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: 19 Mar 2024
Reviewer:  Felipe David Mendonça Chaim
Reviewer's report:
Review of the article Comparative Safety Assessment of Nasogastric versus Nasojejunal
Feeding Initiated Within 48 Hours Post-Admission versus Unrestricted Timing in Acute
Pancreatitis for BMC gastroenterology.
The article deals with a systematic review, however the title does not contain this information
and must be included.
Compares the use of nasogastric versus nasojejunal enteral nutrition, comparing the time to
start the diet (<48h versus 48-72h) regarding morbidity and mortality (diarrhea, pain, infection,
multiple organ failure)
Performs searches in traditional databases; uses the established PRISMA methodology;
registered the study in PROSPERO.
Only 4 articles were identified, totaling 217 patients, with the largest study with 78 patients.
In the inclusion criteria, the article does not make clear who the real population included in the
study is. He mentions that they are RCTs; of patients with pancreatitis; starting a diet via NG
or NJ within the first 72 hours of hospital admission. However, the results identify a mortality
rate of 64% (139/217 patients), which is much higher than the average mortality of patients
with pancreatitis. Only when evaluating the articles is it possible to notice that the majority deal
with patients with moderate/severe pancreatitis. Since these patients represent the minority of
cases of pancreatitis, the conclusions of the meta-analysis cannot be extrapolated to all patients
with pancreatitis. Therefore, it must be clear in the title that the article evaluates “...timing in
moderate/severe pancratitis”
Still regarding the time of starting the diet, contrary to what is mentioned in the title (unrestricted
timing), the study selection defines that the inclusion criterion is only patients who started the
diet within the first 72 hours of admission. Thus, the groups are divided into <48h and 48-72h,
and this determination must be made explicit throughout the text, and not “unrestricted timing”.
In the method, the Search term nasoduodenal feeding was used, while the work aims to evaluate
nasojejunal feeding (a term not searched in the databases). Could the fact of not having searched
for the term that was the objective of the work have compromised the results? (as an example,
nasoduodenal feeding has 107 articles on pubmed, while nasojejunal feeding has 424 articles).
The appropriate use of the terms sought in relation to the objective of the article can considerably
improve the casuistry.
Os autores foram corretos ao considerar as possíveis limitações do artigo.
The authors sought to evaluate, in addition to the route of administration of the diet (NG vs
NJ), the time to start the diet (<48h vs 48-72h) and the age of the patients (<45 years vs >45
years). However, age was not described in the title of the article as a variable to be studied.
Furthermore, it was evaluated for mortality and complications (diarrhea), but was not evaluated
for organ failure, length of stay, complications (pain), infection, surgical intervention, need for
parenteral nutrition and success rate of the procedure. If there was no difference between ages
for any of the variables, I suggest mentioning this finding instead of omitting the information.
The same comment is valid for the time of starting the diet in relation to organ failure; length of
stay; and rate of infection, having been evaluated regarding mortality, complications, surgical
intervention, requirement for parenteral nutrition, success rate of the procedure.
Regarding age, there are two considerations: 1. Groups are described as having an AVERAGE
age of <45 years vs >45 years. I believe that it is not appropriate to consider the average age
of the group for its division, but rather to ensure that ALL patients in that group are younger
or older than 45 years old. For example, to be clear, if in the group we have a patient aged 20
and another aged 69, the average age of the group will be 44.5 years, but they are patients of
very different ages, making the analysis unfeasible. I suggest redefining the groups according
to the patient's age and not the average.
2. What was the criterion for defining the age cutoff point at 45 years? In the discussion, a
comment is made that the literature shows that age is a factor related to mortality, but the meta-
analysis findings did not reach the same conclusion. However, this incongruity may be due to the
age used, since Gardner's article, when specifically studying the influence of age on mortality,
uses the age of 70 as a cutoff.
Regarding the Success rate of procedure, success was described in 147/157 patients who
underwent NG feeding, but there is no description in relation to NJ, making comparison
unfeasible.
In the discussion, right after citing articles 21, 27 and 28: “The infection rates, ....” the same
information that there is no difference between the two groups is repeated 3 times in different
ways, becoming tiring and repetitive the reading.
Therefore, I believe that the article provides relevant information that can guide the choice of
feeding route in patients with severe acute pancreatitis. However, it needs adjustments to allow
publication.