The lights are dim and a stereo plays classical music. Khoruts makes conversation to gauge the sedative’s effects. He’s listening for a quieting of the voice, a slowing of words. “Do you have any pets?”
The room is quiet for a moment. “. . . pets.”
“I think we’re ready to go.”
A nurse brings the bowl with the vials. I ask her if the red color of the caps on the vials signifies biohazard.
“No, just the brown color inside.”
Unless one is watching closely, a fecal transplant looks very much like a colonoscopy. The first thing to appear on the video monitor is a careering fish-eye view of the exam room as the scope is pulled from its holder and carried over to the bed. If you are young enough to be unfamiliar with a colonoscope, I invite you to picture a bartender’s soda gun: the long, flexible black tube, the controls mounted on a handheld head. Where the bartender has buttons for soda water and cola, Khoruts can choose between carbon dioxide, for inflating the colon so he can see it better, and saline, for rinsing away remnants of an “inadequate prep.”
Khoruts works the control buttons with his left hand, torquing the tube with his right. I comment that it’s like playing an accordion or a piano, both arms working independently at unrelated tasks. Khoruts, who plays piano in addition to colonoscope, prefers the analogy of the amputee’s prosthesis. “Over time it becomes part of your body. Even though I don’t have nerve endings there, I kind of know what’s happening.”
We’re in now, heading north. The man’s heartbeat is visible as a quiver in the colon wall. Khoruts maneuvers a crook. Shifting a patient’s position can help unkink a sharp turn, so the nurse leans in hard, like a driver pushing a stall to the shoulder of the road.
Using a plunger on the control head, Khoruts releases a portion of the transplant material. Since the colon has been wiped clean beforehand with antibiotics, the unicellular arrivals won’t have to battle a lot of natives. However many survived the antibiotic, the immigrants are sure to prevail. Within two weeks, Khoruts’s research shows, the microbial profiles of donor and recipient colons are synced.
One more release, at the far end of the colon, and Khoruts retracts the scope.
A couple days later, Khoruts forwards an e-mail from the patient (with surname deleted). The pain and diarrhea that had kept him from going to work for a year were gone. “I had,” he wrote, “a small solid bowel movement on Saturday evening.” It may not be your idea of an exciting Saturday evening, but for Mr. F., it was tough to top.
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THE FIRST FECAL transplant was performed in 1958, by a surgeon named Ben Eiseman. In the early days of antibiotics, patients frequently developed diarrhea from the massive kill-off of normal bacteria. Eiseman thought it might be helpful to restock the gut with someone else’s normals. “Those were the days when if we had an idea,” says Eiseman, ninety-three and living in Denver at the time I wrote him, “we simply tried it.”
Rarely does medical science come up with a treatment so effective, inexpensive, and free of side effects. As I write this, Khoruts has done forty transplants to treat intractable C. diff infection, with a success rate of 93 percent. In a University of Alberta study published in 2012, 103 out of 124 fecal transplants resulted in immediate improvement. It’s been fifty-five years since Eiseman first pushed the plunger, yet no U.S. insurance company formally recognizes the procedure.
Why? Has the “ick factor” hampered the procedure’s acceptance? Partly, says Khoruts. “There is a natural revulsion. It just doesn’t seem right.” He thinks it has more to do with the process by which a new medical procedure goes from experimental to mainstream. A year after I visited, the major gastroenterology and infectious disease societies invited “a little band of fecal transplant practitioners” to put together a “best practice” paper outlining optimal procedures: a common first step toward establishing codes for billing for the procedure and making the case for insurance companies to cover it. As of mid-2012, there was no billing code or agreed-upon fee. Khoruts estimates the process will take one to two years more. In the meantime, he simply bills for a colonoscopy.