Nasogastric or Nasojejunal,Abstract,Nasojejunal tube feeding is considered the current standard of care in patients with severe and critical acute pancreatitis. However, it is not known whether enteral nutrition is best delivered into the jejunum. This Commentary discusses recent clinical studies that have shown that tube feeding into the stomach is safe and well tolerated in the vast majority of patients with acute pancreatitis, thus overthrowing the notion of putting the pancreas at rest. Development of a new conceptual framework is warranted to further advance nutritional management of patients with acute pancreatitis.,back,The study by Chang and colleagues 1 adds an important perspective to the discussion regarding the pancreatic rest concept, which is perhaps the oldest dogma in the management of AP. The central tenet of this concept is that enteral nutrition delivered into any part of the upper gastrointestinal tract other than the jejunum stimulates pancreatic secretion and, consequently, exacerbates the severity of AP.,back,The corollary is that non-stimulatory nutrition had been widely advocated, being total parenteral nutrition two to three decades ago and nasojejunal tube feeding in the past decade. That is why the majority of randomised controlled trials in the past studied non-stimulatory regimens as both intervention and comparator, that is, either parenteral nutrition versus nil peros, or parenteral nutrition versus jejunal tube feeding, or jejunal tube feeding versus nil peros 7,8.,Definitions of the four severity categories,The recent international multidisciplinary classification of AP has redefined the severe category of severity and introduced the new critical category of severity (Table 1), thus putting a high emphasis on the need to optimise manage ment of these most challenging patients .,(Peri)pancreatic necrosis is : 1.nonviable tissue located in the pancreas alone, 2.or in the pancreas and peripancreatic tissues, 3.or in peripancreatic tissues alone. It can be solid or semisolid (partially liquefied) and is without a radiologically defined wall. Sterile (peri)pancreatic necrosis is the absence of proven infection in necrosis.,Definitions of the four severity categories,Infected (peri)pancreatic necrosis is defined when at least one of the following is present: 1.gas bubbles within (peri)pancreatic necrosis on computed tomography; 2. a positive culture of (peri)pancreatic necrosis obtained by image guided fine-needle aspiration; 3. a positive culture of (peri)pancreatic necrosis obtained during the first drainage and/or necrosectomy.,Organ failure is defined for three organ systems (cardiovascular, renal, and respiratory) on the basis of the worst measurement over a 24-hour period. In patients without pre-existing organ dysfunction, organ failure is defined as either a score of 2 or more in the assessed organ system using the SOFA (Sepsis-related Organ Failure Assessment) score or when the relevant threshold is breached, as shown: Cardiovascular, need for inotropic agent; Renal, creatinine 171 mol/L (2.0 mg/dl); Respiratory, PaO2/FiO2 (partial pressure of oxygen/fractional inspired oxygen concentration) 300 mmHg (40 kPa).,Definitions of the four severity categories,Persistent organ failure is the evidence of organ failure in the same organ system for 48 hours or more. Transient organ failure is the evidence of organ failure in the same organ system for less than 48 hours.,Definitions of the four severity categories,The systematic literature review has appraised the current best evidence regarding the use of nasogastric tube feeding (presumed to be stimulatory) in patients with AP. It demonstrates that the evidence base is (still) relatively small but does show that enteral nutrition given via the nasogastric route is well tolerated in more than 90% of patients with AP 9-11.,New,In line with the previous systematic review 2, it shows no statistically significant difference between non-stimulatory and stimulatory regimens in terms of morbidity and mortality. The new, and somewhat surprising, finding here is that both routes of enteral feeding appear to be equivalent in terms of delivery of target calories.,New,There are two possible explanations for the observed results. First, tube feeding into the stomach might have been non-stimulatory in patients with AP. Unfortunately, little is known about the secretory response of the pancreas during the acute phase of clinical AP, let alone the effect of feeding on it 12.,But a study in healthy volunteers demonstrated that both oral and duodenal tube feeding stimulate pancreatic enzyme secretion in comparison with placebo 13. Moreover, the degree of pancreatic stimulation is very similar between oral and duodenal tube feeding. Second, tube feeding into the stomach might have stimulated the pancreas in patients with AP but it has no clinical ramifications, essentially meaning that the concept of pancrea