Dr. Joseph Brasco: 5 Points on Fecal Microbiota Transplant in an ASC

Gastroenterology and Endoscopy

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Joseph Brasco, MD, spent a year and a half convincing the board of directors of the Huntsville (Ala.) Center for Colon and Digestive Disease to allow him to perform fecal microbiota transplant in the center. 

The procedure, which involves transplanting a healthy fecal sample from a donor into the GI tract of a patient suffering from recurrent C. difficile infections, is gaining popularity, but Dr. Brasco says the idea of transplanting poop has yet to be completely accepted. "You wouldn't have even thought about doing this a year and a half or two years ago," he says. "More and more people are doing it now."

Dr. Brasco shares five thoughts on incorporating this simple and successful — albeit "yucky" — procedure into an ASC.

1. The procedure works. When asked why he fought so hard to get the FMT procedure added to the Center for Colon and Digestive Disease's offerings, Dr. Brasco says simply: "Because it works." To date, the center has completed 15 transplants, with a 100 percent success rate.

Dr. Brasco has seen articles about FMT dating back to the 1960s but says the procedure fell out of favor when antibiotics became more mainstream. However, the nature of the C. difficile infection itself has changed, and more strains of the bacteria are resistant to antibiotics. One-quarter of patients who contract a C. difficile infection will have a recurrence, and those who do have a recurrence have a 40-50 percent risk of multiple recurrences.

2. People will find a way to pay. Patients undergoing an FMT often do so as a last resort. For this reason, they will find a way to cover the cost of the procedure, Dr. Brasco says. Although ASCs cannot bill for the procedure directly, he says physicians can bill for a colonoscopy because that is how the sample is delivered to the digestive tract. To cover the rest of the expenses, Dr. Brasco charges patients an extra fee of $1,600.

One of the most expensive parts of the procedure is the testing beforehand. Unfortunately, for the donors, the testing will most likely not be covered under their insurance plans because they should be in good health. However, this testing is done before the patient and donor come to the ASC, and Dr. Brasco says his patients have always found a way to pay.

3. The procedure itself is simple. Dr. Brasco says the procedure is simple. In actuality, the procedure is exactly what it sounds like: transplanting poop from a donor to a recipient. The science behind the procedure is the healthy bacteria in the healthy fecal sample will repair the imbalance in the affected GI tract and oust the problematic C. difficile bacteria.

First, both the donor and recipient are tested for HIV, hepatitis and syphilis-causing bacteria. The donor is tested for parasites, cultures and C. difficile. For the sample itself, Dr. Brasco says the fresher the better, but he uses six hours prior to a procedure start time as the upper cutoff. "Believe it or not, we've had to delay a few cases because the donor couldn't poop on command," he says. "You have to laugh a little with this procedure."

After the sample is collected, a nurse processes the stool. The father of FMT, Thomas J, Borody, MD, based in Sydney, Australia, uses a blender to process the stool sample, but Dr. Brasco has taken an even simpler approach. He mixes three tablespoons of the stool sample with sterile water and shakes it up. The mixture is then strained through cheesecloth to filter out some of the particulate material. A nurse then draws 10 60cc syringes, and those are administered into the right colon with the use of an endoscope.

The procedure is easy to perform in an ASC because if gastroenterologists can perform a screening colonoscopy, they can do this procedure. ASCs also already have the equipment needed: chimney syringes, disposable cups, cheesecloth and sterile water.

"This procedure couldn't be easier," Dr. Brasco says. "It's almost embarrassing. It's just the intellectual thing that keeps people from doing this. It's just obviously aesthetically unappealing."

Recovery is a bit different than for a colonoscopy. Whereas colonoscopy patients are encouraged to pass gas and stool after the procedure, FMT patients need to refrain from doing so for 30-45 minutes after the procedure to ensure that the enema sticks. At the Huntsville Center for Colon and Digestive Disease, nurses sit one-on-one with the patients in the recovery area to make this step easier.

4. Performing this procedure can put an ASC ahead of the curve. C. difficile infections are becoming more common and more resistant to current antibiotic treatment. A study published in The Lancet found the incidence of C.difficile infections in hospitals in Europe rose to 4.1 per 10,000 patient days in 2008 from 2.45 per 10,000 patient days in 2005. C. difficile incidence is rising in the U.S., too. A 2008 report from the Association for Professionals in Infection Control and Epidemiology found there could be up to 7,000 C. difficile infections and up to 300 deaths on any given day in U.S. hospitals.

The first choice treatment for C. difficile infections is antibiotics. However, the more times patients experience recurrent infections, the higher their risk for developing additional recurrent infections. The increase in these infections presents an opportunity for this procedure to take off, Dr. Brasco says.

The procedure is in high demand from patients who know about it. Although the Huntsville Center for Colon and Digestive Disease does not market the procedure, Dr. Brasco has had patients come from as far as Georgia because they couldn't find anyone doing the procedure in their local areas. But he sees that trend changing.

"Within the next couple years, more local physicians will be doing it," he says. "It's just not that hard, and it works. I don't mean to give away my thunder, but this is not brain surgery."

Dr. Brasco even imagines a day where this procedure becomes the therapy of choice rather than a last resort.

5. The procedure is rewarding to perform. Because many of the patients currently undergoing fecal microbiota transplant are using it as a last resort, Dr. Brasco says it's extremely rewarding to perform the procedure. He remembers one young woman who contracted a C. difficile infection after a C-section. She had multiple recurrent infections and had been sick the entire time her baby was at home. Despite keeping the infections under control with antibiotics, she never felt good, he says. After undergoing an FMT, her infections subsided, and she gained the weight back. Dr. Brasco says she told him, "Thank you for giving me my life back."

"That's very gratifying," he says, "When these people come back to see you, they're really improved."

Related Articles on Fecal Microbiota Transplants:
Study: Fecal Microbiota Transplantation Effective Treatment of Recurrent Clostridium difficile
Dr. Tim Rubin Featured on Medical Show for Fecal Transplant Procedure
Commentary: Fecal Transplants Work, the Regulations Don't


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