Journal of Parenteral and Enteral

Nutrition http://pen.sagepub.com/

Comparison of the Safety of Early Enteral vs Parenteral Nutrition in Mild Acute Pancreatitis
Stephen A. McClave, Lisa M. Greene, Harvy L. Snider, Laszlo J.K. Makk, William G. Cheadle, Nancy A. Owens,
Larry G. Dukes and Linda J. Goldsmith
JPEN J Parenter Enteral Nutr 1997 21: 14
DOI: 10.1177/014860719702100114

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 Comparison of the Safety of Early Enteral
Acute Pancreatitis
STEPHEN A. McCLAVE, MD; LISA M. GREENE, RN; HARVY L. SNIDER, MD; LASZLO J. K. MAKK, MD; WILLIAM G.
NANCY A. OWENS, RD; LARRY G. DUKES, RPH; AND LINDA J. GOLDSMITH, PHD
From the Departments of Medicine and Surgery, University of Louisville School of Medicine and Veterans’ Affairs Medical Center, Louisville, Kentucky
ABSTRACT. 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 pancreati-
tis or an acute flare of chronic pancreatitis, characterized by abdomi-
nal 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 periph-
eral 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 re-
ceived 71.3% goal calories by day 4 vs 85.2% for TPN patients (not sig-
nificant). 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. How-
ever, the mean cost of TPN per patient was over four times greater
Acute pancreatitis is a hypermetabolic, hyperdynamic
disease process that creates a catabolic stress state pro-
moting a systemic inflammatory response and nutritional
deterioration. Nutrition support plays an important role
in the adjunctive management of these patients. Total
parenteral nutrition (TPN) has been the standard of prac-
tice for providing exogenous nutrients, while avoiding
pancreatic stimulation. Two prospective nonrandomized
trials in pancreatitis suggested a benefit from TPN given
early (within 72 hours of admission) to maintain positive
nitrogen balance.2,3 However, the only prospective random-
ized trial that evaluated the impact of early TPN in acute
pancreatitis showed that the group receiving early TPN
had significantly longer hospitalization (16 vs 10 days, P <
.04) and a higher rate of catheter sepsis (10.5% vs 1.5%, p
.003) compared with the control group, which received
only analgesia and IV fluid resuscitation.’ The results of
this study suggested that the widespread use of TPN might
not be warranted.~4
Received for publication, May 20, 1996.
Accepted for publication, September 3, 1996.
Correspondence: Stephen A. McClave, MD, Division of Gastroenterology/
Hepatology, University of Louisville School of Medicine, Louisville, KY
40292.
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Parenteral Nutrition in Mild
vs
CHEADLE, MD;
than that for TEN vs $761, respectively,
($3294 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, respec-
tively) reached statistical significance (p .002). Stress-induced hy-
=
perglycemia 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 place-
ment 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. (Journal of Parenteral and Enteral Nutrition
014-020, 1997)
21:
Benefits from the use of total enteral nutrition (TEN)
have been noted in a number of other disease states, such
as burns, trauma, and sepsis.11 In comparison with TPN,
use of TEN reduces nosocomial infection, multiple organ
failure (MOF), and length of hospitalization .5, 1,11 Recent
evidence suggests that use of TEN in pancreatitis may be
feasible. In a dog model, Ragins et a19 showed that the site
in the gastrointestinal (GI) tract to which feedings are
delivered determines whether the pancreas is stimulated
and that jejunal feedings result in negligible increases in
enzyme, bicarbonate, and volume output from the pan-
creas. In both animal and human studies, elemental or
semi-elemental small peptide formulas have been shown
to be well tolerated and efficiently absorbed in a gut lu-
= menal environment with little or no pancreatic enzyme
secretion. 10-13 Case series have documented that TEN could
be used safely as transitional feeding in patients who had
peaked and had begun to resolve the inflammatory re-
sponse associated with pancreatitis. 14-21
The potential advantages of TEN over TPN and the fea-
sibility that TEN administered via jejunal feedings might
be well tolerated prompted us to set up this prospective
randomized trial comparing early TEN to TPN in acute
pancreatitis. The objectives of this study were to deter-
mine the safety of TEN in a setting of acute pancreatic
inflammation and to determine any benefit of TEN over
14

