Low Anterior Resection Syndrome David Cotton Jessie Mansell

Low Anterior Resection Syndrome David Cotton, Jessie Mansell, Jon Randall

Low Anterior Resection • Curative treatment for low rectal cancer • Avoiding permanent stoma + wound complications of APER • Sphincter preservation as an aim has led to very low tumours being resected • Total Mesorectal Excision • Anastomotic leak + pelvic complications • Neoadjuvant chemoradiotherapy (+ adjuvant treatment for many) • Clinical concentration often on disease/survival

Low Anterior Resection Syndrome (LARS) • “Disordered bowel function after rectal resection leading to a detriment in quality of life” 1 • In reality this varies and has been said to include urgency, loose stool, frequency, altered stool consistency, obstructed defecation and incontinence • If present at one year after surgery (or stoma closure) then it is likely to be present after 10 years 2

Reproduced from Chen et al 3

The LARS score • Developed by Emmertsen + Laurberg 4 in Denmark • Subsequently validated in English by Juul et al 5 • Quality of life after rectal cancer surgery is dependent on a number of factors • However it is closely linked to LARS – ‘Major’ LARS causes a significant reduction in quality of life compared to no LARS 6

Likely risk factors 1, 3, 7 Neoadjuvant chemoradiotherapy Short/no remnant rectum (<5 cm) Clinical anastomotic leak/abscess/defect Prolonged presence of defunctioning ileostomy • Nerve dysfunction (pudendal neuropathy) • Older age • Preoperative dysfunction • •

Differential diagnoses • • Radiation enteritis Chemotherapy-induced enteritis Malabsorption Anastomotic stricture Disease recurrence Primary (pre-operative) dysfunction Other causes of altered bowel habit

Medical (‘traditional’) management • • • Dietary advice Loperamide Bulking agents Amitriptyline Buscopan

Advanced management • • Stool training + advanced education Counselling Biofeedback Rectal irrigation

Sacral Nerve Stimulation • Still an evolving technique for LARS • 2015 review article in Colorectal Disease 8 found 43 patients considered for SNS for LARS • In this instance for incontinence + LARS – Median follow-up 15 months – 34 implants placed – 94. 1% improvement in symptoms (74. 4% on intention to treat) • PTNS may also have similar efficacy 9

References 1. 2. 3. 4. 5. 6. 7. Bryant CL, Lunniss PJ, Knowles CH, Thaha MA, Chan CL. Anterior resection syndrome. Lancet Oncol. (2012); 13(9): e 403 -8. Sturiale A. , Martellucci J. , Valeri A. Long term functional results after laparoscopic low anterior resection for rectal cancer. Colorectal Disease (2015), Poster Abstracts. 17: 38– 101. doi: 10. 1111/codi. 13053 Chen T, Wiltink L, Nout R et al. Bowel Function 14 Years After Preoperative Short. Course Radiotherapy and Total Mesorectal Excision for Rectal Cancer: Report of a Multicenter Randomized Trial. Clin Colorect Cancer (2015); 14(2): 106 -114. Emmertsen KJ, Laurberg S. Low anterior resection syndrome score: development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer. Ann Surg (2012); 255(5): 922 -8. Juul T, Battersby N, Christensen P et al. Validation of the English translation of the low anterior resection syndrome score. Colorectal Dis (2015); 17(10): 908 -16 Juul T, Ahlberg M, Biondo S et al. Low anterior resection syndrome and quality of life: an international multicenter study. Dis Col Rectum (2014); 57(5): 585 -91. Ziy Y, Zbar A, Bar-Shavit Y, Igov I. Low anterior resection syndrome (LARS): cause and effect and reconstructive considerations. Tech Coloproctol (2013 ); 17(2): 15162.

References 8. 9. Ramage L, Qiu S, Kontovounisios C et al. A systematic review of sacral nerve stimulation for low anterior resection syndrome. Colorectal Dis. (2015); 17(9): 762 -71. Troncoso P, Vigorita V, Garrido L et al. Preliminary results in the use of posterior tibial nerve stimulation in the treatment of Low Anterior Resection Syndrome. Colorectal Dis. (2015); 17(S 2): 44.