British Journal of Surgery 1997, 84, 1665-1669 Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial F. KALFARENTZOS, J. KEHAGIAS, N. MEAD, K. KOKKINIS* and C. A. GOGOSt Departments of Surgery, Nutritional and Metabolic Unit, *Anaesthesiology and Critical Care Medicine, and tInternal Medicine, University of Patras, Fatras, Greece Correspondence to: Dr F Kalfarentzos, 5 Platia Voriou 1pirou Street, 264-41 Patras, Greece Background Parenteral nutrition is well established for providing nutritional support in acute pancreatitis while avoiding pancreatic stimulation. However, it is associated with complications and high cost. Benefits of enteral feeding in other disease states prompted a comparison of early enteral feeding with total parenteral nutrition in this clinical setting. Methods Thirty-eight patients with acute severe pancreatitis were randomized into two groups. The first (n = 18) received enteral nutrition through a nasoenteric tube with a semi-elemental diet, while the second group (it = 20) received parenteral nutrition through a central venous catheter. Safety was assessed by clinical course of disease, laboratory findings and incidence of complications. Efficacy was determined by nitrogen balance. The cost of nutritional support was calculated. Results Enteral feeding was well tolerated without adverse effects on the course of the disease. Patients who received enteral feeding experienced fewer total complications (P < 0-05) and were at lower risk of developing septic complications (P < 0-01) than those receiving parenteral nutrition. The cost of nutritional support was three times higher in patients who received parenteral nutrition. Conclusion This study suggests that early enteral nutrition should be used preferentially in patients with severe acute pancreatitis. Severe acute pancreatitis is accompanied by increased resting energy requirements and loss of protein mass resulting from the inflammatory response following necrosis or inflammation of the pancreas and retroperitoneal tissues 1 . This, combined with the absence of oral intake, leads to a persistently negative nitrogen balance that appears to be associated with a higher mortality rate as a result of the loss of function and structural integrity of vital organs 2-4 . Thus, the provision of early aggressive nutritional support is of utmost importance in this clinical setting. Total parenteral nutrition (TPN) has been the standard practice for providing exogenous nutrients to patients with acute pancreatitis in order to improve nutritional status and at the same time to avoid pancreatic stimulation 5-8 . Howcver, TPN is associated with certain disadvantages. In particular, there is an increased risk of central catheter infection, severe hyperglycaemia, and other metabolic and clectrolyte disturbances 5-8 . TPN may also promote gut barrier alterations due to increased intestinal permeability 9-10 . The use of early enteral feeding (EF) for nutritional support in patients with acute pancreatitis has not been evaluated systematically. The commonly encountered problems of gastric atony and outlet obstruction have limited the successful delivery of enteral formulas to patients with severe acute pancreatitis. However, these problems may be overcome if enteral nutrition were to be delivered to the small intestine distal to the ligament of Treitz using elemental or semi-elemental low-fat diets 1,11,12 . The efficacy, tolerance. clinical outcome and cost of EF and TPN have been evaluated in patients with severe acutc pancreatitis. Patients and methods Between July 1990 and December 1995, 326 patients with acute pancreatitis were treated in this unit. Some 40 consecutive patients with severe necrotizing pancreatitis admitted during this period were studied. The study was designed in accordance with the principles of the declaration of Helsinki and was approved by the local hospital committee. Informed consent was obtained from all participating patients or from the next of kin if patients were unable to respond for themselves. Inclusion criteria Inclusion criteria for randomization were the presence of three or more criteria according to the Imrie classification 13 or Acute Physiology And Chronic Health Evaluation (APACHE) II score 14 of 8 or more, C-reactive protein concentration greater than 120 mg/l within 48 h of admission, and grade D or E by computed tomography (CT) according to the Balthazar criteria15. Patients who were treated elsewhere for more than 2 days before admission to this hospital were not included. Conservative treatment All patients required intensive monitoring for more than 72 h. During the acute phase, treatment consisted of adequate fluid replacement through a central venous catheter with haemodynamic monitoring and assistance of respiratory or renal function when needed. Analgesics were given as required to all patients, and an H 2 blocker was given to prevent stress ulcers. A nasogastric tube was inserted as needed to keep the