiology of gut function in acute pancreatitis and the rationale and evidence for parenteral and enteral nutritional support are reviewed herein. An algorithm on the nutritional management of acute pancreatitis is suggested.

Impact of pancreatic head resection on direct medical costs in patients with chronic pancreatitis

OBJECTIVE

To quantitate disease-specific hospital-based medical costs in 34 patients with chronic pancreatitis before and after treatment by either duodenal-preserving pancreatic head resection (DPPHR) or pylorus-preserving pancreaticoduodenectomy (PPPD).

SUMMARY BACKGROUND DATA

Pancreatic head resection in selected patients with chronic pancreatitis provides pain relief and improves quality of life, but the effect on healthcare costs is unknown.

METHODS

This observational cohort study comprised 34 selected patients with chronic pancreatitis followed up exclusively at the authors' institution treated by either DPPHR or PPPD between 1992 and 1997.

RESULTS

Twenty-one patients had DPPHR and 13 had PPPD. Patients in the PPPD group were slightly older, but other clinical characteristics were similar. Before surgery, the mean number of admissions per patient per year, days in the hospital per patient per year, and disease-specific hospital-based medical costs per patient per year were not significantly different between groups. After surgery, those three variables were similar between the groups but significantly less than preoperative values. Pain control remained significantly improved after 36 months of follow-up.

CONCLUSIONS

In selected patients with chronic pancreatitis, DPPHR and PPPD are equally effective in providing long-term pain relief and decreasing disease-specific hospital-based costs.

Nutrition in acute pancreatitis

The majority of patients (80%) admitted with acute pancreatitis recovers after a few days of bowel rest and intravenous fluids. However, some cases progress to a fulminant disease complicated by a severe systemic inflammatory response and multiple organ failure, a condition in which mortality is related to the degree of negative nitrogen balance. The goal of nutrition support in this situation is to cover the increased metabolic demands without stimulating pancreatic secretion and exacerbating the "autodigestion" that characterizes the condition. Although human and animal studies have shown conflicting results regarding the effect of composition and location of feeding on pancreatic enzyme secretion, there is consensus that total parenteral nutrition (TPN), given at moderate infusion rates, does not significantly stimulate secretion in humans and that enteral diets stimulate enzyme secretion unless delivered below the jejunum. Consequently, until recently TPN has been the standard of therapy. The fact that the cost and complications of TPN can often outweigh its benefits (catheter sepsis, hyperglycemia) has led to a series of recent controlled clinical trials of modified enteral diets in which the diet is delivered by nasojejunal tube. Results have demonstrated that enteral nutrition, with either elemental or polymeric formulas, was cheaper, safer, and at the same time more effective in reducing the systemic inflammatory response. The pathophysiologic explanation for these observations needs further investigation.

Evolution of nutritional support in acute pancreatitis

BACKGROUND

Acute pancreatitis is a catabolic illness and patients with the severe form have high metabolic and nutrient demands. Artificial nutritional support should therefore be a logical component of treatment. This review examines the evidence in favour of initiating nutritional support in these patients and the effects of such support on the course of the disease.

METHODS

Medline and Science Citation Index searches were performed to locate English language publications on nutritional support in acute pancreatitis in the 25 years preceding December 1999. Manual cross-referencing was also carried out. Letters, editorials, older review articles and most case reports were excluded.

RESULTS AND CONCLUSION

There is no evidence that nutritional support in acute pancreatitis affects the underlying disease process, but it may prevent the associated undernutrition and starvation, supporting the patient while the disease continues and until normal and sufficient eating can be resumed. The safety and feasibility of enteral nutrition in acute pancreatitis have been established; enteral nutrition may even be superior to parenteral nutrition. Some patients, however, cannot tolerate enteral feeding and this route may not be practical in others. Parenteral nutrition still has a role, either on its own or in combination with the oral and enteral routes, depending on the stage of the illness and the clinical situation.

Enteral nutrition support in acute pancreatitis

OBJECTIVE

To review the controversies surrounding the use of nutritional interventions, particularly enteral support, in patients with acute pancreatitis.

DATA SOURCES

Articles were obtained through a MEDLINE search (1966-June 1999). Additionally, several textbooks containing information on the diagnosis and management of acute pancreatitis were reviewed. The bibliographies of retrieved publications and textbooks were reviewed for additional references.