TPN with regard to cost, efficacy, and impact on patient
outcome in pancreatitis patients.
MATERIALS AND METHODS
Patients admitted to the hospital with acute pancreati-
tis or an acute flare of chronic pancreatitis, characterized
by abdominal pain with elevated amylase and lipase, were
entered in this study. Patients were excluded if they had
any evidence of short bowel syndrome, Crohn’s disease,
major pancreatic resection, or failure to start TEN or TPN
within 48 hours of admission. After entry into the study,
patients were excluded if they failed to adhere to dietary
restrictions or to the protocol terms for enteral tube place-
ment.
Upon admission patients were prospectively random-
ized to receive either TEN or TPN. Both groups were
placed on isocaloric-isonitrogenous feedings (with simi-
lar carbohydrate-to-fat ratio) designed to provide a goal
amount of 25 kcal and 1.2 g protein/kg per day. The TPN
was infused through a central or peripheral line. The TEN
group received full strength Peptamen (Clintec Nutrition
Company, Deerfield, IL) infused through a nasojejunal tube
placed endoscopically down into the jejunum. Routine
endoscopic placement was used instead of fluoroscopic
placement to assure placement of the feeding tube at or
below the level of the ligament of Treitz. The study period
was defined as that time interval from admission to the
emergency room to advancement to diet by mouth. Spe-
cifically, days to diet by mouth was defined by the point at
which the patient showed signs of clinical resolution (no
pain or nausea and vomiting with amylase decreasing for
48 hours), and the patient was advanced to clear liquids.
Patients were then followed peripherally after that until
time of discharge.
Throughout the study patients were monitored by a va-
riety of parameters. Safety parameters included serial
amylase, lipase, serum glucose, serum albumin, subjec-
tive pain score, Ranson criteria, APACHE III score, and a
MOF score. The Ranson criteria, APACHE III criteria, and
MOF score were calculated within 48 hours of admission
and then were repeated every 2 to 3 days through the study
period. The subjective pain score (determined daily) was
defined by the following scale: 0, no pain; 1-2, tolerable
pain; 3-4, mild pain; 5-6, moderate pain; 7-9, severe pain;
10 worst pain imaginable. The MOF score was adapted
from that of Marshall et all’ (see Appendix A). Additional
safety parameters included incidence of nosocomial in-
fection and mortality. Efficacy parameters included per-
cent of goal calories (25 kcal/kg/d) achieved, days to ad-
vancement to diet by mouth, and length of hospitalization.
Because true cost of raw materials, cost to third-party
payers or even cost to the patient is very difficult, if not. 30 patients were ultimately included in this study. The 30 pa-
impossible, to calculate, cost of nutrition support was; tients were evaluated during 32 admissions, with TPN being
based on charges to the patient. Cost of nutrition support5 given on 16 and TEN on 16 (2 of the 30 patients were ran-
was determined by assigning a dollar amount to endo-
scopic tube or IV line placement and volume of nutritiona’1 16 patient studies for each group). Eight patients were ex-
hyperalimentation infused. The dollar amounts were basecl cluded after entry into the study for the following reasons:
on the mean charges to the patient for the Veterans’ Af
fairs Medical Center and University of Louisville Hospital
For the TEN group, $600 per endoscopic tube placementt fusing replacement, two for inability to place the nasoenteric
and $6 per can (250 mL) of Peptamen infused was assigned
For the TPN group, $500 for central line placement an(I anatomy (postgastrectomy with a Roux-en-Y formation), and
$200 per liter of TPN infused was assigned. The charge folr one for noncompliance with dietary restrictions.
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15
central line placement was assigned to each TPN patient
regardless of whether a peripheral or central route was
used. Each time a nasoenteric tube or IV line had to be
replaced for nutrition support, the $600 charge for endo-
scopic tube placement or $500 charge for central line place-
ment was added to the patient’s cost of nutrition support.
The initial APACHE III score calculated on admission was
determined by adding the scores for neurologic abnormali-
ties, acid-base disturbances, and age and chronic health
evaluation to the acute physiological score.~-’3 Serial
APACHE III scores were determined using only the acute
physiological score.23 Days to normalization of amylase was
a clinical endpoint irrespective of lipase (lipase could still
be elevated). Thirteen specific nosocomial infections were
defined (see Appendix B). No patient received empiric
antibiotics upon admission for acute pancreatitis. Any an-
tibiotics given were chosen to treat specific nosocomial
infections according to bacterial cultures and sensitivities.
For purposes of statistical analysis, chi-square and t tests
were used to verify random assignment with regard to age
and sex. For comparisons of Ranson criteria, MOF scores,
APACHE III scores, length of hospitalization, and days to
normalization of amylase, the two-group independent
sample t test was used. Kolmogorof-Smirnof test did not
reject the hypothesis of normality in these data. Compari-
sons were made using the Mann-Whitney U tests for the
following measures: days to diet by mouth, days in the in-
tensive care unit, percent of goal calories achieved, initial
APACHE III score, and cost of nutrition support. These
variables were judged not normal through the Kolmogorof-
Smirnof test of the data. Repeated-measures analysis of
variance was used to test for overall differences or differ-
ences in trends between groups. Measures tested were
amylase levels, lipase levels, glucose levels, albumin lev-
els, and pain scores over time.
Sample size was calculated before the study based on
achieving 80% power with a significance level of .05. A
planned sample size of 20 per group afforded an 80% power
to detect a difference of 1.8 days in length of hospitaliza-
tion, assuming a standard deviation of 2.0. Similar calcula-
tions were completed for days to normalization of amy-
lase-lipase and days to diet by mouth. This sample size also
afforded an 80% power to detect a $1000 difference in cost,
assuming a standard deviation of 1100.
This study was approved by the Human Studies Com-
mittee at the University of Louisville School of Medicine,
and the Human Studies Subcommittee at the Veterans’
Affairs Medical Center, Louisville, Kentucky.
RESULTS
.
Of 38 patients initially evaluated who met study criteria,
-
domized to both groups on separate admissions resulting in
-
two for failing to be started on TPN or TEN within 48 hours
. of admission, two for pulling their nasoenteric tube and re-
. tubes initially, one because of complicated postoperative
16

