Maxim S. Petrov

A Randomized Controlled Trial of Enteral versus Parenteral Feeding in Patients with Predicted Severe Acute Pancreatitis Shows a Significant Reduction in Mortality and in Infected Pancreatic Complications with Total Enteral Nutrition

Background: Infectious complications are the main cause of late death in patients with acute pancreatitis. Routine prophylactic antibiotic use following a severe attack has been proposed but remains controversial. On the other hand, nutritional support has recently yielded promising clinical results. The aim of study was to compare enteral vs. parenteral feeding for prevention of infectious complications in patients with predicted severe acute pancreatitis. Methods: We screened 466 consecutive patients with acute pancreatitis. A total of 70 patients with objectively graded severe acute pancreatitis were randomly allocated to receive either total enteral nutrition (TEN) or total parenteral nutrition (TPN), within 72 h of onset of symptoms. Baseline characteristics were well matched in the two groups. Results: The incidence of pancreatic infectious complications (infected pancreatic necrosis, pancreatic abscess) was significantly lower in the enterally fed group (7 vs. 16, p = 0.02). In the TEN group, 7 patients developed multiple organ failure whereas 17 parenterally fed patients developed multiple organ failure (p = 0.02). Overall mortality was 20% with two deaths in the TEN group and twelve in the TPN group (p < 0.01). Conclusion: Early TEN could be used as prophylactic therapy for infected pancreatic necrosis since it significantly decreased the incidence of pancreatic infectious complications as well as the frequency of multiple organ failure and mortality.

Systematic review : nutritional support in acute pancreatitis

Backgroundu2002 There has been controversy concerning the merits of enteral and parenteral nutrition compared with no supplementary nutrition in the management of patients with acute pancreatitis.

A systematic review on the timing of artificial nutrition in acute pancreatitis

Artificial nutrition is an inherent part of management in acute pancreatitis. However, there is no consensus regarding the optimal time of the commencement of feeding in these patients. Our aim was to compare the effect of enteral v. parenteral nutrition with regard to the time points when they were administered in the randomised controlled trials. The search was undertaken in the Cochrane Central Register of Controlled Trials, MEDLINE and Science Citation Index as well as in the proceedings of major gastroenterology meetings. The summary estimate of the effect associated with artificial nutrition was calculated using a random-effects model and presented as a risk ratio (RR) and 95 % CI. A total of eleven randomised controlled trials were included. When started within 48 h of admission, enteral nutrition, in comparison with parenteral nutrition, resulted in a statistically significant reduction in the risks of multiple organ failure (RR 0.44; 95 % CI 0.23, 0.84), pancreatic infectious complications (RR 0.46; 95 % CI 0.27, 0.77) and mortality (RR 0.46; 95 % CI 0.20, 0.99). After 48 h of admission, enteral nutrition, in comparison with parenteral nutrition, did not result in a statistically significant reduction in the risks of multiple organ failure (RR 0.73; 95 % CI 0.33, 1.63), pancreatic infectious complications (RR 0.31; 95 % CI 0.07, 1.34) and mortality (RR 0.67; 95 % CI 0.22, 2.10). Enteral nutrition is more effective than parenteral nutrition in reducing the risk of multiple organ failure, pancreatic infectious complications and mortality in patients with acute pancreatitis. The magnitude of these benefits may depend on the timing of the commencement of nutrition.

Advanced enteral therapy in acute pancreatitis: is there a room for immunonutrition? A meta-analysis

