Education

Doctor of Dung: Lawrence Brandt Teaches Med Students the Ins and Outs of Fecal Transplants

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Two or three times a week, a patient asks Dr. Lawrence Brandt to be injected with poop.

A 70-year-old former Army doctor and current gastroenterology professor at Yeshiva University’s Albert Einstein College of Medicine, Brandt says he was derided as a quack in the Aughts for performing a treatment that helped patients even as it disgusted everybody else. Fecal Microbial Transplants (FMTs) aim to introduce healthy bacteria into a sick person’s gut by taking feces from a healthy donor and injecting it into a patient suffering from gastrointestinal disorders. For treating Clostridium difficile, or C. diff — a spore-forming microbe that can grow in the intestines of people whose healthy gut bacteria have been wiped out by a course of antibiotics, and which can cause potentially deadly bouts of diarrhea — FMT has a 92 percent success rate, according to one 2012 study.

Brandt was not the first American doctor to perform a fecal transplant, though for a time he thought he was. In 1999, he told a patient suffering from recurrent C. diff that her best chance for relief might lie in the bacteria being collected in her husband’s colostomy bag. Because FMT had received little mention in American medical literature, at first Brandt believed he’d invented it himself.

That patient called him just a few hours after returning home, he recalls, and said, “I haven’t felt this good in six months.”

Since then, Brandt has performed about 200 fecal transplants. He leaves it up to
patients to find a donor themselves, suggesting only that they query “anyone who is healthy,” even a total stranger. (More often than not, the donor is a relative or friend.) After passing a health screening that
includes both a detailed questionnaire and blood and stool tests, donors must provide their waste, which usually arrives in a
double-wrapped plastic container. “The stool that I get is prepared as if you would think it’s a radioactive threat,” says Brandt.

The next step is turning the sample into a fecal slurry, for which Brandt typically uses a blender that he asks his patients to provide. (After the treatment is over, he says, “nobody wants the blender back.”) It’s a process that he will occasionally
invite his Einstein students to help with: “Their eyes get as big as saucers,” he says.

After filtering the resulting solution through a gauze pad, Brandt pours it into syringes, then injects about ten ounces into the interior reaches of the colon, where it will remain for a few hours as the good bacteria take hold. In the best cases, Brandt says, “Within hours you see their white blood cell count coming down, their fever coming down.”

Sara Welinsky, who shadowed Brandt on FMT cases last spring as a fourth-year medical student, says she was struck by the simplicity of the concept. “You would think maybe this is something we could have come up with years ago, but we’re set in our ways to use medicines and surgeries and procedures,” she says. FMT, she adds, provides a reminder that modern medicine can be about more than prescribing drugs and performing operations: “You might be able to take a step back and think about the science of things. There are other ways of approaching medicine that work.”

Olga Aroniadis, a gastroenterology fellow at Montefiore Medical Center in the Bronx, where Brandt also practices, says she plans to use FMT as one of her treatments when she joins the hospital’s staff this summer. She first encountered Brandt as a third-year medical student at Einstein, and says he’s an “ideal clinician-educator” who’s open to his students’ ideas.

Marc Fiorillo can vouch for that: While studying with Brandt eight years ago, Fiorillo pointed out that filling multiple
syringes and then emptying them one by one was too time-intensive. He asked Brandt if they could instead insert the specimen directly into the colonoscopy’s pedal-controlled irrigation system, and Brandt agreed. (This streamlined technique worked well at first but ended up having to be abandoned, says Fiorillo, when the solution “started leaking all over the place.”)

Now a gastroenterologist practicing in New Jersey, Fiorillo called Brandt for
advice about how to implement FMT in his own practice after he began seeing
patients with recurrent C. diff. “I never thought I’d be doing this,” Fiorillo says, “but I’ve become a kind of pioneer in my own little microcosm.”

Zain Kassam, the chief medical officer of OpenBiome, an MIT-launched “stool bank” that ships FMT-ready materials directly to hospitals (“like the Red Cross, but for poop”), estimates there are currently a few hundred FMT practitioners in the United States. But even as more physicians begin to perform FMT, the future of the treatment is far from certain. Concerned that fecal transplants could expose recipients to as yet
unidentified harmful elements carried in stool, the FDA announced in 2013 that it would begin regulating human feces as a drug, meaning physicians would have to
apply for special permission to use it in FMT. Under pressure, the FDA has made a special exception for cases of C. diff. Brandt, who has lobbied against regulation, ruefully notes that now, “if you move your bowels in New Jersey, and you put the bowel movement in a plastic container, and you drive across the George Washington Bridge, you’ve just committed a federal offense.”

But Brandt says that won’t stop him from “taking this disgusting waste product and using it to cure people.” And patients, at least, seem to be able to see past their
distaste to the potential benefits of FMT: “I don’t introduce the subject to patients,” says Brandt. “They introduce the subject to me.”

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