2004 MacLean-Mueller prize enteral or parenteral nutrition for severe pancreatitis: a randomized controlled trial and health technology assessment.
BACKGROUND
The optimal route of nutrition in severe pancreatitis is controversial. Parenteral nutrition (PN) is preferred, but enteral nutrition (EN) promises to attenuate inflammation and prevent sepsis. We hypothesized that EN was at least equivalent to PN in reducing inflammation, providing effective nutrition and being cost-effective.


METHODS
We conducted a randomized controlled trial comparing PN to EN in pancreatitis in an academic, multi-institutional, tertiary care health system. We screened 728 consecutive patients. Twenty-eight patients with a Ranson's score greater than 2 who did not tolerate clear fluids 4 days after admission were randomized: 18 to PN and 10 to EN. Both groups were provided daily 105 kJ (25 kcal)/kg and 1.5 g/kg of protein, respectively, until they could tolerate a regular diet.


RESULTS
C-reactive protein in EN patients was reduced by 50% 5 days faster than PN patients (Wilcoxon test, p = 0.09). Both groups received a similar number of kilojoules and achieved near normal prealbumin and 24-hour urinary nitrogen values. Neither regimen caused a change in cholecystokinin levels. Overall mortality was 4.9% (3 patients in the PN group). In 5 patients (4 PN, 1 EN) there were infected pancreatic collections. Nine EN patients dislodged the nasojejunal tube. EN had an average cost of dollar 1375 per patient compared with dollar 2608 for PN (p = 0.08). After sensitivity analysis, EN cost dollar 957 compared with dollar 2608 for PN (p = 0.03).


CONCLUSIONS
EN or PN is safe and provides adequate nutrition in severe pancreatitis. EN shows a trend toward faster attenuation of inflammation, with fewer septic complications and is the dominant therapy in terms of cost-effectiveness. This study favours EN for nutritional support in severe pancreatitis.
Louie
Brian E
BE
Department of Surgery, University of Alberta, Edmonton.
Noseworthy
Tom
T
Hailey
David
D
Gramlich
Leah M
LM
Jacobs
Philip
P
Warnock
Garth L
GL
D000208:Acute Disease; D000328:Adult; D000368:Aged; D001363:Awards and Prizes; D002097:C-Reactive Protein / Q000276:immunology; D003362:Cost-Benefit Analysis; D004750:Enteral Nutrition / Q000191:economics; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010195:Pancreatitis / Q000191:economics / Q000209:etiology / Q000276:immunology / Q000628:therapy*; D010288:Parenteral Nutrition / Q000191:economics; D013673:Technology Assessment, Biomedical; D016896:Treatment Outcome
D002097:C-Reactive Protein