Because of longer than anticipated duration of the study,

as well as problems with patient compliance and difficul-
ties in obtaining informed consent, the study was termi-
nated at a sample size of 32 (16 per group). When the data
were analyzed at this point, one of the four study endpoints
from the initial power analysis (done before the start of
the study), cost of nutrition support, did reach statistical
significance with the sample size of 32. Further analysis
yielded sample standard deviations for the other three
endpoints that were larger than planning values, so much
so that significance would not have been achieved even
with the originally planned sample size of 20 per group.
Table I shows the initial demographic data of the study
patients at entry into the study. The data in this table indi-
cate that the study patients were predominantly middle-
aged male alcoholics. The etiology of pancreatitis was
chronic ethanol abuse in 19 of the study patients, gallstone FiG. 1. Serial mean percent goal feedings achieved (±SEM).
in 3, postoperative in 1, and idiopathic in 7. An initial mean
Ranson criteria of 1.3 (range 0 to 5) indicates that in gen-
eral these patients had a mild degree of pancreatitis. Table
I shows that there were no significant differences between virtually superimposed on each other with no significant
the two groups with respect to age, sex, etiology of pan- difference at any point.
creatitis, initial Ranson criteria, APACHE III, or MOF Table II shows additional clinical endpoints for the study.
scores. Although those patients in the TEN group had slightly
In a disease process prone to ileus and gastroparesis, fewer days to normalization of amylase, days to diet by
there was concern as to whether the TEN group would mouth, length of hospitalization, and length of time in the
tolerate enteral feedings enough to achieve their goal calo- intensive care unit compared with the TPN group, none of
ries. Figure 1 shows the percentage of goal feedings these differences was statistically significant. There was
achieved. Most of the first day of hospitalization was spent a 12.5% incidence of nosocomial infection in both groups.
in the emergency room and neither group received much As is shown in Table III for the TPN group, one patient
feeding. The TEN group lagged approximately 1 day be- had five infections and another had four. In the TEN group,
hind the TPN group in approaching goal calories. By the one patient had three infections and another had one.
fourth day of hospitalization, which was usually the third There were no deaths in either group.
day of feeding, the TEN group had achieved a mean of The mean cost of nutrition support (based on charges
72% goal feedings, which was not significantly different to the patient, not on cost of raw materials) was signifi-
from the 81% goal feedings achieved by the TPN group. cantly different for the TPN group, being over four times
Figure 2 shows the mean serial amylase and lipase lev- greater than that seen in the TEN group ($3294 vs $761,
els over time for the two groups. Biochemically, the groups respectively, p < .005).
behaved similarly, showing no significant difference be- The first three values for serial Ranson criteria, MOF
tween the groups for these serial pancreatic enzyme lev- scores, and APACHE III scores were calculated at a mean
els. time of 2.1, 4.1, and 6.3 days after admission for the study
Clinically, the TEN and TPN groups resolved their ab- patients. As Figure 4 shows, mean serial Ranson criteria
dominal pain, and nausea or vomiting similarly. The pat-
tern in the serial pain scores between groups reflected that
which was seen biochemically in the serial enzyme levels.
Figure 3 shows the mean serial pain scores determined on
a daily basis, with the curves for the TEN and TPN groups

