The use of probiotics in patients with lower gastrointestinal surgical condition and following lower GI surgery: A narrative review

Background: Probiotics are commonly used to modulate lower gastrointestinal conditions, by both patients and clinicians. Alterations in the gut microbiota in disease states may support their theoretical use, but the current evidence base is uneven. We reviewed the use of probiotics, prebiotics and synbiotics in conditions commonly seen by lower GI surgeons and following lower gastrointestinal surgery. Methods: A systematic review was conducted in Pubmed and Cochrane Reviews, using search terms for the following disease states and conditions: colectomy, Crohn's disease, ulcerative colitis, pouchitis, diverticulitis, and diverticular disease. We performed a narrative review to better guide clinicians in the use of probiotics, as well as prebiotics and synbiotics. Results: Probiotics have been studied in a number of conditions treated by lower GI surgeons. Our search identified 1993 records, of which 145 abstracts were screened. Ultimately, 52 articles described the use of probiotics in patients with surgical lower GI conditions. There is inadequate support for the use of probiotics following colectomy or in patients with IBD exacerbations, although 4 RCT's suggest some symptomatic improvement in patients with mild symptoms. Patients with chronic pouchitis may benefit from a probiotic, such as VSL#3, and it would be reasonable to treat acute pouchitis with an antibiotic and a probiotic. There is presently insufficient evidence to support their use in symptomatic diverticular disease. There is good evidence for their use in prevention of antibiotic-associated and C. difficile-associated diarrhoea, in both inpatients and outpatients, although not in patients post-surgery. This data may be extrapolated to support the use of probiotics in outpatients post-surgery requiring shortcourse antibiotics (say, for wound infection). As the majority of studies excluded postsurgical patients, and indeed any patient with GI illness, there is no evidence to support their use in this patient category. Limitations: There remains significant scope for further high quality research on probiotics in lower GI outpatient and surgical conditions. Furthermore, the benefits of one probiotic cannot be extrapolated to other probiotics, as different bacteria and preparations have varying effects. Conclusion: Although generally safe, there is little rigorous evidence outside of chronic pouchitis and prevention of antibiotic-associated and community acquired C. difficile-associated to support the use of probiotics. There is, however, little evidence to discourage their use in most conditions, outside of critically ill patients.