STUDY SELECTION

All original investigations in humans pertaining to the use of enteral nutritional support in acute pancreatitis were reviewed for inclusion. Studies that investigated parenteral nutrition in acute pancreatitis were also reviewed, with preference given to controlled comparisons with enteral regimens or no nutritional support.

DATA EXTRACTION

The primary outcomes extracted from the literature were time to oral feeding tolerance, complications (e.g., infection) associated with nutritional support, and length of stay.

DATA SYNTHESIS

The duration of pancreatitis and time to oral feedings is similar whether patients receive enteral (i.e., jejunal tube feedings) or parenteral nutrition. Additionally, complications, length of stay, and costs are either similar or decreased with enteral versus parenteral nutrition.

CONCLUSIONS

Current evidence suggests that the enteral rather than parenteral route should be used to provide nutrition to patients with acute pancreatitis. Parenteral nutrition should be reserved for patients in whom nasojejunal feeding is not possible.

Pseudocysts of the pancreas in children in Morocco

BACKGROUND/PURPOSE

Five children with pancreatic pseudocyst were treated from 1986 to 1998, 4 of these pseudocysts have a traumatic origin. Medical therapy reduces the pancreatic stimulation and favors the resolution or the maturation of the pseudocyst.

METHODS

First, all the children were treated with ultrasound-guided drainage. The duration of this drainage varied from 1 to 10 days with successful results in 3 cases. The internal drainage by cystogastrostomy was used in 2 cases.

RESULTS

The first showed a cystogastric fistula in the fifth day of the external drainage, the second was drained 2 times without success. There were no pseudocyst recurrences, and children treated surgically were discharged home within 7 to 10 days after operation.

Nutrition in acute pancreatitis

Pancreatitis is a common disorder. Numerous factors have been implicated in the pathogenesis of acute and chronic pancreatitis, but the exact mechanisms of these conditions are still poorly understood. Depending on the cause of the disorder, patients who have pancreatitis are usually not malnourished and are able to eat within 5 to 7 days of disease onset. In these patients, nutritional support is unnecessary. However, severe disease induces a catabolic state similar to that seen in trauma and sepsis, resulting in rapid weight loss and increased morbidity and mortality. Thus, vigorous nutritional support may be useful in the treatment of severe pancreatitis. Studies have shown that parenteral and enteral nutritional support are well tolerated and can maintain or improve nutritional status in patients with pancreatitis. This article reviews nutritional assessment and therapy in pancreatitis.

Prognosis of advanced pancreatic cancer patients with reference to calorie intake

Progressive weight loss and nutritional deterioration are commonly found in patients with advanced pancreatic cancer. There have been few studies of whether nutritional support improves survival for these patients. We retrospectively investigated the relationship between calorie intake and survival in 50 patients who died from cancer. The survival period was calculated from the day when their serum albumin level measured < 3.0 mg/dl. Total calorie intake was calculated on the basis of diet and parenteral nutrition for the week before the day when serum albumin levels fell to < 3.0 mg/dl. Patients were divided into a low- and a high-calorie intake group using the median of calorie intake per predictive basal metabolism. The survival period was significantly longer for the high- than for the low-calorie intake group (median 50 vs. 32 days, p = 0.02). We also investigated the relationships between calories of parenteral nutrition and survival. High-calorie parenteral nutrition subgroups tended to survive longer than low-calorie parenteral nutrition subgroups irrespective of enteral nutrition. Sufficient calorie intake may have the potential to prolong survival for patients with advanced pancreatic cancer.

Alcohol and the pancreas

Alcoholic pancreatitis may be one of the most serious adverse consequences of alcohol abuse. Its diagnosis, as it has for many years, depends primarily on clinical acumen in interpreting properly the symptoms and signs of abdominal distress, buttressed by elevated pancreatic enzymes (amylase and lipase). More recently, the use of computerized tomography (CT) in selected situations has been both of confirmatory and prognostic value. Severity of abnormality by CT correlates reasonably well with a variety of clinical-laboratory clusters (APACHE system, Ranson's criteria, etc.) and aids in therapy. The pathogenesis of alcoholic pancreatitis is not fully defined. The ultimate picture is one of tissue autolysis by activated proteolytic enzymes. The triggers for such activation, however, are still not known. They are represented by three main theories: (1) large duct obstruction and/or increased permeability relative to pancreatic secretion, (2) small duct obstruction due to proteinaceous precipitates, and (3) a direct toxic-metabolic effect of ethanol on pancreatic acinar cells. While not mutually exclusive, we favor the last hypothesis as being most consistent with the effects of ethanol on other organ systems. The direct effects of ethanol and/or its metabolites may be mediated, at least in part, via oxidative stress or the generation of fatty acid ethyl esters. Autolysis (regardless of proximate mechanism(s)) leads to inflammation likely mediated via release of various cytokines. It also should be appreciated that "acute" pancreatitis (the topic of this chapter) likely represents an acute process within a chronic pancreatic exposure and injury from alcoholic abuse. The key question of why pancreatitis develops in only a small number of alcohol abusers is not resolved. Therapy depends on the severity of alcoholic pancreatitis, which is defined by clinical-laboratory and often CT criteria. Mild pancreatitis usually resolves acutely with alcohol abstention and supportive therapy. Severe pancreatitis has a significant morbidity and mortality, mainly related to the degree of pancreatic necrosis and infection. It requires meticulous combined medical-surgical care.

