Fecal Transplants

Podcast Transcript

Dr. Scott Steele: Butts and Guts, a Cleveland Clinic podcast, exploring your digestive and surgical health from end-to-end. Hi again, everyone, and welcome to another episode of Butts and Guts. I'm your host, Dr. Scott Steele, the president of main campus here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today I'm very pleased to have one of our experts, Dr. Bret Lashner, a gastroenterologist in the Center for Inflammatory Bowel Disease here at the Cleveland Clinic in the Department of Gastroenterology. Bret, welcome to Butts and Guts.

Dr. Bret Lashner: Thank you, Scott. Very happy to be here.

Dr. Scott Steele: So, we always like to start out with getting a little bit more background about yourself. So, can you tell us a little bit where you're from, where'd you train, and how long have you been here at the Cleveland Clinic?

Dr. Bret Lashner: Well, I've been at the Cleveland Clinic 31 years, born in Philadelphia, trained in New York, Philadelphia, and Chicago, and I was recruited by the Cleveland Clinic 31 years ago to run the Inflammatory Bowel Disease Center. And we accomplished an awful lot in those 31 years. I'm very proud of what we did and I'm very happy to be part of all of that.

Dr. Scott Steele: Well, we're super excited to have you here. It's been a pleasure working with you. Today we're going to talk a little bit about something that maybe not a lot of people have heard of, and that's fecal transplantation. Yes, I did say it, fecal transplantation. To start, can you tell us a little bit about what is a fecal transplant?

Dr. Bret Lashner: So, in certain diseases or in certain conditions, your fecal microbiome, all the bacteria that live in your large bowel, gets broken, gets diminished, and that sets you up for lots and lots of diseases. The purpose of a fecal transplantation is to build up this broken microbiome, to repair it, so that you're able to fight off certain diseases and basically improve your overall health. It's an interesting idea. You could say it's innovative, but it's been around for centuries. The ancient Chinese have developed this and it does work. It even works in veterinary medicine to help animals with diarrhea.

Dr. Scott Steele: Two questions at you with that. Kind of interesting to hear that it's been around for centuries. What does fecal transplant treat and is this a common sort of a treatment?

Dr. Bret Lashner: It's not common, but the microbiome or a broken microbiome is associated with lots of different diseases such as ulcerative colitis and Crohn's disease, such as type 2 diabetes and hepatic steatosis, such as atherosclerotic heart disease, which that type of research is going on at the Cleveland Clinic. Of course recurrent Clostridioides difficile infection. That's really what we use fecal transplant for, recurrent C. diff infections.

Dr. Scott Steele: Yeah, very interesting. It's amazing actually to see me, the evolution of this entire idea of the fecal microbiome, including things in my wheelhouse in terms of colorectal surgery, just having anastomosis when we cut out a piece of bowel and put them back together, how the fecal microbiome could relate to good outcomes or in some cases poor outcomes. Even some data that talks about the fecal microbiome's role in terms of some of the responses to cancer treatment.

Let's get to the nitty-gritty here. How is a fecal transplant done? If I'm a patient out there and you get approached by you, what can a patient expect during the procedure?

Dr. Bret Lashner: Excellent question. Let's step back a bit. Why is the fecal microbiome broken, in need of repair? Well, with certain chronic diseases, chemotherapy, antibiotics, older age, there are lots of factors that diminish the microbiome. A treatment adjunct for all of these conditions is to improve or repair this broken microbiome. How do we do it? The best way all of us can do it is to increase our dietary fiber, fruits and vegetables in our diet, to give these good bacteria something to munch on and reproduce. Probiotics often help and a fecal transplant, where we take the actual microbiome of the human and transplant it into this broken microbiome, is another way to repair the microbiome.

Dr. Scott Steele: Is this something that's done where people actually get a fecal enema or do they take a pill or do they got to swallow stool? What are we talking about here?

Dr. Bret Lashner: No, none of those things. Okay, so in the old days we would take a normal person, take their stool, homogenize it so to speak, and instill it in the colon via colonoscopy. That worked very well but you can imagine that is quite a bit distasteful and it could be associated with complications and side effects so we stopped doing that several years ago. There are now commercially available ways to improve the microbiome. One is an oral capsule filled with Firmicute spores that have been treated to get rid of any contaminants and patients swallow it and the spores germinate in the colon to repoopulate the bowel, repoopulate. Another one is an enema of stool that has been harvested from normal and well-tested individuals. There are commercially available ways to do this and we are doing quite a bit of it here at the Cleveland Clinic.

Dr. Scott Steele: Truth or myth, truth or myth. The only successful to-date disease that has been treated with a fecal transplant is C. diff.

