Total enteral vs. parenteral nutrition in severe acute pancreatitis: an updated systematic review and GRADE-assessed meta-analysis

Abstract

BACKGROUND: Severe acute pancreatitis (SAP) is a life-threatening condition marked by systemic inflammation, organ failure, and high morbidity. Nutritional support plays a critical role in SAP management, with total enteral nutrition (TEN) and total parenteral nutrition (TPN) being the primary approaches. While TEN maintains gut integrity and may reduce complications, TPN bypasses the gastrointestinal tract and may worsen systemic inflammation. This study aimed to perform an updated systematic review and meta-analysis comparing the efficacy and safety of TEN versus TPN in SAP patients. METHODS: Following PRISMA guidelines, we searched PubMed, Scopus, and Web of Science for randomized controlled trials and cohort studies comparing TEN and TPN in SAP. Outcomes included infection rate, organ failure, mortality, necrosis, surgical intervention, hospital stay, and serum markers (amylase, lipase, albumin, IL-6). Quality assessment was done using ROB2 and NOS tools. GRADE methodology was applied to assess evidence certainty. RESULTS: A total of 23 studies involving 7,674 patients (2,750 TEN and 4,924 TPN) were analyzed. TEN was significantly associated with lower odds of infection (OR = 0.35; 95% CI: 0.18-0.70; p = 0.003), multiple organ failure (OR = 0.41; 95% CI: 0.21-0.78; p = 0.007), and mortality (OR = 0.50; 95% CI: 0.33-0.76; p = 0.001), compared to TPN. The requirement for surgical intervention was also reduced with TEN (OR = 0.26; 95% CI: 0.07-1.00; p = 0.05), although with high heterogeneity and low certainty. No significant differences were observed in pancreatic necrosis (OR = 0.88; p = 0.62) or hospital stay (MD = 1.9 days; p = 0.11). Biochemical markers including serum amylase, lipase, albumin, and IL-6 showed no statistically significant differences between the two groups. GRADE analysis rated the certainty of evidence as moderate for infection and hospital stay, low for organ failure and mortality, and very low for surgical intervention. CONCLUSION: Our updated meta-analysis demonstrates that total enteral nutrition is associated with significantly better clinical outcomes than total parenteral nutrition in patients with severe acute pancreatitis, particularly in reducing infection, organ failure, and mortality. Although differences in secondary outcomes were not statistically significant, the overall evidence supports TEN as the preferred nutritional approach in SAP management.