TABLE I
Demographic data on study patients at entry into the study

Values are means ± SEM. TEN, total enteral nutrition; TPN, total
parenteral nutrition; EtOH, ethyl alcohol; APACHE IH; MOF, multiple
organ failure. FiG. 2. Serial mean amylase and lipase levels (-SEM).
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 17

TABLE II
Clinical study endpoin£

Values are means ± SEM. For abbreviations, see Table I. LOH, length
of hospitalization; *p < .005.

decreased steadily over time for the TEN patients. For the
TPN patients, slower decreases in actual Ranson criteria
for some patients caused the mean value to actually in- FIG. 3. Serial mean pain scores (±SEM).
crease over time, such that the third mean Ranson criteria
determined for the TPN group was significantly higher than
that for the TEN group (2.8 vs 0.5, p .002). Although a
=

similar pattern was seen for serial MOF scores and

APACHE III scores, none of the differences between the
TEN and TPN groups reached statistical significance.
Stress-induced hyperglycemia was worse in the TPN
group. As Figure 5 shows, mean serum glucose levels in-
creased significantly with time over the first 5 days of hos-
pitalization for the TPN group (~ < .02), whereas those in
the TEN group showed no significant change. By the sixth
hospital day, the difference in the mean serum glucose lev-
els for the TPN and TEN groups (206 vs 150 mg/dL, re-
spectively) approached but just missed statistical signifi-
cance (p = .07). Five patients in the TPN group (3 of whom
had a previous history of diabetes mellitus) and four pa-
tients in the TEN group (2 of whom had a past history of
diabetes mellitus) received insulin or an oral hypoglyce-
mic agent. There was no difference in serial albumin lev-
els between the two groups.
Three patients randomized to TEN initially failed to tol-
erate progression to oral diet. Figure 6 shows that over
the first 5 days of hospitalization, all three patients nor-
malized their serum amylase levels while resolving their
abdominal pain and nausea or vomiting. When on the fifth
day they were advanced to a clear liquid diet, all three
patients developed recurrence of abdominal pain, nausea
or vomiting, and hyperamylasemia (within 24 hours of in-
gestion of the clear liquids by mouth). The most dramatic
was subject A who had one clear liquid meal, developed
abdominal pain and nausea and vomiting 2 hours later and
then over the next 24 hours had a rise in serum amylase
from 50 to 450 U/L. Two patients were given nothing by
mouth, whereas the third was placed back on jejunal
feedings, and symptoms again resolved with normaliza-
tion of amylase. Patients were advanced successfully to
oral diet later in hospitalization.
A more dramatic scenario is shown in Figure 7. This
patient was a 72-year-old black male with diabetes melli-
tus and chronic renal insufficiency (blood urea nitrogen,
50; creatinine, 4.5) who upon presentation with pancreati-
tis (with 5 Ranson criteria) was randomized to TEN. Over
the first several days of hospitalization, amylase and li-
pase gradually normalized, and white blood cell count
decreased from 22,000 to 18,000 (at a time when the pa-
tient developed respiratory insufficiency and required in-
tubation with mechanical ventilation). On the sixth day of
hospitalization, the white blood cell count began to climb
to 30,000 with an increase in fever and an overall picture
that suggested sepsis. Blood cultures and urine cultures
were negative; sputum culture showed normal flora. In the
course of the fever work-up, an abdominal film was ob-
tained that showed that the tube had been displaced from
the jejunum into the stomach. The tube was replaced back
into the jejunum and tube feedings were resumed. Over
the next 3 days, the white blood cell count dropped from
30,000 to 17,000. There was never an increase in amylase
or lipase during this time, but results of the computed to-
mography scan showed dramatic diffuse edema through-
out the gland (suggesting the pancreas may have been too

