OBJECTIVE: To compare the effect of enteral vs parenteral nutrition in patients with severe acute pancreatitis for clinically relevant outcomes. DATA SOURCES: A computerized literature search was performed in the MEDLINE, EMBASE, and Cochrane databases for articles published from January 1, 1966, until December 15, 2006. STUDY SELECTION: From 253 publications screened, 5 randomized controlled trials comparing enteral and parenteral nutrition in patients with predicted severe acute pancreatitis met the inclusion criteria. DATA EXTRACTION: Information on study design, patient characteristics, and acute pancreatitis outcomes were independently extracted by two of us using a standardized protocol. DATA SYNTHESIS: A meta-analysis of randomized controlled trials was performed using a random-effects model. Enteral feeding reduced the risk of infectious complications (relative risk, 0.47; 95% confidence interval, 0.28-0.77; P < .001), pancreatic infections (0.48; 0.26-0.91; P = .02), and mortality (0.32; 0.11-0.98; P = .03). The risk reduction for organ failure was not statistically significant (0.67; 0.30-1.52; P = .34). CONCLUSIONS: Enteral nutrition results in clinically relevant and statistically significant risk reduction for infectious complications, pancreatic infections, and mortality in patients with predicted severe acute pancreatitis.