The role of probiotics in primary and secondary prevention of pouchitis: A Systematic Review and Meta-Analysis

BACKGROUND: Pouchitis is the most common long-term complication after ileal pouch anal anastomosis (IPAA) surgery. Its cumulative incidence is approximately 50% after a 10- year follow up. Several trials have looked at the use of probiotics in prevention of pouchitis, and showed a significant decrease in the development of pouchitis, but other showed no difference. Our data is very limited and the most recent Cochrane review in 2015 showed a possible benefit of probiotics in maintaining the remission, but it’s not widely used in practice, especially in primary prevention. In this systematic review and meta-analysis, we aimed to discern whether probiotics are actually beneficial in primary and secondary prevention of pouchitis.
 

METHODS: A comprehensive search of MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews was conducted from each database’s inception to May, 20th, 2017 to search for comparative studies of probiotics use in the prevention of primary (first episode) and secondary (recurrent episodes) pouchitis. The outcome of interest was the development of pouchitis.
 

RESULTS: Nine studies with a total of 376 patients were included. The use of probiotics in the primary prevention was associated with a decreased incidence of pouchitis (RR: 0.18, 95% CI: 0.08-0.39, p<0.01, heterogeneity I2: 0%) with a NNT of 3.2, and their use in the secondary prevention was associated with a decreased incidence of recurrent pouchitis compared to placebo (RR: 0.20, 95% CI: 0.11-0.36, p-value <0.01, heterogeneity I2: 0%). Overall risk of developing pouchitis was decreased with the use of probiotics use (RR: 0.19, 95% CI: 0.12-0.30, p <0.01, heterogeneity I2: 0%) with a NNT of 2.
Sub-group analysis included only studies that used VSL#3 showed a significant decrease in pouchitis in both primary prevention (RR: 0.23, 95% CI: 0.10-0.50, p<0.01, heterogeneity I2: 0%), secondary prevention (RR: 0.17, 95% CI: 0.09-0.31, p-value <0.01, heterogeneity I2: 0%), and overall risk RR: 0.19, 95% CI: 0.12-0.36, p <0.01, heterogeneity I2: 0%).
 

CONCLUSION(S): The current systematic review and meta-analysis showed that probiotics are superior to placebo in the primary and secondary prevention of pouchitis with a very significant NNT. These findings suggest the use of probiotics in patients after ileal pouch anal anastomosis (IPAA) surgery for primary prevention, or in patients with recurrent pouchitis.