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

BACKGROUND

Parenteral nutrition is well established for providing nutritional support in acute pancreatitis while avoiding pancreatic stimulation. However, it is associated with complications and high cost. Benefits of enteral feeding in other disease states prompted a comparison of early enteral feeding with total parenteral nutrition in this clinical setting.

METHODS

Thirty-eight patients with acute severe pancreatitis were randomized into two groups. The first (n = 18) received enteral nutrition through a nasoenteric tube with a semi-elemental diet, while the second group (n = 20) received parenteral nutrition through a central venous catheter. Safety was assessed by clinical course of disease, laboratory findings and incidence of complications. Efficacy was determined by nitrogen balance. The cost of nutritional support was calculated.

RESULTS

Enteral feeding was well tolerated without adverse effects on the course of the disease. Patients who received enteral feeding experienced fewer total complications (P < 0.05) and were at lower risk of developing septic complications (P < 0.01) than those receiving parenteral nutrition. The cost of nutritional support was three times higher in patients who received parenteral nutrition.

CONCLUSION

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

Clinical nutrition in pancreatitis

In patients with acute pancreatitis or an acute flare of chronic pancreatitis, a discrepancy exists between increased protein/calorie requirements induced by a hypermetabolic stress state and reduced ingestion/assimilation of exogenous nutrients, which promotes progressive nutritional deterioration. Patients with severe pancreatitis (defined by > or =3 Ranson criteria, an APACHE II score of > or =10, development of major organ failure, and/or presence of pancreatic necrosis) are more likely to require aggressive nutritional support than patients with mild disease. The type of formula and level of the gastrointestinal tract into which nutrients are infused determine the degree to which pancreatic exocrine secretion is stimulated. Animal studies and early prospective randomized controlled trials in humans suggest that total enteral nutrition via jejunal feeding may be the preferred route to parenteral alimentation in this disease setting.

Nutrition support in clinical practice: review of published data and recommendations for future research directions. National Institutes of Health, American Society for Parenteral and Enteral Nutrition, and American Society for Clinical Nutrition

In the last 30 years, marked advances in enteral feeding techniques, venous access, and enteral and parenteral nutrient formulations have made it possible to provide nutrition support to almost all patients. Despite the abundant medical literature and widespread use of nutritional therapy, many areas of nutrition support remain controversial. Therefore, the leadership at the National Institutes of Health, The American Society for Parenteral and Enteral Nutrition, and The American Society for Clinical Nutrition convened an advisory committee to perform a critical review of the current medical literature evaluating the clinical use of nutrition support; the goal was to assess our current body of knowledge and to identify the issues that deserve further investigation. The panel was divided into five groups to evaluate the following areas: nutrition assessment, nutrition support in patients with gastrointestinal diseases, nutrition support in wasting diseases, nutrition support in critically ill patients, and perioperative nutrition support. The findings from each group are summarized in this report. This document is not meant to establish practice guidelines for nutrition support. The use of nutritional therapy requires a careful integration of data from pertinent clinical trials, clinical expertise in the illness or injury being treated, clinical expertise in nutritional therapy, and input from the patient and his/her family.

Comparison of the safety of early enteral vs parenteral nutrition in mild acute pancreatitis

BACKGROUND

This prospective study was designed to compare the safety, efficacy, cost, and impact on patient outcome of early total enteral nutrition (TEN) vs total parenteral nutrition (TPN) in acute pancreatitis.

METHODS

Patients admitted with acute pancreatitis or an acute flare of chronic pancreatitis, characterized by abdominal pain and elevated serum amylase and lipase, were randomized to receive either isocaloric and isonitrogenous TEN (via a nasojejunal feeding tube placed endoscopically) or TPN (via a central or peripheral line) started within 48 hours of admission.

