The author has worked for many years as a biofeedback nurse in secondary care settings providing care for patients with low anterior resection syndrome (LARS). The aim of this article is to present some of the most recent evidence-based information in conjunction with experiential observations from clinical practice.
Background
In 1948, the results of the restorative anterior resection for rectal cancer and avoidance of a permanent stoma were published (Dixon, 1948). The anterior resection procedure is now a common operation for rectal cancers, often combined with a total mesenteric exenteration (TME) for mid or low rectal cancers. TME involves the careful removal of the tissue surrounding the rectum up to the levators, thereby reducing the risk of local cancer recurrence (Taylor and Bradshaw, 2013). Patients have a temporary ileostomy to allow healing, and then undergo restoration of continuity (stoma reversal).
LARS was originally described as the symptoms occurring after temporary stoma reversal, or ‘bowel dysfunction following low rectal resection’ (Keane et al, 2020). In 2020 the first consensus definition was formulated following a large Delphi study with patient and clinician engagement (Keane et al, 2020).
Eight symptoms were identified:
- Variable, unpredictable bowel function
- Altered stool consistency
- Increased stool frequency
- Repeated painful stools
- Emptying difficulties
- Urgency
- Incontinence
- Soiling.
Avoidance of a permanent stoma has come at a high cost for some patients. As many as 90% of patients may be affected by bowel dysfunction to some extent (Bryant et al, 2012). LARS symptoms can consist of diarrheoa, faecal and/or flatus incontinence, urgency, frequency, fragmentation of stools, constipation and evacuatory dysfunction—‘clustering’ (repeat evacuations), incomplete emptying, painful evacuation and tenesmus (Keane et al, 2020). Ultimately these symptoms have led to a diminished quality of life for many patients (Kupsch et al, 2019; Burch et al, 2021; Pape et al, 2021).
Most studies into treatments for LARS have involved the use of a single intervention, particularly sacral nerve stimulation, and yet conservative measures should be tried prior to this (National Institute for Health and Care Excellence (NICE), 2020; Burch et al, 2021). There are several studies on ‘biofeedback’ to treat LARS, but this umbrella term can cover a range of interventions from manometry and rectal balloons to pelvic floor exercises and behavioural advice—often the exact methods used are not described (Burch et al, 2021). LARS treatment comparisons may be particularly difficult to assess because there is such variance in symptoms, with day-to-day ‘unpredictability’, and symptoms often change over time (Keane et al, 2020; NICE, 2020). Quality of life for patients with LARS is said to improve over time but there is no agreement on whether this is due to true symptomatic improvement, or patients adjusting to living alongside their symptoms (Pape et al, 2021).
There are various hypotheses as to the exact pathophysiology and why LARS occurs, but simply put it is multifactorial, with partial organ removal affecting nerve reflexes, muscles, motility, storage capacity and hormones within the gastrointestinal tract (Ridolfi et al, 2016).
The current research and symptom profile of LARS seem to indicate that a systematic and multi-modal treatment approach could be most effective. Some of the management options that can be easily implemented will be discussed here.
Nursing assessment tools for LARS patients
The nursing assessment aims to understand what the main problems are for the individual (Ness, 2018). Red Flags for cancer recurrence or other diseases should be excluded first and foremost (NICE, 2021a).
Patients often develop an array of coping strategies to self-manage before they see a specialist nurse. There is advice from health professionals, both online and in patient information leaflets, which prove very useful. Asking which interventions have been tried, and the efficacy and acceptability of these, is helpful.
The next stage is to ascertain the specificity of the problems: when they occur, the precipitating and palliating factors, and how they impact the patient. Goals for treatment should be a priority in terms of what is practicable and acceptable to the individual.
Tools for assessment, for most colorectal nurses, will include use of the Bristol Stool Chart to show stool form. The LARS score from the European Society of Coloproctology (https://tinyurl.com/3577hfez) is a symptom-based scoring system and is widely used—this can be used at baseline appointments and the end of treatment (NICE, 2020; 2021b). Patient diaries are beneficial because it is very rare for any individual to remember their specific pattern of frequency, associated symptoms and the possible contributory factors. An example format is shown in Table 1.
Table 1. Example format for a LARS patient diary
| Date/time | Food | Time | Medications Type/dosage | Time | Bowels (Stool form Bristol type 1–7) | Time | Other symptoms(Patient inserts own symptoms and own terminology for example: abdominal pain, leakage, soreness/itching internal/external) |
|---|---|---|---|---|---|---|---|
It is the author's opinion that monitoring the impact of proposed interventions is pivotal to getting the right treatment, at the right time, and that this can be most easily achieved through patient diaries. The most bothersome symptoms for the individual can be incorporated in the ‘other symptoms’ column along with the time at which they occur. Patterns, precipitants and palliating factors can be established fairly quickly and this guides the most effective plan of management.
Diaries can be hand-written and scanned, sent as a spreadsheet, or posted back to the nurse between appointments for ongoing assessment and recommendations.
Treatment options
Available literature and resources seem to agree that conservative management should be the first approach but there remains no consensus on exactly what should be employed, or in which order, because the symptom profile is so vast, and specific to the individual.
NICE guidance on optimal management of LARS makes recommendations ‘based on experience due to the dearth of randomised controlled trials (NICE, 2020) (Box 1).
Box 1.Optimal management of LARS
- Dietary management
- Laxatives
- Bulking agents
- Anti-diarrhoeal
- Anti-spasmodic
- Physiotherapy input
Source: National Institute for Health and Care Excellence 2020
Dietary management
Dietary manipulation is often the first port of call for treating LARS. This is particulary helpful in the early stages after ostomy reversal where low-fibre diets are recommended for a few weeks. Using soluble fibre can reduce transit time and fragmentation of stools (Christensen et al, 2021). Laxatives for patients with constipation-type symptoms can be hard to titrate without causing diarrhoea and potentially incontinence, so foodstuffs such as prunes/prune juice or stewed apple can be suggested in the first instance.
Pharmacotherapy
Many patients will have tried taking the antidiarrhoeal loperamide but again, titrating the dose can be difficult. Depending on symptom specificity, slowing and bulking stools can reduce frequency and diarrhoea. Oro-dispersible loperamide offers faster absorption, whereas loperamide syrup allows for accurate titration in smaller, split doses. Timings, dosages and effect can be monitored using the patient diary. A rapid post-prandial response—eating and having to rush to the toilet—can be managed with taking pre-emptive loperamide. Nocturnal frequency and/or incontinence can be addressed by suggesting a dose be taken last thing at night.
From the author's clinical experience, using loperamide with soluble fibre supplements, taken at the same time, can be very effective with a dual slowing and bulking effect thereby promoting complete clearance and reducing frequency.
Peppermint oil capsules, 3-4 drops of peppermint oil in hot water taken as a tea, and simeticone can help with excess wind or abdominal spasm. Sore perianal skin is often reported from frequency or soiling and warm-water sitz baths with application of barrier creams can help soothe the area. Anal skin just inside the anus can get very sore so advising patients, if it is acceptable to them, to apply cream ‘just inside the anus’ can help.
Sphincter/pelvic floor exercises
Sphincter exercises and pelvic floor exercises that incorporate sphincter squeezes are a simple way to improve strength and tone of the anus and reduce anal incontinence (Visser et al, 2014; Christensen et al, 2021). These are particularly important for patients who have had very low or intersphincteric resections, and those that have had radiotherapy due to fibrosis of the tissues. There are now many accessible online leaflets and videos on how to perform these, which can be accessed by the nurse or patient. Patients can set an alarm on their phone to remind them to perform the exercises or use the NHS Squeezy app (Squeezyapp.com), which sends notifications direct to their phones.
Transanal irrigation (TAI)
TAI is a method of introducing water, via the anus, to evacuate faeces. The current available devices allow the water to be kept inside the bowel using a cone or catheter to promote a greater amount of controlled clearance (Emmanuel et al, 2019).
TAI can be used as an adjunct to other measures, or as a single intervention to manage many of the symptoms of LARS. It is becoming more widely used and shown as effective, in that clearance of the distal end of the bowel can ameliorate many of the symptoms such as incontinence, sore skin from anal leakage, incomplete evacuation, clustering and constipation (Rosen et al, 2020; Mekhael et al, 2021). There are a variety of TAI systems available and a decision guide was published to help clinicians identify which systems to use for specific conditions (Emmanuel et al, 2019). Studies have shown that higher volumes of water seem to be most effective (Rosen et al, 2020; Embleton and Henderson, 2021).
If treatments fail to improve symptoms to an acceptable level for the patient, ongoing referral should be made to the colorectal surgeon, gastroenterologist, biofeedback team or tertiary referral centre.
Conclusion
LARS has a varied symptom profile. Effects can be debilitating and have an impact on quality of life. It is multifactorial, and therefore likely to respond to combined treatment modalities. First-line treatments can be tried, and treatments can be combined and evaluated. Patient diaries provide a valuable tool for ongoing assessment and can indicate the need for introducing the right treatment at the right time. If treatment modalities, alone or combined fail to ameliorate symptoms to an acceptable level for the patient, ongoing referral should be made.