Fecal transplants in an outpatient endoscopy setting offer big reward with little risk


Patients often go to hospitals for fecal transplants, but according to Paul Allegretti, M.D., many patients are healthy enough to have the procedure performed in endoscopy center or ambulatory surgery center (ASC).

“AMSURG was great because they had had some preliminary research, preliminary data on how to put something like that in an endoscopy center,” Allegretti said. “I had written a protocol with the help of another physician who sort of pioneered fecal transplant from a physician end of it. So that protocol was in place, they reviewed it. [They] really were great. No significant interference. Everything they had to say was really additional info that was helpful in getting it on board.”

Allegretti, an AMSURG physician partner at Lancaster Gastroenterology Procedure Center in Lancaster, Pa., has been a long-time proponent of using probiotics to treat gastrointestinal diseases, but the increase of Clostridium difficile (also known as C. difficile or C. diff) infections over the last several years has caused him to focus particularly on fecal transplants.

“The reason I started doing fecal transplants was, I always had kind of an interest in the microbiome and the bacterial contribution to gastrointestinal disease,” Allegretti said. “More and more, as time is going on, you see C. diff throughout the hospital becoming much more common than it was even when I was a medical resident, even more common in the community than it was 5 to 10 years ago. So in the short time I’ve been practicing, it’s become really a difficult disease to manage with what we had, which were just antibiotics. So seeing this becoming a new way to treat something and having the success rates that it had really kind of pushed me to work towards getting this procedure locally.”

Anyone can become infected with C. diff, but those who have been recently treated with antibiotics are most vulnerable. When antibiotics fight off harmful bacteria, they also destroy the healthy bacteria that protect the body against infection, leaving the body susceptible to C. diff. Once a C. diff infection is established, the bacteria release toxins that attack the lining of the intestine. C. diff infections can range from mild to life-threatening.

Fecal transplants are a highly successful way to treat the increasing number of patients infected with C. diff. According to a new review, infusion of healthy bacteria through donor stool helped 55 percent of patients heal who did not respond to standard drug treatments. Fecal transplant helps break the cycle of recurrence for C. difficile. With a fecal transplant, 90 percent of people improve.

In July of 2013, the U.S. Food and Drug Administration (FDA) dropped the regulation that required doctors to complete an investigational drug application before performing fecal transplants. According to Allegretti, this decision greatly contributed to making fecal transplants more accessible to interested practitioners.

“That really opened it up to people who were interested in doing it that maybe didn’t have a full university staffing behind them to do all the paperwork that’s sometimes involved," said Allegretti. "So, less paperwork allowed it to be done.”

Overall, Allegretti said that the reaction from patients has been quite positive. Most patients turn to the internet to do their own research, and they come into the office well-informed and asking good questions.

“They ask about our own success rates. They ask about success rates nationally. They want to reiterate what the positive research has shown. They ask a lot of questions about the donor – who is an appropriate donor – and they ask a lot of questions about cost, because that’s something you can’t really find on the internet necessarily," said Allegretti.

Allegretti added that many patients have concerns about the cost of the procedure, but it typically turns out to be quite affordable with insurance coverage.

For physicians who are interested in offering fecal transplants, Allegretti offered these recommendations.

“The best advice to give other gastroenterologists who might be considering this procedure is to make sure you, obviously, review literature, have your protocol in place before you present, make sure you’re well-read so you can answer any questions that an advisory board or a safety board or your nurses will have," said Allegretti. "A lot of questions pop up in the process, and generally these questions are answered by prior research, prior protocols that are available. So if you’re able to be well-read in those, it’s pretty straightforward, very rewarding and worth it once you’re able to do those things.”

Click here to watch the complete interview with Dr. Allegretti. Be sure to subscribe to our YouTube channel and be notified when AMSURG physician partners discuss surgery center insights and their experiences with an AMSURG partnership.

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