SPECIAL ARTICLE
Early Enteral Feeding Versus Total Parenteral Feeding After Surgery in Severe Acute Pancreatitis:
An Evidence-Based Case Report Roy Akur Pandapotan1,2.
Anissa Syafitri3.
Andre Setiawan4.
Burhan Gunawan5.
Nathalia Gracia Citra6.
Josephine Alicia Bierhuijs6.
Johana Titus7* Department of Internal Medicine.
Faculty of Medicine.
Kristen Krida Wacana University.
Jakarta.
Indonesia.
Department of Internal Medicine.
Sumber Waras Hospital.
West Jakarta.
Indonesia.
Department of Nutritional Sciences.
Faculty of Medicine.
Universitas Indonesia Ae Cipto Mangunkusumo Hospital.
Jakarta.
Indonesia.
Department of Surgery.
Sumber Waras Hospital.
Jakarta.
Indonesia.
General Practitioner.
Sumber Waras Hospital.
Jakarta.
Indonesia.
Faculty of Medicine.
Tarumanagara University.
Jakarta.
Indonesia.
Department of Nutritional Sciences.
Faculty of Medicine.
Universitas Indonesia - Sumber Waras Hospital.
Jakarta.
Indonesia.
Corresponding Author:
Johana Titus.
MD.
Department of Nutritional Sciences.
Faculty of Medicine.
Universitas Indonesia - Sumber Waras Hospital.
Bakordik 7th floor.
Jl.
Kyai Tapa No.
1 Grogol Petamburan.
Jakarta 11440.
Indonesia.
Email:
jt@gmail.
ABSTRACT
Background: Acute pancreatitis is a self-limiting inflammatory disease that in some cases may lead to severe acute pancreatitis.
To prevent this development, multimodal management, including nutritional management, is used in treating acute pancreatitis patients.
The controversy between parenteral and enteral feeding has led to major debate.
This case report aims to assess which method has better outcomes based on multiple cases of organ failure, inflammatory response, and length of hospital stay.
Methods: A 46-yearold male presented to the Emergency Department of our hospital with acute abdominal pain, nausea, and vomiting, 12 h before admission.
Based on physical and further examination, the patient was diagnosed with severe acute pancreatitis and underwent a necrotomy procedure.
Articles from multiple databases were obtained and assessed using the Cochrane Collaboration Risk of Bias tool.
The articles were analyzed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyse.
guidelines and a forest plot model.
Effect size quantification for continuous and categorical variables was analyzed using continuous and binary random effect models, respectively.
Results: Seven articles were obtained after exclusion and review.
A total of 491 patients with acute/severe acute pancreatitis were assessed.
These seven articles conclude that enteral nutrition has advantages over parenteral nutrition.
Conclusion: Our study concluded that early enteral feeding provides better clinical improvement, reduced lipase enzyme levels, and shortened length of hospital stay.
Keywords: acute pancreatitis, early enteral feeding, clinical improvement, length of stay, case report.
Acta Med Indones - Indones J Intern Med A Vol 57 A Number 2 A April 2025 Roy Akur Pandapotan INTRODUCTION Acute pancreatitis (AP) is an acute inflammatory process of the pancreas with various outcomes, ranging from self-limiting to severe acute pancreatitis (SAP).
1-3 The severity of acute pancreatitis can be grouped using a scoring system such as RansonAos Score.
BISAP Score.
Acute Physiology and Chronic Health Evaluation (APACHE) II score, and Sequential Organ Failure Assessment score.
The incidence of AP is increasing worldwide.
Moreover, biliary acute pancreatitis caused by alcohol is also increasing significantly.
Statistically, men and women have the same incidence rate of AP.
Higher mortality rates are found in hospitalized AP patients with organ failure or necrotizing pancreatitis.
Inflammation of the pancreatic gland is accompanied by abdominal pain and exocrine failure leading to decreased oral intake, which is frequently related to malnutrition.
7 To prevent malnutrition, reduce inflammation, and improve the outcome of AP, nutritional support plays an important role in AP management.
The traditional theory of Aupancreatic restAy is trusted and has been widely used.
8 By allowing the intestines to rest, the autodigestion process will stop, thereby reducing the inflammatory process in the pancreas.
9 Many studies show the superiority of enteral nutrition over parenteral Enteral nutrition has been proven to maintain the intestinal mucosa's function and Moreover, lower mortality, multiple organ failure, and infection rates have been found by giving enteral nutrition.
