A meta‐analysis including 20 randomized controlled trials determined that there is no specific type of EN or immune nutrition that improves outcomes in acute pancreatitis [45,46]. Likewise, a 2015 Cochrane review [47] showed no beneficial effects of one specific EN formulation over another. Cochrane also specifically looked at immune nutrition formulations compared with control and found a reduction in all‐cause mortality. However, when analysis was stratified only for studies comparing it to other EN formulations, this effect could not be confirmed, and the authors remarked that all these findings are based on low‐quality evidence. With regard to safety issues of probiotic provision to critically ill patients, cases of fungemia in ICU patients associated with the use of Saccharomyces boulardii, as well as worsened clinical outcomes in severe pancreatitis, have been reported [48,49]. POPATRIA, a randomized controlled trial that investigated the use of a multispecies probiotic with Bifidobacterium in AP patients, was stopped early due to increased rate of bowel ischemia and MOF [48]. Based on the risk of adverse events, routine probiotic use cannot be recommended in the treatment of AP at this time [42].
A systematic review and meta‐analysis of the literature regarding EN formulations in AP found that the use of polymeric, compared with semi‐elemental, formulations does not lead to a significantly higher risk of feeding intolerance, infectious complications, or death in patients with acute pancreatitis [45]. Neither the supplementation of EN with probiotics, nor the use of immune nutrition, significantly improve clinical outcomes [45]. A separate meta‐analysis that investigated the effect of immune nutrition only also corroborated its lack of effectiveness [46]. Though underpowered, one small randomized prospective pilot study comparing semi‐elemental formula with polymeric formula in AP found that both formulas were similarly well tolerated (no difference in pain, bloating, or analgesic consumption). However, the semi‐elemental formula was associated with decreased weight loss and reduction in length of stay [50]. The study population was composed of patients with moderately severe pancreatitis; the authors remarked that it would not be expected that these patients would have pancreatic exocrine insufficiency, nor any difficulty tolerating a polymeric formula. Theoretically, the patients expected to benefit from an elemental formulation are those with severe pancreatitis. A retrospective cohort study using a Japanese national administrative database compared patients who received elemental formula with a control group, which received either semi‐elemental or polymeric formulation. The study found that there was no significant difference observed for in‐hospital mortality and all secondary outcomes, including sepsis, readmission, and cost [51]. The American Society for Parenteral and Enteral Nutrition and the Society of Critical Care Medicine recommend using a standard polymeric formula when initiating EN in the ICU setting [52]. ESPEN [42] and the International Consensus Guidelines [43] recommend a peptide‐based medium‐chain triglyceride oil formula to improve tolerance, which is in line with the fact that most human studies have been carried out utilizing a peptide‐based formula [53–59]. In clinical practice, it is reasonable to start EN using a standard formula and then, if not tolerated, switching to a peptide‐based formula, given the higher expense of the latter.
In terms of when patients can be weaned from EN, most AP patients on EN have more severe pancreatitis and may have ongoing MOF and/or peripancreatic fluid collections, with a higher likelihood of OFI. Oral feeding can be progressively attempted once concern for gastric outlet obstruction has resolved, provided it does not result in pain, and provided that complications are under control [42]. Tube feeds can be gradually withdrawn as intake improves.
References
1 1 Guo ZZ, Wang P, Yi ZH, et al. The crosstalk between gut inflammation and gastrointestinal disorders during acute pancreatitis. Curr Pharm Des 2014; 20:1051–1062.
2 2 Pagliari D, Saviano A, Newton EE, et al. Gut microbiota–immune system crosstalk and pancreatic disorders. Mediators Inflamm 2018; 2018:7946431.
3 3 McClave SA. Factors that worsen disease severity in acute pancreatitis: implications for more innovative nutrition therapy. Nutr Clin Pract 2019; 34(Suppl 1):S43–S48.
4 4 Al‐Omran M, Albalawi ZH, Tashkandi MF, et al. Enteral versus parenteral nutrition for acute pancreatitis. Cochrane Database Syst Rev 2010;(1):CD002837.
