Optimizing nutritional support in acute pancreatitis: A systematic review and network meta-analysis of timing and route of feeding.

BACKGROUND

Acute pancreatitis (AP) is a common inflammatory condition with significant morbidity and mortality. Nutritional management is central to treatment, but uncertainties remain regarding the optimal timing and route of feeding.

METHODS

We conducted a systematic review and network meta-analysis of randomized controlled trials (RCTs) assessing feeding strategies in AP. Databases searched included PubMed, Embase, Scopus, Web of Science, and CENTRAL up to July 2025. Eligible interventions included very early oral feeding (VEOF), early oral feeding (EOF), delayed oral feeding (DOF), early enteral nutrition (EEN), delayed enteral nutrition (DEN), and parenteral nutrition (PN). Risk of bias was assessed using the Cochrane RoB 2 tool. The network and pairwise meta-analysis were conducted using R (version 4.4.3). PROSPERO (CRD420251152683).

RESULTS

Twenty-three RCTs involving 2095 patients were analyzed. EOF demonstrated the most significant mortality reduction compared with PN (RR 0.06, 95% CI 0.00-0.68; SUCRA 92%). DOF (RR 0.19, 95% CI 0.06-0.58) and EEN (RR 0.31, 95% CI 0.17-0.58) also reduced mortality. MOF risk was significantly reduced with DOF (RR 0.25, 95% CI 0.08-0.79) and EEN (RR 0.32, 95% CI 0.20-0.51). No intervention significantly affected sepsis, necrosis, or overall complications. VEOF reduced C-reactive protein (MD -47.3 mg/L, 95% CI -89.8 to -4.8) and LOHS (MD -4.3 days, 95% CI -8.1 to -0.4).

CONCLUSION

EOF should be prioritized in AP as it offers the most substantial mortality benefit while preserving gut integrity and reducing inflammation. DOF and EEN strategies remain effective alternatives, and rhubarb-supplemented EEN may further reduce the length of hospital stay.