The role of the gut microbiota in health and disease is gaining unprecedented attention, with its influence extending to surgical outcomes [1]. Recent studies underscore the value of microbiota modulation in surgical prehabilitation – a strategy that seeks to enhance patient readiness and recovery. The scoping review titled “Microbiota modifications in prehabilitation – the next step towards comprehensive preparation for surgery. The scoping review”, presented in the current issue of the “Gastroenterology Review” [2], builds upon this evolving narrative, proposing the integration of microbiota-targeted interventions as a core element of prehabilitation. Surgical site infections (SSIs) remain a major challenge, accounting for significant morbidity and financial burden worldwide, as documented in comprehensive global studies [3, 4]. The detrimental impact of microbial imbalances, frequently named as dysbiosis [5], exacerbated by surgical stress, has been well documented, showing increased risks of complications such as bacterial translocation and systemic infections [6]. Targeted microbiota modulation strategies, such as the administration of prebiotics, probiotics and synbiotics have demonstrated the potential to mitigate these risks by restoring intestinal barrier function and enhancing systemic immunity [7]. Moreover, enhanced production of short-chain fatty acids (SCFAs), particularly butyrate, has been identified as a crucial mechanism for improving intestinal barrier integrity and immune modulation, playing a crucial role in mitigating healthy outcomes in patients recovering from surgery. Emerging evidence highlights the role of specific microbial species, such as Akkermansia muciniphila, in improving outcomes. For instance, Akkermansia muciniphila has been shown to reduce systemic inflammation and enhance chemotherapy efficacy in colorectal cancer—factors that are critical for surgical resilience [8]. Such findings advocate for the development of personalized microbiota-based prehabilitation strategies tailored to an individual’s microbial profile in surgical context. The incorporation of perioperative microbiota-targeted approaches within enhanced recovery after surgery (ERAS) protocols exemplifies this shift toward precision medicine [6]. The development of prehabilitation is not the achievement of isolated efforts but rather a collective endeavor of the entire surgical and scientific community. Surgeons, gastroenterologists, anesthesiologists, dietitians, microbiologists as well as researchers and scientists with different medical interests have all contributed to shaping this multidisciplinary approach. In Poland, the efforts have been unified under the guidance of visionaries like authors of the current review [2], whose leadership has been pivotal in implementing prehabilitation protocols and elevate/improve surgical standards. Their collaboration reflects the broader commitment of the surgical community to innovate and improve patient care, especially in the light of overwhelming evidence, which underscores the integral role of intestinal microbiota in surgical infections and outcomes. The dual nature of the microbiota – as both an asset and a liability – highlights the complexity of its role in patient recovery. Advanced molecular assessments of bacterial phenotype transitions, interspecies interactions, and local microenvironment influences are essential to fully understand and address surgical complications. However, the establishment of standardized methodologies and protocols is still in its infancy [9], highlighting the need for continued research and collaborative efforts in this area.
Current methods, such as fecal microbiological cultures, lack the molecular precision needed to predict and mitigate these risks. Harnessing next-generation sequencing, proteomics, and metabolomics will enable detailed analysis of microbial communities and their functional dynamics, both pre- and postoperatively. These tools can inform the design of novel strategies for intestinal antisepsis and microbiota reconstitution, such as targeted antibiotics, non-microbicidal anti-virulence compounds, postbiotics and innovative cleansing solutions.
This evolving understanding offers a unique opportunity to develop personalized microbiota-based therapies, including probiotics, postbiotics, engineered bacteria, and CRISPR/Cas9 technologies, to optimize surgical outcomes. By advancing the molecular and mechanistic knowledge of postoperative complications, we can refine gastrointestinal tract preparation and ultimately prevent devastating complications like anastomotic leaks, motility disorders, and tumor recurrence, ushering in a new era of precision perioperative care. Therefore integration of microbiota-targeted strategies in surgical prehabilitation represents a transformative opportunity to improve patient outcomes. As highlighted in the current review [2] and supported by the perspective of our own studies [7, 10] as well as studies of others [11, 12], these interventions have the potential to reduce SSIs, enhance recovery, and lower healthcare costs. The concept of “surgical bioresilience” emerges as a novel approach aimed at optimizing intestinal homeostasis and microbiome interactions to enhance the immune response, mitigate systemic inflammation, and improve perioperative outcomes [13]. This strategy underscores the importance of maintaining a balanced gut environment through microbiome augmentation using diet, probiotics, postbiotics, synbiotics, fecal transplantation and lifestyle changes. It highlights the need for targeted research to better understand and prioritize interventions that promote resilience within the surgical microbiome landscape, ultimately improving patient recovery and reducing complications. With rigorous research and clinical implementation, we can harness the power of the microbiota to revolutionize surgical outcomes and the care of our patients.