Early enteral feeding within 48Ae72 h after the onset of AP is 4,10-12 There is still much controversy concerning the benefits of enteral versus parenteral nutrition in AP.
This, therefore, leads to the aim of this case report, which is to answer several questions:
Which methods of enteral versus parenteral nutrition can improve the clinical condition? Which methods of enteral and parenteral nutrition can reduce pancreatic inflammation based on lipase enzyme Acta Med Indones-Indones J Intern Med Which feeding method will result in a shorter length of stay (LOS), enteral or parenteral nutrition? CASE ILLUSTRATION A 46-year-old male presented to the Emergency Department.
Sumber Waras Hospital.
West Jakarta.
Indonesia, complaining of acute abdominal pain 12 h before admission with nausea and vomiting.
Since his teenage years, the patient had been smoking around 1-2 packs per day.
He had been an alcoholic for 13 years with a habit of drinking 5 shots of Chinese wine per day.
He had poor nutritional habits with inadequate calorie intake.
had a history of epigastric pain for half a There was no history of diabetes or Physical examination showed abdominal distention, reduced bowel sounds, and diffuse and rebound tenderness.
On the day of admission, the patientAos heart rate was 90 beats per minute, respiratory rate 22 breaths per minute, and visual analog scale (VAS) of 4Ae5.
He was categorized as grade I obese according to the Asia-Pacific body mass index (BMI) classification.
Laboratory findings on admission revealed elevated lipase serum and electrolyte imbalance.
Two days before discharge, a blood glucose check showed high serum levels of glycated hemoglobin (HbA1.
An abdominal computed tomography (CT) scan showed edematous pancreatitis with signs of necrosis on the caput and cauda of the pancreas.
The patient was diagnosed with SAP based on the Revised Atlanta Criteria.
The preoperative diagnosis was general peritonitis caused by necrotic pancreatitis.
The patient underwent an emergency exploratory laparotomy and debridementnecrosectomy of the pancreatic head within 6 h after admission.
Intraoperative findings included: black serous hemorrhagic necroticlike fluid, about 200 mL.
fibrin tissue around the duodenogastric area and necrotic tissue in the pancreatic head.
The necrotomy of the pancreas was performed, and three drains were installed.
Vol 57 A Number 2 A April 2025 Early Enteral Feeding Versus Total Parenteral Feeding After Surgery In the post-operative procedure, a clear yellowish residue with a volume of more than 125 mL was found in the nasogastric tube.
Laboratory findings revealed leukocytosis, elevated urea, and creatinine.
Several parameters were found to have decreased, such as the VAS score, which decreased to a score of 1Ae2, heart rate below 90 beats per minute, and a normal respiratory rate.
One day after the surgery, the patient managed to flatus, and to defecate on the second postoperative day.
However, a significant decrease in lipase enzyme was found.
Nutrition was given parenterally immediately after surgery.
Early enteral nutrition was given on day two of admission with clear fluids that were increased to milk/broth/juice on day four.
Nutritional management of the patient is described in Table 1.
The acute kidney injury resolved on postoperative day 4.
There were no incidences of sepsis, re-surgery, or mortality during the post-operative period.
The pharmacologic prescriptions for the patient include Omeprazole IV 40 mg,Ondansetron IV 4 mg.
Ketorolac IV 30 mg.
Ciprofloxacin 2 y 200 mg and Meropenem 3 y 1 g IV.
Metronidazole 3 y 500 mg IV.
Paracetamol 3 y 1 g, and Novorapid 5 units/h.
The patient was discharged on the twelfth post-operative day.
METHODS
Articles were collected from PubMed.
ProQuest.
Scopus, and Springer databases using the keywords Auacute pancreatitis,Ay Ausevere acute pancreatitis,Ay Aunecrotic pancreatitis,Ay Auearly enteral feeding,Ay and Auparenteral feeding.
Ay The Inclusion criteria in this report were patients with AP who use early enteral feeding as the main nutritional AP was diagnosed according Table 1.
Daily Nutritional Management Post-Operative Day (POD) Nutrition Prescription POD-0.
Jan 14, 2023 POD-1.
Jan 15, 2023 Parenteral formula 1000 mL/24 h Parenteral formula 1440 mL/24 h Clear liquid 6 y 50 mL Parenteral formula 1440 mL/24 h Clear liquid 6 y 50 mL Parenteral formula 1440 mL /24 h Clear liquid 6 y 50 mL Parenteral formula 1440 mL/24 h Milk/broth/juice 6 y 50 mL Parenteral formula 1000 mL/24 h Enteral formula 3y 15 mL/h .
h, then stop for 1 .
