Early versus on-demand nasoenteric tube feeding in acute pancreatitis

O.J. Bakker, S. van Brunschot, H.C. van Santvoort, M.G. Besselink, T.L. Bollen, M.A. Boermeester, C.H. Dejong, H. van Goor, K. Bosscha, U. Ahmed Ali, S. Bouwense, W.M. van Grevenstein, J. Heisterkamp, A.P. Houdijk, J.M. Jansen, T.M. Karsten, E.R. Manusama, V.B. Nieuwenhuijs, A.F. Schaapherder, G.P. van der SchellingM.P. Schwartz, B.W. Spanier, A. Tan, J. Vecht, B.L. Weusten, B.J. Witteman, L.M. Akkermans, M.J. Bruno, M.G. Dijkgraaf, B. van Ramshorst, H.G. Gooszen

Research output: Contribution to journalArticleAcademicpeer-review

Abstract

BACKGROUND: Early enteral feeding through a nasoenteric feeding tube is often used in patients with severe acute pancreatitis to prevent gut-derived infections, but evidence to support this strategy is limited. We conducted a multicenter, randomized trial comparing early nasoenteric tube feeding with an oral diet at 72 hours after presentation to the emergency department in patients with acute pancreatitis. METHODS: We enrolled patients with acute pancreatitis who were at high risk for complications on the basis of an Acute Physiology and Chronic Health Evaluation II score of 8 or higher (on a scale of 0 to 71, with higher scores indicating more severe disease), an Imrie or modified Glasgow score of 3 or higher (on a scale of 0 to 8, with higher scores indicating more severe disease), or a serum C-reactive protein level of more than 150 mg per liter. Patients were randomly assigned to nasoenteric tube feeding within 24 hours after randomization (early group) or to an oral diet initiated 72 hours after presentation (on-demand group), with tube feeding provided if the oral diet was not tolerated. The primary end point was a composite of major infection (infected pancreatic necrosis, bacteremia, or pneumonia) or death during 6 months of follow-up. RESULTS: A total of 208 patients were enrolled at 19 Dutch hospitals. The primary end point occurred in 30 of 101 patients (30%) in the early group and in 28 of 104 (27%) in the on-demand group (risk ratio, 1.07; 95% confidence interval, 0.79 to 1.44; P=0.76). There were no significant differences between the early group and the on-demand group in the rate of major infection (25% and 26%, respectively; P=0.87) or death (11% and 7%, respectively; P=0.33). In the on-demand group, 72 patients (69%) tolerated an oral diet and did not require tube feeding. CONCLUSIONS: This trial did not show the superiority of early nasoenteric tube feeding, as compared with an oral diet after 72 hours, in reducing the rate of infection or death in patients with acute pancreatitis at high risk for complications. (Funded by the Netherlands Organization for Health Research and Development and others; PYTHON Current Controlled Trials number, ISRCTN18170985.).
Original languageEnglish
Pages (from-to)1983-1993
Number of pages11
JournalNew England Journal of Medicine
Volume371
Issue number21
DOIs
Publication statusPublished - 20 Nov 2014

Keywords

  • EARLY ENTERAL NUTRITION
  • CRITICALLY-ILL PATIENT
  • SMALL-BOWEL MOTILITY
  • NECROTIZING PANCREATITIS
  • INTERNATIONAL CONSENSUS
  • BACTERIAL TRANSLOCATION
  • PRACTICE GUIDELINES
  • ESPEN GUIDELINES
  • CONTROLLED-TRIAL
  • ORGAN FAILURE

Cite this

Bakker, O. J., van Brunschot, S., van Santvoort, H. C., Besselink, M. G., Bollen, T. L., Boermeester, M. A., Dejong, C. H., van Goor, H., Bosscha, K., Ahmed Ali, U., Bouwense, S., van Grevenstein, W. M., Heisterkamp, J., Houdijk, A. P., Jansen, J. M., Karsten, T. M., Manusama, E. R., Nieuwenhuijs, V. B., Schaapherder, A. F., ... Gooszen, H. G. (2014). Early versus on-demand nasoenteric tube feeding in acute pancreatitis. New England Journal of Medicine, 371(21), 1983-1993. https://doi.org/10.1056/NEJMoa1404393