TABLE III
Specific nosocomial infections per patient basis for each group

-
F!G. 4. Serial scores over time for Ranson criteria (RC), analyzed by the
For abbreviations, see Table I. two-group independent sample t test.
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18
I~G. 5. Serial mean serum glucose levels (±SEM), as evaluated by repeated-
measures analysis of variance.
inflamed to mount a response). No antibiotics were ever
started, and the patient was ultimately discharged on day 16.
DISCUSSION
Considerable evidence exists that the degree to which
the pancreas is stimulated by enteral feedings is deter-
mined by the site in the GI tract at which the feedings are
infused. 14 Feeding by mouth increases pancreatic secre-
tion by invoking three levels of stimulation via the cepha-
lic, gastric, and intestinal phases. Multiple factors at each
of these levels are involved in the stimulation of the pan-
creas. These factors include vagal stimuli, chemical stimuli
(gastric acid, gastric distention, intestinal proteins, and
fat), and hormonal stimuli (gastrin, secretin, vasoactive
intestinal polypeptide, and cholecystokinin). The more
distal the site of feeding in the GI tract, the fewer the num-
ber of these factors or levels of stimulation that are in-
volved. A lower limit of stimulation appears to exist at the
level of the duodenum, such that feedings infused into the
jejunum result in minimal or negligible stimulation.24 In a
1973 animal study,9 Ragins compared an elemental prod-
uct (Vivonex) to saline control infused into the stomach,
duodenum, and jejunum of dogs. Whereas gastric feedings
increased volume, bicarbonate, and protein enzyme out-
FiG. 6. Failure to tolerate progression to oral diet.
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FIG. 7. Effect of nasoenteric tube displacement from jejunum to stomach
(SB, small bowel; STOM, stomach).
put from the pancreas, duodenal infusions increased only
the volume of pancreatic secretion. Jejunal feedings
caused no significant change in any aspect of pancreatic
secretion compared with saline control.9 Other studies in-
volving either animals25 or humanslo,l2°26 have all shown de-
creases in pancreatic secretion in response to jejunal
feedings. Only one study in humans27 showed that a high
rate of amino acid infusion into the jejunum increased
pancreatic stimulation. A study in dogs by Cassim2S showed
that jejunal feedings increased volume and bicarbonate
output from the pancreas, but caused no increase in pro-
tein enzyme output. At least eight studies are reported in
the literature in which the infusion of enteral nutrients
into the jejunum were used as transition feeding in pan-
creatitis patients in whom the inflammation had clearly
peaked and begun to subside. 14-21
In our study, there was concern that even if jejunal
feedings did cause some pancreatic stimulation, that an
adverse clinical response might not be evident simply be-
cause the patients had only a mild degree of predominantly
alcoholic pancreatitis. Anecdotal experience in the three
TEN patients who failed to tolerate advancement to diet
by mouth and the one TEN patient in whom the jejunal
tube became displaced into the stomach provided reas-
surance against such concern. Clearly in these four pa-
tients, jejunal feedings resulted in negligible stimulation
and appeared to put the pancreas at rest, whereas feedings
either into the mouth or stomach led to obvious stimula-
tion of a potentially inflammed gland and clear-cut exac-
erbation of pancreatitis.
In a number of disease processes, use of TEN has been
shown to reduce or contain the stress response when com-
pared with use of TPN in patients with equivalent injury
or degree of critical illness. In disease processes includ-
ing burns, trauma, and major surgery, use of TEN in com-
parison with TPN results in higher visceral protein lev-
els,19 reduction in stress-induced hyperglycemia (or the
amount of insulin required to keep blood glucose levels
below a certain level),29 reduction in energy expendi-
ture,29,30 and a more rapid return of elevated cytokinins to
baseline levels.&dquo; Although both groups on entry into our
study had a similar degree of severity of pancreatitis, the