RESULTS

Thirty patients were studied over 32 admissions (TEN given on 16 and TPN on 16) for acute pancreatitis. There were no differences on admission in mean age, Ranson criteria, multiple organ failure score (MOF), or APACHE III score between TEN and TPN groups. Although slower to approach goal feeding over the first 72 hours of admission, TEN patients received 71.3% goal calories by day 4 vs 85.2% for TPN patients (not significant). There were no deaths and no differences between groups in serial pain scores, days to normalization of amylase, days to diet by mouth, serum albumin levels, or percent nosocomial infection. However, the mean cost of TPN per patient was over four times greater than that for TEN ($3294 vs $761, respectively, p < .001). Mean serial Ranson criteria, APACHE III, and MOF scores recorded every 2 to 3 days decreased in the TEN group, whereas those in the TPN group increased. Only the difference in the third Ranson criteria (mean 6.3 days after admission) for the TEN and TPN groups (0.5 vs 2.8, respectively) reached statistical significance (p = .002). Stress-induced hyperglycemia was worse in the TPN group, as serum glucose levels increased significantly over the first 5 days of hospitalization (p < .02), whereas those in the TEN group showed no significant change. An exacerbation of pancreatitis, occurring in one TEN patient when the nasojejunal tube was dislodged into the stomach, resolved after placement back in the jejunum. Three patients who became asymptomatic and normalized amylase on TEN flared upon advancing to diet by mouth.

CONCLUSIONS

TEN for acute pancreatitis is as safe and effective, but is significantly less costly than TPN. Compared with TPN, TEN may promote more rapid resolution of the toxicity and stress response to pancreatitis. TEN via jejunal feeding should be used preferentially in this disease setting.

Resting energy expenditure in patients with alcoholic chronic pancreatitis

The aim of this study was to assess resting energy expenditure in patients with chronic pancreatitis; 33 patients with alcohol-related chronic pancreatitis (group 1: 13 normal weight, group 2: 20 underweight) and 11 undernourished patients without identifiable disease (group 3) were studied. Body composition was determined by bioelectric impedance analysis and fat-free mass was similar among the three groups (76.4 +/- 1.5%, 78.6 +/- 1.3% and 76.8 +/- 2.1% for groups 1, 2, and 3, respectively). The measured resting energy expenditure (REE) was higher than the predicted EE (Harris and Benedict formula and Cunningham's equation) for the underweight patients with chronic pancreatitis (group 2) (P < 0.05), but not for the two other groups. According to Cunningham's equation, 65% of the group 2 patients were hypermetabolic (REE > 110% of predicted EE) versus 23.1% and 20% in groups 1 and 3. When adjusted for fat free mass, REE was significantly (P < 0.01) higher in group 2 (35.0 +/- 0.9 kcal/kg/24 hr) than in the other two groups (30.1 +/- 0.7 kcal/kg/24 hr and 30.8 +/-1.4 kcal/kg/24 hr in groups 1 and 3, respectively). During chronic pancreatitis, weight loss is accompanied by hypermetabolism, which should be taken into consideration during nutritional support.

Effects of parenteral nutrients on gastrointestinal motility and secretion

BACKGROUND

The stimulation of gastrointestinal motility and secretion during nutrient digestion is generally divided into a cephalic, gastric and intestinal phase. Little is known about the effects of macronutrients on gastrointestinal function during the postabsorptive or circulatory phase of digestion.

METHODS

Review of studies investigating the effects of circulating macro-nutrients such as fat, amino acids and glucose on gastrointestinal motility and secretion.

RESULTS

Intravenous infusion of fat emulsions delays gastric emptying and interrupts the interdigestive intestinal motor pattern. Intravenous amino acids, administered in high doses, stimulate gastric acid secretion, pancreatic secretion, gallbladder contraction, and intestinal motility. Patients receiving total parental nutrition (TPN) have inert gallbladders and are at risk of developing gallbladder sludge and stones. Administering a proportion of the daily amino acid requirement by rapid intravenous infusion may prove useful in the prevention of sludge and stone formation during TPN by promoting gallbladder contraction. Intravenous infusion of glucose, already at physiological postprandial plasma levels, inhibits gastrointestinal motility and secretion. The inhibitory effect of glucose is dose-dependent, that is, more pronounced at higher plasma glucose levels. Recent studies have indicated that in patients with diabetes mellitus alterations in gastrointestinal function are related to the degree of hyperglycaemia.