If residue < 100 mL, enteral formula 6 y 50 mL Parenteral formula 1000 mL/24 h Enteral formula 3 y 15 mL/h .
h, then stop for 1 .
If residue < 100 mL, enteral formula 6 y 50 mL Parenteral formula 1000 mL/24 h Enteral formula 3 y 15 mL/h .
h, then stop for 1 .
If residue < 100 mL.
Peptamen 6 y 50 mL Parenteral formula 1000/24 h Enteral formula 3 y 15 mL/h .
h, then stop for 1 .
If residue < 100 mL.
Peptamen 6 y 50 mL Parenteral formula 500 mL/24 h Enteral formula 6 y 50 mL Sugar-free rice flour porridge without coconut milk 2 y 1/2 portion Extra fruit juice 1 y 100 kcal Nasogastric tube was removed Parenteral formula was stopped Enteral formula 6 y 50 mL Sugar-free rice flour porridge without coconut milk 3 y 1 portion steamed egg Extra fruit juice 1 y 100 kcal Porridge with minced meat and vegetables steam white egg 1 portion coconut oil 1 tsp .
Enteral formula 3 y 100 kcal Fruit juice 2 y 50 kcal POD-2.
Jan 16, 2023 POD-3.
Jan 17, 2023 POD-4.
Jan 18 2023 POD-5.
Jan 19, 2023 POD-6.
Jan 20, 2023 POD-7.
Jan 21, 2023 POD-8.
Jan 22, 2023 POD-9.
Jan 23, 2023 POD-10.
Jan 24, 2023 POD-11.
Jan 25, 2023 1 portion = 300 kcal Roy Akur Pandapotan Acta Med Indones-Indones J Intern Med to the Revised Atlanta Criteria.
Early enteral feeding is defined as providing enteral nutrition within 3 days after surgery for AP.
The main outcomes were improvement in clinical condition and inflammatory parameters .
ipase enzym.
, and reduced length of hospital Clinical conditions were determined by the proportion of infection, organ failure, mortality incidence, and other clinical parameters such as the visual analog scale (VAS), systemic inflammatory response syndrome (SIRS), and intestinal motility.
Only randomized controlled trial (RCT) studies that met the inclusion criteria were used in this report.
Exclusion criteria were studies that did not use English and had no full text available.
The selected articles were then assessed based on the Cochrane Collaboration Risk of Bias tool.
Analysis and quality assessment were conducted using Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, and the interpretation was carried out using a forest plot model.
Effect size quantification was carried out based on standardized mean difference (SMD) for continuous variables using a continuous random effect model (Der SimonianAeLair.
For categorical variables, effect size was quantified based on log relative risk (RR) using a binary random effect model (Der SimonianAeLair.
RESULTS
Using keywords, 101 articles were found.
After duplicates were removed, 38 articles were obtained.
Based on the title and abstract, 21 articles were excluded.
Of the remaining 17 articles, 3 full texts were not acquired, leaving 14 articles to be reviewed.
Applying the exclusion criteria, 7 more articles were Finally, only 7 articles were included in this report: Petrov et al.
,6 Casas et al.
,17 Doley et al.
,18 Hui et al.
,19 Noor et al.
,20 Horibe et al.
,21
and Farooq et al.
A total of 247 subjects with AP/SAP were in the intervention group, and 244 subjects were in the control group.
There was no significant baseline difference between the two The control group used total parenteral nutrition or delayed enteral nutrition as a comparison of management.
All studies conduct an intention-to-treat (ITT) analysis, except Petrov et al.
6 Detailed studies are shown in Table 2.
Table 2.
Study Description No.
Author (Yea.
Country Subject Analysis Intervention Number Petrov et Russia Severe acute Total enteral ITT Total enteral Severe acute ITT Total enteral Severe acute ITT Total enteral Noor et al.
Pakistan Severe acute ITT
Early enteral Horibe et
Japan
Acute
ITT
Early enteral Farooq et
India
Acute
ITT
Early enteral Total Total Total Total Delayed Delayed Total Casas et al.
Spain Severe acute Doley et al.
India Hui et al.
China Number Main outcome (Intervention subjects against Contro.
Clinical improvement >.
CRP = Clinical improvement >.
LOS = Clinical improvement =.
CRP =.
LOS = Clinical improvement >.
CRP > LOS > LOS > Clinical improvement >.
LOS > *PP, per protocol.
ITT, intention to treat.
CRP.
C-reactive protein.
LOS, length of stay.
>, significantly better.
no significant difference.