TPN group appeared to develop less stress-induced hyper-
glycenua and was slower to resolve the stress response as-
sociated with pancreatitis (as evidenced by the difference
in pattern of serial Ranson criteria) compared with the TEN
group. It may be speculated that by maintaining gut integ-
rity and preventing the translocation of bacteria or their
antigenic by-products, the use of TEN reduces the activa-
tion of macrophages associated with the gut lymphoid tis-
sue. Decreased macrophage activation would reduce the
subsequent release of cytokinin mediators, activation of the
arachidonic acid cascade, and generation of prostaglandins,
leukotrienes, and the systemic inflammatory response.5,7.S,32
Our study was performed in patients with mild predomi-
nantly alcoholic pancreatitis, and thus the results may not
be directly applied to recommend enteral nutrition in se-
vere acute pancreatitis. The results from our study, how-
ever, are qualitatively similar to those reported in patients
with greater severity of pancreatitis.6 Kudsk et all reported
on 11 patients requiring exploratory laparotomy for either
hemorrhagic pancreatitis or septic complications from their
pancreatitis. Nine of the 11 patients underwent successful
surgical placement of a jejunostomy tube and were begun
on enteral feedings immediately postoperatively. These nine
patients received feeding for a mean of 31 days, with reso-
lution of abdominal pain and a decline of amylase levels to
normal within the first 5 days of feeding. Even these pa-
tients with pancreatitis and complications severe enough
to require surgical intervention (and who had the added
stress of a major operation), appeared to tolerate jejunal
feedings well with resolution of their pancreatic inflamma-
tion. At least four other reports reach similar conclusions,
and suggest that early attempts to utilize the enteral route
is the &dquo;logical step&dquo; in the treatment of pancreatitis regard-
less of overall severity.33-36
The results of our study suggest that TEN is as safe and
effective as TPN. Both groups showed similar clinical and
biochemical resolution of their pancreatitis. Other studies
have shown that the greater the severity of critical illness,
the greater the likelihood that use of TEN will reduce length
of hospitalization, nosocomial infection, and organ failure
compared with TPN .5, The mild degree of pancreatitis in
our study patients may have explained overall similarities
in hospital course for the two groups. Even in these patients
with mild pancreatitis, however, there was evidence to sug-
gest a more favorable impact by TEN on patient stress re-
sponse to pancreatitis, with less hyperglycemia and a short-
ened time course to resolution compared with the TPN
group. The tremendous cost differential (based on charges
to the patient) between access routes would suggest that
TEN was the superior method for nutritional alimentation
compared with TPN in patients with healthcare fmancial
constraints (however, an understanding of the actual cost
of materials and labor associated with nutrition support is
needed to understand the managed care implications of
these results). The likelihood for complications of nosoco-
mial infection and organ failure in pancreatitis, the observed
benefits of TEN compared with TPN in reducing these com-
plications in other disease states, the lack of evidence in
the literature for any benefit from early TPN, and the re-
sults of this study regarding cost of nutrition support and
patient stress response would all suggest that TEN via jeju-
nal feedings should be used preferentially in this disease
setting.
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19
ACKNOWLEDGMENTS
We acknowledge the help of Dave Madsen, Amy Buhl,
and Cindy Podraza in the development of this project. This
study was supported by a research grant from Clintec
Nutrition Company, Deerfield, Illinois.
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APPENDIX A
Multiple organ failure scoring

Adapted from Marshall.22 CNS, central nervous system; DTH, delayed-type hypersensitivity.

APPENDIX B

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