Early Enteral Feeding in Severe Acute Pancreatitis: A Randomized Clinical Trial Between Gastric vs Distal Jejunal Feeding

Background and Aims: Severe acute pancreatitis is one of the most catabolic illnesses. Meta-analyses have shown that enteral nutrition is safer and more effective than parenteral nutrition in suppressing these losses. However, there is intense debate about how the enteral nutrition should be delivered. Methods: The design was a randomized controlled trial of early nasogastric (NG) vs distal jejunal (DJ) tube feeding with a semi-elemental diet during the first 4 weeks of severe acute pancreatitis. The setting involved multiple national tertiary care centers. Two hundred and twenty-eight patients were screened, and 26 met the inclusion criteria for new onset severe acute pancreatitis based on an APACHE II score >8, computed tomography evidence of >30% necrosis or computed tomography score >8, and/or a Marshall score >2. The intervention was a randomized allocation to either feeding tube bedside placement by NG or transnasal endoscopy for DJ. The primary endpoint was “feeding failure” to tolerate a rate of >10% of the goal for a 48-hour period. Results: Twenty-six eligible patients were randomized, 12 to NG and 14 to DJ, 20 of 26 from the Pittsburgh center. Most were obese (BMI 31.5 kg/m²). Feeding failure occurred in 0 of 14 in the DJ group and in 6 of 11 (55%) in the NG group (P = 0.0026). NG failures were crossed over to DJ feeding with good tolerance and eventual recovery. As a result, the quantity of feed delivered was significantly higher in the DJ group (P < 0.05). Serious adverse events (cardiorespiratory arrests, unrelated to endoscopy) occurred in 2 of the DJ and none of the NG group; 3 patients from the DJ group died of progressive organ failure, 2 with associated compartment syndrome. Conclusion: This randomized controlled trial indicates that in patients with acute pancreatitis of this level of severity, NG feeding will be ineffective. Although this is a common indication for parenteral nutrition, a safer alternative would be endoscopic-assisted DJ feeding tube placement to bypass the usually dysfunctional or obstructed upper gastrointestinal tract.