CONCLUSIONS

Nutrients during the circulatory phase of digestion influence gastrointestinal motility and secretion. Knowledge of these effects is relevant for conditions with increased plasma levels of macro-nutrients such as in patients with diabetes mellitus or during total parenteral nutrition.

Nutrition support in pancreatitis

Nutrition support in patients with pancreatitis has created a challenge for clinicians. Because the pancreas is normally stimulated by the ingestion of food, particularly fat, patients are often denied oral nutrition. This reduction in the ingestion of food, together with the increased metabolic demands of this disease, often results in a negative energy balance and occasionally undernutrition or malnutrition. This review summarizes the etiologies and methods for staging pancreatitis, the physiology of pancreatic exocrine secretion and the response of the pancreas to different methods of nutrition support. The results of clinical trials, which examine both parenteral and enteral nutrition in animals and humans with this disease, are reviewed. Recommendations for nutrition management of patients with acute and chronic pancreatitis and areas for future research are discussed.

[Effect of postoperative complications on nutritional status: therapeutic consequences]

The occurrence of a postoperative complication represents an additional stress factor for patients and leads in many cases rapidly to a malnutrition status. Thus a nutritional support is required as soon as the foreseeable duration of starvation has a longer duration than one week. Considering its lower risk of septic complications and lower cost, enteral feeding should be initiated as soon as possible. Appraisal of caloric needs with standard formulas often leads to inappropriate nutritional management. Therefore the requirements should be assessed by indirect calorimetry if available. Nutritional support is a part of the management of a postoperative septic patient. It must be initiated when initial phase of haemodynamic instability is amended. Branched chain amino acids, medium chain triglycerides and other specific nutrients have failed to demonstrate a real clinical beneficial effect. In case of acute respiratory failure, nutritional support must be cautious with regard to caloric load, as carbohydrates may increase CO2 production and lipids may worsen hypoxaemia. In case of postoperative acute renal failure, nutritional management is facilitated by continuous haemofiltration techniques allowing an unlimited nutrient intake. Solutions containing only essential amino acids are not recommended. During severe acute pancreatitis, enteral feeding is indicated when ileus does not permit the use of the intestinal tract. Jejunal access must be preferred to stomach or duodenum. Lipid emulsions can be used safely if serum triglyceride concentrations remain below 4 g.L-1 during infusion and below 2 g.L-1 between infusions.

The influence of early total parenteral nutrition on experimental pancreatitis in rats

The main purpose of this study was to investigate the influence of early total parenteral nutrition on acute sodium-taurocholate-induced pancreatitis in rats. Total parenteral nutrition did not change the survival rate, serum amylase, calcium or liver transaminase level on the degree of pancreatic damage, but reduced serum acid phosphatase and lactate dehydrogenase levels. Hyperglycemia occurred during the use of total parenteral nutrition. Total parenteral nutrition is not harmful in the course of acute experimental pancreatitis, and could be used with few side effects.

Insulin requirements in lipodystrophic diabetes

A ten-fold increase in daily insulin requirements during the administration of total parenteral nutrition (TPN) is described in a patient with congenital generalized lipodystrophy, insulin-requiring diabetes mellitus, and acanthosis nigricans during an episode of acute pancreatitis secondary to hypertriglyceridaemia. After a period of 13 days on TPN, insulin requirements increased dramatically to an average of 1428 units per day for a period of 12 days, to achieve a mean blood glucose level of 10.9 mmol l-1. When the patient resumed feeding and the TPN was discontinued, the average daily insulin requirement was 104 units with a mean 24 h blood glucose of 11.8 mmol l-1. Parenteral administration of energy substrates in a rare case of diabetes mellitus and congenital lipodystrophy complicated by acute pancreatitis resulted in a severe insulin insensitive state due to the combination of the hypermetabolism conferred by the pancreatitis plus transient impairments of the glucose disposal mechanism by the energy substrates provided.

Nutritional support for the patient with pancreatobiliary disease

Critically ill patients with severe pancreatobiliary disease exhibit multiple nutritional alterations compounded by the stress response. Acute pancreatitis may present as a life-threatening illness; patients are likely to be hypermetabolic and may have hyperglycemia and hypocalcemia. Nutritional support from parenteral or enteral feeding will probably be required in patients presenting with three or more positive risk factors as determined by Ranson criteria. Nutritional therapies for liver disease vary according to the specific disorder manifested. Patients with fulminant hepatic failure need to be monitored for profound hypoglycemia. Encephalopathy may develop in patients with acute-on-chronic liver disease, necessitating a protein restriction. Patients undergoing liver transplant are a perioperative challenge due to the combination of preoperative malnutrition, an extensive surgical procedure, and postoperative stress. Such patients require individualized assessment and management.