<, significantly worse.
Vol 57 A Number 2 A April 2025 Early Enteral Feeding Versus Total Parenteral Feeding After Surgery Bias of included trials was assessed according to the Cochrane Collaboration Risk of Bias tool.
Blinding of personnel and participants had the highest risk of bias.
Studies from Petros et al.
Hui et al.
, and Farooq et al.
were graded as being of the highest quality.
Details of the bias assessment are shown in Table 3.
The five studies shown in Figure 1 include clinical condition outcomes.
Two Table 3.
Quality Assessment Petrov et al.
Casas et al.
Doley et al.
Random sequence Allocation Blinding of participants and Blinding of outcome Assessment Incomplete outcome Selective reporting Other bias studies (Doley et al.
Hui et al.
) did not show a significantly better clinical condition after the intervention period between the two RR .
% confidence interva.
was 427 .
249 to 0.
P < 0.
Clinical improvement was significantly higher in the intervention group.
Heterogeneity was I2 = 93% and P = 0.
012, showing significant heterogeneity (Figure .
Hui et al.
Noor et al.
Horibe et Farooq et Oe Oe Oe Oe Oe Oe Oe *Green represents low risk, red represents high risk, and yellow represents unclear risk .
o evidence foun.
Figure 1.
Results of clinical improvement using a forest plot.
Roy Akur Pandapotan The four studies in Figure 2 include laboratory inflammatory outcomes.
One study (Casas et al.
) did not show a significant decrease in CRP (C-reactive protei.
between the two groups after intervention.
SMD .
CI) was Ae9.
569 (Ae18.
973 to Ae0.
P = 0.
CRP level was significantly lower in the intervention group.
Heterogeneity I2 = 97.
and P < 0.
001, meaning there was significant heterogeneity (Figure .
The six studies in Figure 3 include laboratory inflammatory outcomes.
One study (Doley et al.
) did not show a significant decrease in LOS in the intervention group.
SMD .
% CI) was Ae3.
139 (Ae5.
831 to Ae0.
P = 0.
The LOS decreased significantly in the intervention group.
Heterogeneity was I2 = 98.
85%, and P < 0.
001 was interpreted as significant heterogeneity (Figure .
DISCUSSION
Nutrition has a great impact on the management and recovery of AP.
When the issue became controversial, new theories were proposed.
8,9 The majority of studies state that enteral nutrition outperforms the Acta Med Indones-Indones J Intern Med parenteral option.
The meta-analysis of RCT studies included in this case report showed the superiority of early enteral nutrition therapy in all outcomes.
The treatment of choice is currently enteral feeding within 3 days onset of AP.
4,10-12
To analyze the clinical outcomes, parameters such as fewer infection incidences, organ failure, mortality rate, and other parameters were used.
Petrov et al.
16 found a lower infection incidence in patients who received early enteral feeding (P < 0.
, as in our case, where there were no infection Wilson et al.
23 stated that SIRS may become a mortality predictor in AP.
Although two criteria of SIRS24 were fulfilled on the admission day, after intervention, the heart rate was successfully controlled below 90 beats per minute, and the respiratory rate was found to be within the normal range.
In addition, patients in this case may experience flatus on post-operative day one and defecate on post-operative day two.
Sun et al.
further reported that early enteral nutrition had proven to enhance immunomodulating agents and maintain intestinal integrity, whereby a Figure 2.
Results of inflammatory parameters (CRP) of the forest plot.
Figure 3.
Results of length of stay using a forest plot.
Vol 57 A Number 2 A April 2025 Early Enteral Feeding Versus Total Parenteral Feeding After Surgery lower incidence might be achieved.
Of the five articles that evaluated clinical outcomes.
Petrov et al.
,16 Hui et al.
,19 and Farooq et al.
revealed lower mortality rates with enteral feeding compared with parenteral feeding.
Supported by Olyh et al.
26, enteral nutrition has statistically been proven to have more benefits than parenteral nutrition, and enteral nutrition can be administered safely even when complications occur.
Petrov et al.
16 and Hui et al.
19 stated that parenteral feeding caused more multiple organ failure incidences with P values of 0.
02 and < 0.
01, respectively.
Our case supports the literature, with only a single case of organ failure .
cute kidney failur.
on the fourth post-operative day.
This finding is supported by Schepers et al.
,27 who stated that 51% of organ failures in AP occurred in the first week of disease.
Another study found that single or multiple organ failure will greatly affect the Based on CRP as an inflammatory response, four articles include the difference between parenteral and enteral feeding.
