LARS: A review of therapeutic options and their efficacy

Abstract

Therapeutic intervention in sufferers of low anterior resection syndrome (LARS) involves attempts to ameliorate or, more ideally, cure the range of heterogenous symptoms that characterise this debilitating syndrome. Therapeutic interventions can broadly be summarised into: (1) dietary modification/supplementation and pharmacologic agents; (2) pelvic floor rehabilitation; (3) bowel irrigation techniques; (4) neuromodulation; and (5) diverting/defunctioning stoma formation. Measures to improve stool consistency, involving dietary modifications and pharmacological manipulation, are clinically intuitive, but lack a robust evidence-base. Pelvic floor rehabilitation can also be utilized, with demonstrable improvements in incontinence scores and/or quality of life in a systematic review and randomised controlled trial (RCT). However, the relative benefits of individual techniques are difficult to ascertain. Transanal irrigation achieves significant improvement in bowel function, LARS scores and quality of life in a systematic review, including one RCT. Similarly, percutaneous tibial nerve stimulation achieved significant improvements in LARS and symptom scores in one very small RCT comparing it with medical treatment alone. Finally, three systematic reviews reported improvements in symptom severity and quality of life scores following sacral neuromodulation, with success rates of 74% comparable to its use for “de novo” fecal incontinence. Stoma formation is a dramatic but effective solution in resistant cases. Currently, there is a lack of evidence guiding selection and determining efficacy of different interventions in LARS; addressing this remains a key research priority for clinicians given that the burden of bowel dysfunction following low anterior resection remains substantial for a large proportion of patients.