Nutritional management of acute and chronic pancreatitis

Acute pancreatitis often results in a catabolic state characterized by profound hemodynamic, metabolic, cardiovascular, pulmonary, hematologic, and renal aberrations. Parenteral nutrition and metabolic support are essential if morbidity and mortality are to be minimized. In chronic pancreatitis, nutritional management ranges from fundamental dietary manipulation with or without administration of appropriate digestive enzymes to enteral supplementation with modular chemically defined diets to total parenteral nutrition, depending on the stage, severity, and manifestations of the disease. In prescribing nutrient substrates in both acute and chronic pancreatitis, consideration must be given to their effects on pancreatic enzyme secretion if optimal results are to be achieved.

Total parenteral nutrition in severe acute pancreatitis

The influence of total parenteral nutrition (TPN) was studied in 67 patients with severe acute pancreatitis having three or more criteria according to Ranson (mean +/- SD = 3.8 +/- 0.21). Although TPN has been reported to not be of benefit in the progress and severity of the disease, we have found that the time TPN is started is important in influencing the course of the disease and in the development of local complications, as well as in the mortality rate. Patients whose TPN was started within the first 72 hours of the disease had a 23.6% complication rate and 13% mortality, in comparison with patients whose TPN was started later in the course of the disease, who had a 95.6% complication rate (p less than 0.01) and a mortality rate of 38% (p less than 0.03). The nutritional status of the patients during TPN administration of 28.4 days was maintained either steady or was improved, as assessed by nitrogen balance, serum levels of transferrin (p less than 0.05), and albumin (p less than 0.05). The administration of fat solution, either to prevent essential fatty acid deficiency or to provide part of the caloric requirements, was found to cause neither clinical nor laboratory worsening of the disease. All pancreatic fistulae that developed during the course of the disease spontaneously closed in patients receiving TPN without operation in a mean period of 33.3 days, and all pseudocysts subsided in an average of 18.3 days. Those who died (overall mortality rate 24%) had had uncontrollable sepsis, which resulted in hypercatabolism and multiple system organ failure.(ABSTRACT TRUNCATED AT 250 WORDS)

Total parenteral nutrition during acute pancreatitis: clinical experience with 156 patients

Over a 3-year period, 156 of 815 patients admitted to a single institution with acute pancreatitis received total parenteral nutrition (TPN) for 2,572 patient days. Seventy had "simple" acute pancreatitis (group I) and 86 (group II) developed local complex disease (pseudocyst, abscess, or necrotic gland). In groups I and II, respectively, days without oral intake (NPO) were 13.6 +/- 1.5 (SEM) and 24.0 +/- 2.1 (p less than 0.005), hospital days were 19.8 +/- 1.7 and 35.8 +/- 3.2 (p less than 0.005), and duration of TPN was 10.9 +/- 1.0 and 21.0 +/- 2.3 days (p less than 0.005). Thirty-three patients in group I and 53 in group II required exogenous insulin. Alteration of standard formulas was necessary in 87 patients, but cessation of therapy was necessary in only one instance. Twenty catheters were removed for suspected sepsis with only 3 confirmed cases. Fat-based formulas were well tolerated in 15% of patients. During TPN, body weight rose from 95.0 +/- 2.4% to 97.4 +/- 4.3% of ideal in group I and remained at 90.5 +/- 1.8% in group II. Albumin rose from 3.36 +/- 0.10 to 3.50 +/- 0.08 g/dl in group I and from 3.01 +/- 0.07 to 3.35 +/- 0.07 g/dl in group II. The entire cohort differed from 10 randomly chosen patients who did not receive TPN in terms of days NPO (2.8 +/- 0.3) and hospital days (5.5 +/- 0.6). Variables associated with prolongation of hospital stay and time NPO were number of prognostic criteria, local complex disease, and underlying chronic pancreatitis only in select groups. We conclude that during acute pancreatitis, TPN can be administered safely but with careful monitoring and we recommend early aggressive therapy in the subgroups noted above and when underlying malnutrition exists. In the borderline patient, TPN may be administered by peripheral vein until the severity of disease is manifest.