BACKGROUNDnIt is believed that certain nutrients such as glutamine, arginine and omega-3 fatty acids may play a significant role in metabolic, inflammatory, and immune processes in acute pancreatitis. The present systematic review aimed to define whether the addition of these substances to enteral nutrition provides any clinical benefit over standard enteral formulas in patients with acute pancreatitis.nnnMETHODSnA computerized search on electronic databases (Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE) and manual search of the abstracts of major gastroenterological meetings (UEGW, DDW) were undertaken. The studied outcomes were total infectious complication, in-hospital mortality and length of hospital stay. The data were meta-analyzed using a random-effects model.nnnRESULTSnA total of three randomized controlled trials satisfied the inclusion criteria. When compared with standard enteral nutrition, immunonutrition was not associated with the significantly reduced risk of total infectious complications (risk ratio 0.82; 95% confidence interval 0.44-1.53; P=0.53) and death (risk ratio 0.64; 95% confidence interval 0.20-2.07; P=0.46). Mean difference in length of hospital stay between two groups was not significant (P=0.80).nnnCONCLUSIONSnThere is no evidence that enteral nutrition supplemented with glutamine, arginine and/or omega-3 fatty acids, in comparison with standard enteral nutrition, has any beneficial effect on infectious complications, mortality or length of hospital stay in acute pancreatitis. The pursuit of new compositions of enteral formulations in this category of patients may be advocated.

A systematic review of serologic tests in the diagnosis of necrotizing enterocolitis

BACKGROUNDnAlthough many serologic markers have been suggested for diagnosis of necrotizing enterocolitis, there is little consensus on which of these is potentially clinically useful. Our aims were (i) to systematically review circulating markers that are potentially useful in the diagnosis of NEC and (ii) to compare the relative performance of each serologic marker of NEC by pooling estimates of marker accuracies and presenting their combined diagnostic accuracies.nnnMETHODSnWe undertook a systematic review of the literature to identify studies that reported serologic markers at the time of diagnosis of necrotizing enterocolitis. Where possible, we constructed 2-by-2 tables of diagnostic accuracy from each article, if 2 or more studies investigated the same test, their results were meta-analyzed by pooling estimates of sensitivity, specificity, likelihood ratio for positive index test (LR+), likelihood ratio for negative index test (LR-), diagnostic odds ratio, and their corresponding 95% confidence intervals.nnnRESULTSnTwenty-five articles provided information on serology at the time of diagnosis of necrotizing enterocolitis. Of these, it was possible to construct diagnostic accuracy tables from 16 articles and to combine data from studies that used C-reactive protein, intestinal fatty acid binding protein, and platelet-activating factor. Of these C-reactive protein was a sensitive but nonspecific marker for necrotizing enterocolitis, whereas platelet-activating factor and intestinal fatty acid binding protein were both sensitive and specific.nnnCONCLUSIONSnMost serologic markers of necrotizing enterocolitis have been used in too few studies to evaluate their use. Of those tests that have been tested repeatedly, platelet-activating factor and intestinal fatty acid binding protein are potentially useful, although their use must be further tested in larger prospective studies.

Does endoscopic retrograde cholangiopancreatography reduce the risk of local pancreatic complications in acute pancreatitis? A systematic review and metaanalysis

BackgroundRecent studies have added to the controversy regarding the role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of patients with acute biliary pancreatitis. This debate is due in part to a marked difference between the trials regarding the definition of “complication” as an outcome. This study sought to determine the effect of early ERCP versus conservative treatment on local pancreatic complications (defined by the current classification) experienced by patients with acute biliary pancreatitis.MethodsElectronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, Science Citation Index) and conference proceedings were searched for relevant randomized controlled trials up to December 2007. The effect of both treatment strategies on local pancreatic complications was calculated with random-effects models.ResultsFive trials involving 717 patients were included in this systematic review. Pooled analysis of all the patients with acute pancreatitis did not demonstrate a statistically significant difference between the two treatment strategies (relative risk [RR], 0.94; 95% confidence interval [CI], 0.63–1.40; pxa0=xa00.62). Similar results were observed after subgroup analysis based on the severity of disease as follows: mild acute pancreatitis (RR, 0.79; 95% CI, 0.26–2.47; pxa0=xa00.69); severe acute pancreatitis (RR, 0.77; 95% CI, 0.30–1.98; pxa0=xa00.59).ConclusionThe early use of ERCP did not result in a significantly reduced risk of local pancreatic complications for either patients with mild acute pancreatitis or those with severe form of the disease.

Early Prediction of Severity in Acute Pancreatitis Using Infrared Spectroscopy of Serum

Background: One of the main problems in the management of acute pancreatitis (AP) is the scarcity of accurate predictors of disease severity. Methods: In a prospective design, we compared APACHE II score, C-reactive protein (CRP) level, and infrared (IR) spectral absorption of serum (wavelength 940 nm) in 167 consecutive patients with AP, 34 with predicted severe and 133 with mild form. Results: The IR spectral absorption levels on admission and at 24 h after admission were significantly (p < 0.05) lower in patients with severe AP. On admission, the sensitivity was 74, 56, and 44%; the specificity was 82, 83, and 81%; the positive predictive value was 51, 45, and 37%, and the negative predictive value was 92, 88, and 85%, for IR spectroscopy, APACHE II, and CRP, respectively. At 24 h, the sensitivity, specificity, positive predictive value, and negative predictive value was 82, 74, 44, and 94%; 65, 72, 37, and 89%; 68, 73, 39, and 90%, for IR spectroscopy, CRP, and APACHE II, respectively. Conclusions: IR spectroscopy seems to be useful for early detection of severe AP and, in turn, for identifying patients requiring treatment in the intensive care unit and who can benefit from novel therapies.

Meta-Analyses on the Prophylactic Use of Antibiotics in Acute Pancreatitis: Many Are Called but Few Are Chosen

Meta-Analyses on the Prophylactic Use of Antibiotics in Acute Pancreatitis: Many Are Called but Few Are Chosen

Usefulness of infrared spectroscopy in diagnosis of acute pancreatitis.

Background:u2003 The lack of a gold standard for the diagnosis of acute pancreatitis remains a problem. Our aim was to evaluate whether infrared spectroscopy of serum can establish the diagnosis of acute pancreatitis.

Enteral nutrition: goody or good-for-nothing in acute pancreatitis?

TO THE EDITOR: We read the recently published metaanalysis on dual therapy versus monotherapy in the endoscopic treatment of high-risk bleeding ulcers with a great deal of interest (1). The authors concluded that dual endoscopic therapy proved to be significantly superior to epinephrine injection alone, but had no advantage over thermal or mechanical monotherapy in improving the outcome of patients with high-risk peptic ulcer bleeding. However, these results should be treated with caution. First, as noted in this article, there was significant heterogeneity between the studies concerning recurrent bleeding (Q = 32.2, P = 0.07, I2 =31.6%), and the authors handled this heterogeneity by subgroup analysis and meta-regression and found that the type of dual therapy used and the posthemostasis adjuvant medical therapy with proton pump inhibitors were the only two variables explaining the heterogeneity of the results. Unfortunately, they did not perform a sensitivity analysis, another good approach to heterogeneity. Because it has been suggested that the robustness of findings to different assumptions should always be examined in a thorough sensitivity analysis (2), if the sensitivity analysis that is done does not change the results, it strengthens the confidence that can be placed in these results. If the results change in a way that might lead to different conclusions, this means that there is a need for greater caution in interpreting the results and drawing conclusions, and the robustness of the findings should be doubted. For example, as described in the title of this article, this is a meta-analysis of controlled trials; therefore, we are eager to know what the result would be if the results of randomized, controlled trials were pooled. Second, based on the results from a subgroup analysis, the authors state that dual therapy was significantly superior to injection therapy alone. Nonetheless, we should bear in mind that findings from multiple subgroup analyses may be misleading. Subgroup analysis is observational in its nature and is not a randomized comparison. Both false-negative and false-positive significance tests increase in likelihood rapidly as more subgroup analyses are performed. Thus, subgroup analysis suffers from the limitations of any observational research, including possible bias through other confounding factors (3). If these findings were presented as definitive conclusions, there would clearly be a risk of patients being denied an effective treatment or treated with an ineffective intervention. To summarize, the results in this article should be interpreted with much caution, and more statistical analysis is necessary to answer this important clinical question and draw a definitive conclusion in the presence of the available randomized, controlled trials.