Last month, a familiar package arrived on the doorstep of Sydney gastroenterologist, Professor Tom Borody.
And just like every other time for the past 20 years, he took delivery of the single long stemmed rose and paused for a moment to reflect. The flower always comes with a message, and of all the notes he has received, this one is his favourite – “to the world you may be one person, but to me you are the world”.
The much-appreciated gift has come from a grateful patient who came to him desperate to try and find a cure for the chronic diarrhoea that was crippling her.
“She would need to go (to the toilet) 15 to 30 times in one day and had tried everything, even not eating,” he remembers.
Professor Borody found a cure for his patient, and even after two decades she is symptom-free and enjoying a happy, healthy, and active life. And it’s all because someone donated her some healthy poo which was then transplanted into her own body via her colon.
“The reversal of symptoms happened overnight,” he said. “It’s interesting to think that poo did that,” he tells the limbic.
While his patient hasn’t looked back and many more have undergone the sometimes controversial procedure with outstanding success, Professor Borody has had to endure significant stigma and even revulsion for a procedure that basically involves taking healthy faeces from a donor or multiple donors.
The donor faeces is then filtered to remove larger particles and blended with a saline solution to liquefy it before it is administered to the patient, usually through the colon or via a nasogastric tube.
It’s a good thing that Professor Borody has a sense of humour. He is also unafraid to get his hands dirty in the name of medicine – even if it means getting up close and personal with human poo.
As if that’s not bad enough, he has also had to deal with widespread scepticism in his own profession, and even been called a ‘charlatan’ by a high-profile colleague. Another suggested he was mentally ill.
Professor Borody has spent almost three decades unapologetically pioneering the use of faecal microbiota transplantation (FMT) to treat a range of debilitating and often fatal gut diseases, including antibiotic-resistant C.difficile colitis and Crohn’s cases.
“I’ve got thick skin, and I don’t worry about it anymore,” he said. “I was in deep shit when I started doing this and that’s where I’ve stayed, but it’s made a lot of people much better and that’s what’s important.”
Not quite mainstream
While the procedure is yet to gain widespread mainstream national support, a handful of Australian doctors now offer it and Professor Borody’s Centre for Digestive Diseases has a huge waiting list, while in the US FMT is now recognised as a first line treatment for C.difficile.
And the release of study in The Lancet last month, co-authored by Professor Borody, could signal change is on the horizon.
The randomised placebo-controlled trial was conducted at three hospitals in Australia between 2013 and 2015. Patients with active ulcerative colitis (Mayo score 4-10) were treated either with FMT or placebo colonoscopic infusion, followed by enemas five days per week for eight weeks.
The primary outcome was steroid-free clinical remission with endoscopic remission or response at week eight. This was achieved in 11 (27%) of 41 patients allocated FMT, compared to just three (8%) of the 40 patients who were assigned placebo.
Adverse events were reported by 32 (78%) of patients allocated FMT and 33 (83%) of those who were assigned the placebo. Most were “self-limiting gastrointestinal complaints, with no significant difference in number or type of adverse events between treatment groups”.
“Intensive-dosing, multi-donor, faecal microbiota transplantation induces clinical remission and endoscopic improvement in active ulcerative colitis and is associated with distinct microbial changes that relate to outcome,” the authors concluded.
“Faecal microbiota transplantation is, thus, a promising new therapeutic option for ulcerative colitis. Future work should focus on precisely defining the optimum treatment intensity and the role of donor-recipient matching based on microbial profiles.” (see our story here).
FMT will become a gold standard treatment
Professor Borody is used to controversy and headlines and remembers only too well the scepticism he encountered when he was working on the development of the now well-accepted triple therapy (bismuth, metronidazole and tetracycline) for infection with Helicobacter pylori bacteria.
The triple therapy, pioneered in 1984, has become the gold standard for treating peptic ulcer disease caused by Helicobacter pylori infection, and Professor Borody believes FMT will follow the same route.
“The criticism was unbelievable when we were working on use of antibiotic therapy for the Helicobacter ulcer disease, and it came from a good category of scientists and gastroenterologists,” he said. “It turned out they were wrong.”
So what really drives him to persevere in the face of opposition? Yes he believes in the procedure, but it’s the hope that he can offer his patients that gets him up every morning.
Many people living with colitis, Crohn’s or another gut disease spend their days housebound because they are too afraid to leave the safety of a nearby bathroom, unable to exercise because they are overcome with cramps and pain, and have to suffer the embarrassment of excess gas and even faecal incontinence. It’s a lonely and painful disease, says Professor Borody.
So it’s not too hard to see how desperate they would become that they would be prepared to ingest faecal matter from another person.
He remembers his very first FMT patient, a woman called Josie who came to him suffering terribly from indeterminate colitis after a trip to Fiji.