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Early versus on-demand nasoenteric tube feeding in acute pancreatitis
Olaf J Bakker1, Sandra van Brunschot, Hjalmar C van Santvoort
1The authors' affiliations are listed in the Appendix.
Insights
Early nasoenteric tube feeding does not improve outcomes for severe acute pancreatitis patients. An oral diet initiated after 72 hours showed similar rates of infection and death in high-risk patients.
Area of Science:
- Gastroenterology
- Critical Care Medicine
- Surgical Nutrition
Background:
- Early enteral nutrition via nasoenteric tubes is a common strategy for severe acute pancreatitis to prevent gut-derived infections.
- However, robust evidence supporting this approach remains limited.
- This study aimed to evaluate the efficacy of early nasoenteric feeding versus a delayed oral diet.
Purpose of the Study:
- To compare the effectiveness of early nasoenteric tube feeding against a delayed oral diet in patients with severe acute pancreatitis.
- To assess the impact on the composite endpoint of major infection or death.
Main Methods:
- A multicenter, randomized trial involving 208 high-risk acute pancreatitis patients.
- Patients were randomized to either early nasoenteric feeding (within 24 hours) or an oral diet initiated at 72 hours (on-demand group).
- High-risk criteria included APACHE II score ≥8, Imrie/Glasgow score ≥3, or CRP >150 mg/L.
Main Results:
- The primary endpoint (major infection or death) occurred in 30% of the early feeding group and 27% of the on-demand group (Risk Ratio 1.07; P=0.76).
- No significant differences were observed in major infection rates (25% vs. 26%; P=0.87) or mortality (11% vs. 7%; P=0.33).
- Notably, 69% of patients in the on-demand group tolerated an oral diet without requiring tube feeding.
Conclusions:
- Early nasoenteric tube feeding is not superior to initiating an oral diet after 72 hours for reducing infection or death in high-risk acute pancreatitis.
- The findings suggest that a more conservative, on-demand approach to nutrition may be appropriate.
- Further research may explore optimal timing and methods for nutritional support in this patient population.
Background:
Early enteral feeding through a nasoenteric feeding tube is often used in patients with severe acute pancreatitis to prevent gut-derived infections, but evidence to support this strategy is limited. We conducted a multicenter, randomized trial comparing early nasoenteric tube feeding with an oral diet at 72 hours after presentation to the emergency department in patients with acute pancreatitis.
Methods:
We enrolled patients with acute pancreatitis who were at high risk for complications on the basis of an Acute Physiology and Chronic Health Evaluation II score of 8 or higher (on a scale of 0 to 71, with higher scores indicating more severe disease), an Imrie or modified Glasgow score of 3 or higher (on a scale of 0 to 8, with higher scores indicating more severe disease), or a serum C-reactive protein level of more than 150 mg per liter. Patients were randomly assigned to nasoenteric tube feeding within 24 hours after randomization (early group) or to an oral diet initiated 72 hours after presentation (on-demand group), with tube feeding provided if the oral diet was not tolerated. The primary end point was a composite of major infection (infected pancreatic necrosis, bacteremia, or pneumonia) or death during 6 months of follow-up.
Results:
A total of 208 patients were enrolled at 19 Dutch hospitals. The primary end point occurred in 30 of 101 patients (30%) in the early group and in 28 of 104 (27%) in the on-demand group (risk ratio, 1.07; 95% confidence interval, 0.79 to 1.44; P=0.76). There were no significant differences between the early group and the on-demand group in the rate of major infection (25% and 26%, respectively; P=0.87) or death (11% and 7%, respectively; P=0.33). In the on-demand group, 72 patients (69%) tolerated an oral diet and did not require tube feeding.
Conclusions:
This trial did not show the superiority of early nasoenteric tube feeding, as compared with an oral diet after 72 hours, in reducing the rate of infection or death in patients with acute pancreatitis at high risk for complications. (Funded by the Netherlands Organization for Health Research and Development and others; PYTHON Current Controlled Trials number, ISRCTN18170985.).
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