Feed, or wait and eat, in pancreatitis

Another addition to this year’s flurry of nutrition work.

Tradition has us bypassing the stomach and duodenum for nutrition in pancreatitis – intuitively sensible. To challenge this the Dutch PYTHON trial group has recently published its findings.

Multicentredly, they randomized 200-ish patients with acute ‘high-risk’ pancreatitis (defined as mGlasgow of >/= 3, CRP >150, APACHE >/=8) to start naso-jejunal feeding (25Kcal/Kg/dy if on ICU) within 24 hours or to wait up to 3 days and then encourage (the ‘on-demand’ group). Powered to detect 5% difference in major infection (pancreas or other) OR death within 6 months. The protocol was pretty well-adhered-to.

There was no difference in primary outcome (~30%), major infection rate (~25%), death rate (~10%), necrosis (~60%), mechanical ventilation (~12%). 5-10% got parenteral nutrition. 

• Importantly only a fifth needed ICU care. So of those predicted to get severe pancreatitis presumably many didn’t.
• Target calorie delivery was rarely achieved until day 3 or 4 in the early fed group and 6 or 7 in the other.
• Interestingly, more than 2 thirds of of the ‘on-demand’ group didn’t need tube feeding.

So early NJ feeding doesn’t appear superior to delaying addressing nutrition until day 4 and starting oral intake.

How useful is this result? Accurately predicting severe pancreatitis is clearly problematic and for studies like this mean that the sample ends up being very heterogeneous. Regarding study design, mixing timing and route may have limited the applicability of these results, and many are inherently suspicious of composite outcome measures. 

We need a way to better predict severe pancreatitis. And then perhaps a 2×2 look at timing and route?