Hui et al.
19 and Noor et al.
20 both documented significant decreases in CRP in patients receiving enteral feeding.
On the other hand.
Petrov et al.
16 and Casas et al.
17 stated that there was no significant difference between enteral and parenteral feeding.
In this case, pancreatic inflammation was assessed using levels of the enzyme lipase as a surrogate marker of inflammatory activity.
The lipase level in this case was 2400 U/L at baseline, which decreased to 68 U/L six days postoperatively.
Normally, a threefold lipase elevation is maintained 7Ae14 days post-onset.
Our case showed shorter time to achieve lower lipase enzyme levels, reflecting a rapid fall in the pancreatic inflammation process.
Six out of the seven articles we found, namely Casas et al.
,17 Doley et al.
,18 Hui et al.
,19
Noor et al.
,20 Horibe et al.
,21 and Farooq et al.
,22
include LOS as one of the parameters useful in analyzing AP outcome.
The mean LOS reported was 30.
2 days, 42 days, 22.
3 days, 8 days, 4 days, and 14.
69 days, respectively.
Furthermore.
Hui et al.
,19.
Noor et al.
,20 Horibe et al.
,21 and Farooq et al.
22 found significant differences, with enteral feeding patients showing shorter LOS than parenterally-fed Our patients were discharged after 10 days as inpatients.
A shorter LOS may result in lower medical costs,20,30 and a longer LOS may increase the risk of hospital-acquired The advantage of this evidence-based case report is that it involves only randomized controlled trials, so that the data obtained are rich and varied, with minimal confounding.
Several limitations of our meta-analysis are noteworthy.
First, there was statistical heterogeneity between the studies included.
Second, the clinical improvement outcome may vary between studies.
A large sample size with longer treatment follow-up would be beneficial.
Third, we did not consider the effect of pharmacological treatment on the Furthermore, we did not account for quality and cost shortcomings, and further information, such as CRP and amylase enzyme levels, was not analyzed.
Lipase enzyme levels as a surrogate for inflammation were examined CONCLUSION We were able to respond to the question in this case report based on our case study and literature analysis.
Early enteral nutrition could lead to more significant clinical improvement, including with regard to the incidence, organ failure, mortality, and other post-surgery parameters of AP.
Early enteral nutrition could significantly lower lipase enzyme levels after surgery.
Early enteral nutrition could significantly shorten the length of hospital stay.
This report shows that early enteral nutrition can lead to better clinical improvement, lower inflammatory response, and shorter length of hospital stay than when treating by total parenteral nutrition.
We therefore recommend using early enteral nutrition over total parenteral nutrition in post-surgery AP.
Roy Akur Pandapotan ACKNOWLEDGMENTS AND FUNDING We would like to express our sincere gratitude to all the individuals and organizations that have contributed to the publication of this research paper.
We are grateful to the Sumber Waras Hospital.
Jakarta, for providing financial support for our research.
The generous funding allowed us to conduct our study and complete our work.
We would like to thank Timothy Sean Kairupan and Yohana Elisabeth Gultom (Department of Nutritional Sciences.
Faculty of Medicine.
University of Indonesi.
for caring for the patient and recording the clinical We would also like to thank all of the participants in this study for their time and willingness to share their experiences.
CONFLICT OF INTEREST
The authors have no conflicts of interest to AFFILIATIONS Roy Akur Pandapotan (Department of Internal Medicine.
Faculty of medicine.
K r i s t e n K r i d a Wa c a n a U n i v e r s i t y .
Department of Internal Medicine.
Sumber Waras Hospital.
West Jakarta.
Indonesi.
Anissa Syafitri (Department of Nutritional Sciences.
Faculty of Medicine University of Indonesia-Ciptomangunkusumo Hospital.
Indonesi.
Andre Setiawan (Department of Surgery.
Sumber Waras Hospital.
West Jakarta.
Indonesi.
Burhan Gunawan (General Practitioner.
Sumber Waras Hospital.
West Jakarta.
Indonesi.
Nathalia Gracia Citra (Faculty of Medicine.
Tarumanagara University.
West Jakarta.
Indonesi.
Josephine Alicia Bierhuijs (Faculty of Medicine.
Tarumanagara University.
West Jakarta.
Indonesi.
Johana Titus (Corresponding Author.
Sumber Waras Hospital.
West Jakarta.
Bakordik 7th floor.
Jl.
Kyai Tapa No.
1 Grogol Petamburan 11440, yohanatitus50.
jt@gmail.
com, 081282426.
REFERENCES