Dr. Bret Lashner: True. However, we have at the Clinic the Center for Microbiome and Human Health, CMHH, that is actively doing research on alternative ways to treat diseases like atherosclerotic heart disease, type 2 diabetes, and inflammatory bowel disease. We are finding other uses for this technology other than recurrency difficile. But I think we're going to see a lot more uses in the coming years.

Dr. Scott Steele: That's fantastic. Okay, so we've had organ donation on here in the past on Butts and Guts, but we're going to talk about how does one become a fecal transplant donor and what are the qualifications to become a fecal transplant donor?

Dr. Bret Lashner: Okay, so once again, to donate your stool, you need to go through a third party who will probably pay you for it, but they will test you like nobody's been tested before. Not only will they test your stool for microbiota, but they will test you for everything else, including psychological diseases and anything else that may contribute to poor health. You need to be perfectly healthy and go through lots and lots of testing to be a human donor of stool.

Dr. Scott Steele: If I'm a patient out there and I hear the word "fecal transplant" as a potential procedure that they're going to do on me, I'm not going to lie to you, that might be a little bit overwhelming and maybe even a little bit frightening. Are there questions, if I'm a patient, that I should ask my doctor before receiving a transplant?

Dr. Bret Lashner: Yes, you need to talk about safety. That's critical. There's really nothing else besides safety that you should talk about. You want to know how well the donor's stool was tested to be certain they don't have infectious diseases, including COVID and other infectious diseases. Other than that, it should be pretty safe. Most patients, I'm finding, are very receptive to the idea. They're kind of desperate. They're looking for alternative ways to treat their recurring problem and this is a very effective way to do that.

Dr. Scott Steele: Bret, just digging into safety a little bit more, what are the potential complications associated with a fecal transplant besides, you mentioned some of the infectious potential ones.

Dr. Bret Lashner: That's the big one, and it's not just the COVID. There are other infections out there and there have been some reports of very bad outcomes due to infectious. There's a risk involved. The FDA has now approved those two preparations I talked about because they believe it is safe and certainly effective.

Dr. Scott Steele: You mentioned this a little bit briefly earlier here, what we're trying to do at the Cleveland Clinic, but can you go in a little bit more detail about any advancements that are on the horizon when it comes to fecal transplantation?

Dr. Bret Lashner: Yes. The work going on in heart disease is very exciting. They take atherosclerotic-prone mice, mice that are more likely than others to get hardening of the arteries. They do a fecal transplant on half of them, and it turns out the ones who get the transplant have a better microbiome, do not get the plex. Basically, that's a way to save lives and I'm certain in the coming years this will be a way we can help people who are at high risk for getting heart disease to prevent them from getting heart attacks, saving their lives. Isn't that exciting?

Dr. Scott Steele: That's pretty incredible. C. diff makes sense for a fecal transplant, but to make the leap to atherosclerotic disease, I think that's pretty incredible.

Now it's time for our quick hitters, a chance to get to know you a little bit better, so a couple of things. First of all, what is your favorite sport to play and to watch?

Dr. Bret Lashner: No question, to watch is baseball. I'm a baseball fan from the first day. I've turned into a Guardians fan, but I started out and my first love is still with the Phillies. To play, I used to play tennis until my knees started bothering me, but now it's pickleball.

Dr. Scott Steele: Oh, that's great. Yep, the pickleball, the game that spans the world. What is your favorite food?

Dr. Bret Lashner: Oh boy, that's one of my downfalls. I kind of like everything.

Dr. Scott Steele: That's fantastic. Tell us about a trip that you plan to go to that you're excited, a bucket list trip you want to go on.

Dr. Bret Lashner: Well, I have a lot of things going on this summer, but this summer is my 70th birthday and we're going on a family trip hiking through Oregon to go to Crater Lake and the Columbia River Gorge and other scenic places in Oregon with my whole family. I'm very much looking forward to this and it'll be fun.

Dr. Scott Steele: That's fantastic. Having been in there myself, it's gorgeous, gorgeous terrain. Finally, what was your first car?

Dr. Bret Lashner: A Honda Accord. That was my first car. Now I'm driving a Camry and a hybrid.

Dr. Scott Steele: Fantastic. Can you give us a final take home message to the listeners regarding fecal transplantation?

Dr. Bret Lashner: Yes. This is such an exciting field of research and patient care. It's all over the place on the internet. Please keep an eye on this. I think you're likely to benefit from it in the future.

Dr. Scott Steele: Well, to learn more about fecal transplants or to schedule an appointment for treatment at the Cleveland Clinic, call the Digestive Disease Institute at 216.444.7000. That's 216.444.7000. You can also visit our website, clevelandclinic.org/digestive. That's clevelandclinic.org/digestive.

Bret, thanks so much for coming on Butts and Guts.

Dr. Bret Lashner: Thank you, Scott. My pleasure.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.