5 5 McClave SA, Chang WK, Dhaliwal R, et al. Nutrition support in acute pancreatitis: a systematic review of the literature. JPEN J Parenter Enteral Nutr 2006; 30:143–156.
6 6 Wu BU, Banks PA. Clinical management of patients with acute pancreatitis. Gastroenterology 2013; 144:1272–1281.
7 7 Bouffard YH, Delafosse BX, Annat GJ, et al. Energy expenditure during severe acute pancreatitis. JPEN J Parenter Enteral Nutr 1989; 13:26–29.
8 8 Dungan KM, Braithwaite SS, Preiser JC. Stress hyperglycaemia. Lancet 2009; 373(9677):1798–1807.
9 9 Feller JH, Brown RA, Toussaint GP, et al. Changing methods in the treatment of severe pancreatitis. Am J Surg 1974; 127:196–201.
10 10 Shaw JH, Wolfe RR. Glucose, fatty acid, and urea kinetics in patients with severe pancreatitis. The response to substrate infusion and total parenteral nutrition. Ann Surg 1986; 204:665–672.
11 11 Dickerson RN, Vehe KL, Mullen JL, et al. Resting energy expenditure in patients with pancreatitis. Crit Care Med 1991; 19:484–490.
12 12 Rinninella E, Annetta MG, Serricchio ML, et al. Nutritional support in acute pancreatitis: from physiopathology to practice. An evidence‐based approach. Eur Rev Med Pharmacol Sci 2017; 21:421–432.
13 13 Hill GL. Jonathan E. Rhoads Lecture. Body composition research: implications for the practice of clinical nutrition. JPEN J Parenter Enteral Nutr 1992; 16:197–218.
14 14 Pan LL, Li J, Shamoon M, et al. Recent advances on nutrition in treatment of acute pancreatitis. Front Immunol 2017; 8:762.
15 15 Tenner S, Baillie J, DeWitt J, et al. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 2013; 108:1400–1415; 1416.
16 16 Roberts KM, Nahikian‐Nelms M, Ukleja A, et al. Nutritional aspects of acute pancreatitis. Gastroenterol Clin North Am 2018; 47:77–94.
17 17 Song J, Zhong Y, Lu X, et al. Enteral nutrition provided within 48 hours after admission in severe acute pancreatitis: a systematic review and meta‐analysis. Medicine (Baltimore) 2018; 97:e11871.
18 18 Yi F, Ge L, Zhao J, et al. Meta‐analysis: total parenteral nutrition versus total enteral nutrition in predicted severe acute pancreatitis. Intern Med 2012; 51:523–530.
19 19 Petrov MS, van Santvoort HC, Besselink MG, et al. Enteral nutrition and the risk of mortality and infectious complications in patients with severe acute pancreatitis: a meta‐analysis of randomized trials. Arch Surg 2008; 143:1111–1117.
20 20 Kotani J, Usami M, Nomura H, et al. Enteral nutrition prevents bacterial translocation but does not improve survival during acute pancreatitis. Arch Surg 1999; 134:287–292.
21 21 Kang W, Gomez FE, Lan J, et al. Parenteral nutrition impairs gut‐associated lymphoid tissue and mucosal immunity by reducing lymphotoxin beta receptor expression. Ann Surg 2006; 244:392–399.
22 22 Stigliano S, Sternby H, de Madaria E, et al. Early management of acute pancreatitis: a review of the best evidence. Dig Liver Dis 2017; 49:585–594.
23 23 Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence‐based guidelines for the management of acute pancreatitis. Pancreatology 2013; 13(4 Suppl 2):e1–e15.
24 24 Meier R, Beglinger C, Layer P, et al. ESPEN guidelines on nutrition in acute pancreatitis. European Society of Parenteral and Enteral Nutrition. Clin Nutr 2002; 21:173–183.
25 25 Teich N, Aghdassi A, Fischer J, et al. Optimal timing of oral refeeding in mild acute pancreatitis: results of an open randomized multicenter trial. Pancreas 2010; 39:1088–1092.
26 26 Larino‐Noia J, Lindkvist B, Iglesias‐Garcia J, et al. Early and/or immediately full caloric diet versus standard refeeding in mild acute pancreatitis: