Meta Analysis
Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis
This review may be edited
Posted By: Stephen Drage
Posted Date: 14th June 2004
Title: Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis
Authors: Paul E Marik, Gary P Zaloga
Reference: BMJ 2004 June 12; 7453:1407-10
Link: Click here for a direct link to the paper. A password may be required for access to fulltext.
Abstract: Objective To compare the safety and clinical outcomes of enteral and parenteral nutrition in patients with acute pancreatitis.
Data sources Medline, Embase, Cochrane controlled trials register, and citation review of relevant primary and review articles.
Study selection Randomised controlled studies that compared enteral nutrition with parenteral nutrition in patients with acute pancreatitis. From 117 articles screened, six were identified as randomised controlled trials and were included for data extraction.
Data extraction Six studies with 263 participants were analysed. Descriptive and outcome data were extracted. Main outcome measures were infections, complications other than infections, operative interventions, length of hospital stay, and mortality. The meta-analysis was performed with the random effects model.
Data synthesis Enteral nutrition was associated with a significantly lower incidence of infections (relative risk 0.45; 95% confidence interval 0.26 to 0.78, P = 0.004), reduced surgical interventions to control pancreatitis (0.48, 0.22 to 1.0, P = 0.05), and a reduced length of hospital stay (mean reduction 2.9 days, 1.6 days to 4.3 days, P < 0.001). There were no significant differences in mortality (relative risk 0.66, 0.32 to 1.37, P = 0.3) or non-infectious complications (0.61, 0.31 to 1.22, P = 0.16) between the two groups of patients.
Conclusions Enteral nutrition should be the preferred route of nutritional support in patients with acute pancreatitis.
Are the Results Valid?
1. Did the overview address a focused clinical question?
Yes, to compare enteral nutrition with parenteral nutrition in patients with pancreatitis. The end points were mortality, infectious complications, other complications, need for surgery and length of hospital stay.
2. Were the criteria used to select articles for inclusion appropriate?
Yes, the authors state their criteria for article selection as randomised controlled trials comparing enteral with parenteral nutrition in pancreatitis. Only trials reporting the outcomes listed above were included.
3. Is it unlikely that important, relevant studies were missed?
Yes, an extensive search was carried out including contacting experts in the field for unpublished work.
4. Was the validity of the included studies appraised?
Yes, a Jadad score was given to each paper. This tool judges studies against 7 criteria resulting in a score out of 5. An adequately randomised properly blinded trial reporting loss to follow up would score 5.
Two of the trials included were pseudorandomised. Most methodologists would consider this a major flaw and would not have included them with truly randomised trials.
Although the validity of the included trials is appraised, results for 'high quality' studies are not presented separately from those with major flaws (pseudo-randomised trials).
5. Were assessments of studies reproducible?
Yes, see above
6. Were the results similar from study to study?
No, there was significant heterogeneity with respect to length of hospital stay. Also, patients studied in the indiviual trials were quite different with respect to severity of illness. Similarly, interventions and timing of nutritional support differed between trials.
What are the Results?
1. What are the overall results of the overview?
6 trials were included. Of these 4 had a Jadad score of less than 2. No trial had a score greater than 3. The largest trial studied 89 patients. Overall, the methodological quality of the included trials could be considered poor.
Primary outcomes
Infections RR 0.45 (CI: 0.26 to 0.78).
When only the 4 truly randomised trials were considered, the p-value on the primary outcome (infections) is reduced to 0.05, with RR 0.45 (95%CI .21 to 1.00)[recalculated by Gord]
Other complications RR 0.61 (CI: 0.31 to 1.22).
Other outcomes considered
Difference in hospital mortality between enteral and parenteral nutrition, RR 0.66 (CI:0.32-1.37).
For length of hospital stay mean reduction 2.9 days (CI:1.6 to 4.3 days) however, due to heterogeneity, it is difficult to interpret this result.
Need for surgery, RR 0.48 (CI: 0.23 to 0.99).
2. How precise were the results?
See pooled estimates and confidence intervals above.
Will the Results Help Me In Caring For My Patients?
1. Can the results be applied to my patient care
Unclear, this meta-analysis is of small, poor quality controlled trials but it does suggest EN may be preferable to PN. The major flaw is the inclusion of pseudorandomised trials and so using the results of this meta-analysis to guide patient care must be done with caution. Also, the patient groups in the individual trials varied from the critically ill to those with mild pancreatitis. It is possible that these two types of patients respond to nutritional support differently.
2. Were all clinically important outcomes considered?
Yes, mortality, complications and need for surgery are clinically meaningful outcomes however, it is important to note that infectious complications, and some other outcomes, were defined very differently in each trial.
3. Are the benefits worth the harms and costs?
Unclear. Because infectious complications were defined differently in each trial, it is hard to determine their clinical importance. This meta-analysis highlights the need for high quality RCTs of parenteral vs enteral nutrition in pancreatitis but does not provide a clear answer with regards to costs and harms. Indeed, we may find that the true answer depends upon how critically ill the patient population is.

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