Review for 10.1186/s12876-024-03290-z (2024)

Title: Comparative Safety Assessment of Nasogastric versus Nasojejunal Feeding Initiated
Within 48 Hours Post-Admission versus Unrestricted Timing in Moderate or Severe Acute
Pancreatitis: a Systematic Review and Meta-Analysis
Version: 0 Date: 05 Apr 2024
Reviewer:  Furqan A. Bhullar
Reviewer's report:
In their meta-analysis, Wang et al. offer a comparative examination of nasogastric (NG) and
nasojejunal (NJ) feeding initiated within the initial 48-hour period post-admission for acute
pancreatitis. The study provides pivotal data indicating the absence of significant differences
in mortality and primary clinical outcomes between the two enteral feeding strategies. These
insights may prompt a reevaluation of established clinical protocols, allowing for a tailored
approach to enteral nutrition based on patient-specific needs rather than rigid adherence to a
standard regimen.
The findings of the study also underscore the importance of timely enteral nutrition, de-
emphasizing the exact moment of initiation within the early treatment phase as long as it remains
within the broad window of early intervention. Furthermore, the comprehensive analysis of
secondary outcomes, including organ failure incidence, hospitalization duration, and rates of
surgical and parenteral intervention, substantiates the equivalency in the clinical effectiveness
of NG and NJ feeding routes.
Minor edit recommendations:
1) Results (first paragraph):  consider detailing the initial search output, specifically the number
of studies identified before applying inclusion criteria.
2) Citation for risk of bias tool would be beneficial
2) Results/Mortality: "Mortality data were extracted from three of the included RCTs, totaling
139 deaths". It currently mentions "139 deaths," which seems to refer to the total number of
patients across the three RCTs, not the death toll. Please verify and correct these figures for
accuracy - needs careful revision.
3) Results/Organ failure: "Notably, in the NG Feeding Group, there was a significant increase
in the frequency of multiple organ failures compared to the NJ Feeding Group". It would be
beneficial to quantify the significant increase observed in the NG Feeding Group over the NJ
Feeding Group with specific percentages and the statistical significance (p-value).
4) Figure 6A:  the labeling of the forest plot's x-axis requires clarification or correction for better
interpretability.
5) Reference 19: The authorship in Reference 19 is reversed, causing initial confusion. Please
adjust to match the standard citation format. (first and second name reversed for first author)
6) Discussion: "In fact, studies have shown that NG feeding is as good as NJ feeding in patients
with objectively graded severe acute pancreatitis, with no significant differences in mortality
[21]" Singh N, Sharma B, Sharma M,  Evaluation of early enteral feeding through nasogastric
and nasojejunal tube in severe acute pancreatitis: a noninferiority randomized controlled trial.
Pancreas. 2012 Jan;41(1):153-9. doi: 10.1097/MPA.0b013e318221c4a8. PMID: 21775915.
Reference [21] is cited to support the equivalence of NG and NJ feeding. However, the same
study by Singh et al. suggests advantages for the NJ group in terms of hospital stay duration,
ventilator support requirement, and prevalence of multiple organ failures or infected necrosis.
A higher mortality rate in the NG group is also reported. These points merit inclusion for a
balanced analysis.
7) It is noteworthy that three out of four studies included in this meta-analysis focus on
patients with severe AP, while the study by Vinay et al. considers a broader severity spectrum.
This distinction is crucial and should be explicitly mentioned, as it predominantly reflects the
outcomes of severe AP management.
I appreciate the opportunity to review this interesting meta-analysis, and I extend my best wishes
to the authors as they continue to contribute valuable research to the field of pancreatitis.