The overall goal of this procedure is to treat recurrent and refractory clostridium difficile infections with high therapeutic success by transferring donor stool to the colon of patients during a colonoscopy. This is accomplished through careful selection of recipients and donors using thorough screening tests for both parties. In preparation for the colonoscopy, the recipient must lavage their bowels and the donor's stool is blended with normal saline and strained to make a slurry.
The fecal slurry is then distributed evenly in the colon of the recipient via a standard colonoscopy, and for the majority of the patients, the symptoms caused by the Clostridium difficile infection resolve Visual demonstration of this method is essential to understanding the various steps of the procedure as well as troubleshooting more difficult aspects of the procedure. Generally, individuals new to this method may struggle with stool preparation and processing. However, it is a simple process that can be performed in most endoscopy centers.
Before undertaking these procedures, it is important to consult the hospital's infection control department details on candidate identification. Stool donor selection and screening are all provided in the text protocol. In the endoscopy room, prepare the sample wearing the appropriate protective garments.
If a donor provides multiple stool samples, select the freshest sample liquid stool must be discarded. The workspace should have an 18 inch or larger splash zone. Clean the work area with a disinfectant and then cover it with a disposable pad add.
Now, transfer the stool sample into a 14 ounce single speed disposable blender, and add approximately 500 milliliters of normal saline. Then cover the blender with a protective pad to avoid leakage and blend the stool in saline for at least a minute or until liquified. Be careful to avoid spilling the sample when opening the blender.
Next, to remove any solid material, pour the slurry through an eight inch fine mesh strainer, and into a plastic eight quart basin. Dispose of both the strainer and blender afterwards. Now draw up the strain solution into eight or nine 60 cc lure lock syringes.
Also, draw up saline into one or two 60 cc lure lock syringes for flushes for this protocol. In accordance with the policies of the endoscopy unit, wear the appropriate protective garments. If possible, use light sedation to help with retaining the stool after the infusion.
Now, perform a standard colonoscopy as far as technically possible, ideally to the terminal ileum while inserting the colonoscope, lavage and suction all residual liquid stool. Inspect the mucosal walls for evidence of inflammation. However, performing mucosal biopsies are not a routine part of the FMT procedure.
The degree of inflammation will dictate whether a full colonoscopy is safe. Once in the terminal ileum infuse a slurry via the biopsy channel of the colonoscope using the biopsy channel cap with the extension tubing in between syringe infusions, aspirate any excess air while being careful to avoid suction of liquid stool. After each syringe of slurry has been injected, flush the biopsy channel with normal saline to prevent clogging.
You may need to change the biopsy cap if clogging occurs, infuse a second syringe of slurry into the cecum. Next, the third syringe should be infused into the right colon, then infuse 30 cc of slurry every five to 10 centimeters for an even distribution of slurry along all four colon wall quadrants. Do this until the mid transverse colon is reached.
Flushing with saline between syringes is especially important when thicker slurries are being infused. A thick slurry may require considerable force and the biopsy channel could separate under such pressure. So be careful if the patient has fecal incontinence infused ELA syringe no lower than the hepatic flexor, or they may be leaking immediately post procedure.
After completing the colonoscopy and FMT procedure, the patient must try to retain the stool for several hours if possible. Also, be certain to counsel the patient on the risks of c difficile recurrence with future courses of antibiotics after the procedure is completed, be certain to dispose all waste in the appropriate biohazard containers. The colonoscope must be processed in the decontamination area using standard protocols.
The blender and strainer designed for a single use must have both been disposed of. All the surfaces used during the procedure should also be decontaminated using a facility. Approved product.
24 FMTs were performed on 22 patients using the described protocol. Nine of the patients had concurrent inflammatory bowel disease, six with Crohn's disease and three with ulcerative colitis. All nine had resolution of CDI.
However, one patient with inflammatory bowel disease required a second FMT 11 of the 13 non IBD patients also had complete resolution of symptoms related to c difficile. After one FMT, the average follow-up length was three months with a range from two weeks to 17 months. Once mastered, this technique can be done in 30 to 45 minutes, similar to a standard colonoscopy.
After watching this video, you should have a good understanding of a systematic approach to patient and donor screening, preparation of stool and delivery of the stool during a colonoscopy in order to maximize the therapeutic success of a fecal transplant.
