The efficacy of fecal microbiota transplantation for patients with chronic pouchitis: A case series

Ulcerative colitis (UC) is a diffuse nonspecific chronic inflammation of the colon characterized by erosion or ulcer in the mucosa.1, 2 It has been reported that about 30% of patients with UC require surgical treatment at some time in their lives.3, 4 Surgical indications for UC include colonic perforation, life‐threatening gastrointestinal hemorrhage, toxic‐megacolon, resistant to medical treatment, dysplasia, and colon cancer.5, 6 Most patients undergo a restorative proctocolectomy (RPC) with ileal pouch‐anal anastomosis (IPAA). RPC with IPAA removes the entire colon and rectum while preserving the anal sphincter and, hence, normal bowel function and fecal continence. The pouch serves as an internal pelvic reservoir for intestinal contents.7 Therefore, RPC with IPAA has made surgical management a more attractive option than a total proctocolectomy with a permanent end ileostomy. However, there are some patients who develop inflammation in the ileal pouch, a condition called pouchitis. Pouchitis, which is a term referring to an inflammatory condition of the ileal pouch reservoir, is the most frequently observed long‐term complication occurring in patients with IPAA. Pouchitis occurs almost exclusively in patients with UC and rarely in patients with familial adenomatous polyposis.8 Among patients with UC, the risk of pouchitis is increased in patients with extensive colitis.8 The prevalence of pouchitis ranges from 23% to 46%, with an annual incidence up to 40%, and about 5% of these patients develop chronic pouchitis requiring immunomodulators, biologics, or a resection of the pouch.9, 10 Although the cause of pouchitis remains unknown, it is hypothesized to result from an abnormal immune response to altered gut microbiota in genetically susceptible hosts. Previous reports support this assumption. First, it has been reported that the administration of antibiotics is effective for pouchitis.11, 12 Second, it has also been reported that the administration of a probiotic, VSL # 3, is effective in the prevention of pouchitis.11, 13 In addition, it has been reported that several genes associated with the innate immune response and bacterial recognition mechanisms such as NOD2/CARD15 gene,14 toll‐like receptor gene,15, 16 and IL‐1 receptor agonist gene17 increase the risk of pouchitis. Fecal microbiota transplantation (FMT) is a novel therapeutic procedure that aims to restore the composition of gut microbiota by transferring normal intestinal flora from a healthy donor to a patient. FMT has been recently applied to various kinds of human diseases associated with dysbiosis such asClostridium difficile infection,18, 19, 20 inflammatory bowel disease,21, 22, 23 irritable bowel syndrome,24 type 2 diabetes,25 and autism spectrum disorders.26 In particular, it has been reported that FMT exhibited high efficacy in the treatment of recurrent Clostridium difficile infection that was otherwise resistant to medical treatment.19 To date, there are a few reports available about the efficacy of FMT for pouchitis. Moreover, there is no study about the efficacy of FMT on Japanese patients with pouchitis. Therefore, the efficacy of FMT for pouchitis remains unknown. In this study, we performed FMT on three patients with pouchitis after RPC with PIAA for UC and examined the efficacy and safety.