Symptoms Of Low Anterior Resection Syndrome Research Articles

Enhancing support for patients with low anterior resection syndrome: insights and educational resources from the LARSCAT project

PurposeTo address the educational gaps and support needs of patients with low anterior resection syndrome (LARS) following rectal cancer surgery. The LARSCAT project aimed to develop comprehensive resources to better inform patients and enhance their quality of life.MethodsA qualitative study was conducted between November 2022 and March 2023. Seven focus groups were formed, including six patients, two surgeons, and three nurses. Patients had undergone rectal cancer surgery with stoma reversal 2 to 12 years earlier, and all experienced major LARS. The focus groups, held in-person and online, explored the impact on daily life, social and sexual health, mood, rest, and relationships. Thematic analysis was performed to identify key issues and support strategies following the COREQ guidelines.ResultsParticipants reported insufficient information regarding potential dysfunctions after rectal cancer surgery, and difficulties finding reliable information online. The timing of receiving information varied according to individual coping mechanisms. LARS symptoms significantly impacted daily life, social activities, sexual health, and mood. Patients emphasised the need for more tailored information and supplementary written materials to read at their own pace. Consequently, three comprehensive documents were created and made available online.ConclusionThis study highlights a significant gap in patient education on the long-term effects of rectal cancer surgery. The resources developed by the LARSCAT project aim to provide essential support to patients and healthcare professionals. Future research should focus on integrating these resources into routine care and evaluating their impact on patient outcomes and quality of life.

Predictive factors of major low anterior resection syndrome after surgery for rectal tumors.

To describe the epidemiological and clinical data of impaired functional outcome secondary to anterior resection of the rectum and to identify the predictive factors of major low anterior resection syndrome (LARS) Methods: This retrospective study considered patients operated on for rectal tumors in surgical department in our hospital, between January 1st,2009 and December 31st, 2021. The primary outcome measure was the development of a major LARS immediately or after stoma closure. In order to identify independent predictors of major LARS, patients were divided into two groups: the "Major LARS" group and the "No Major LARS" group, and then we carried out a descriptive study, followed by an analytical study with logistic regression. We enrolled 42 patients operated for rectal tumor and had an anterior resection. Half of our patients developed LARS of which 14 developed major LARS. The median time to onset of LARS symptoms was 9 [2 -24] months. At the end of this study, 2 factors were retained: age (OR=2.48; CI95% [1.2- 5.10], p=0.012) and pT3T4 stage (OR=5.95; CI95% [1.07- 33.33], p=0.041) as independent predictive factors of a major LARS. Neoadjuvant therapy was also a risk factor for major LARS in our study with a statistically significant difference (p=0.025) between the two groups "Major LARS" and "No major LARS". LARS should be appropriately considered in the management of rectal cancer. Based on our results and data from the literature, age and mesorectal invasion were found to be independent predictors of major LARS.

SP5.8 - A survey of the actual incidence of Low Anterior Resection Syndrome in our patients and its effect on their quality of life

Abstract Aim Following rectal surgery, bowel function is often affected and leads to a constellations of symptoms called Low Anterior Resection syndrome (LARS). Whilst several risk factors have been identified from previous studies, the most important question is how these symptoms impact the quality of life (QOL) of our patients. The aim of our study was to gain an overview of LARS among our patients, identify risk factors, quantify how it affects their daily lives and recommend preventive and management options. Method We contacted all patients who had undergone anterior resections 01/10/2020-01/10/2023 via a telephone consultation carried out by a single doctor. Using the LARS questionnaire which has been internationally validated, we quantified the severity of LARS symptoms and effects on QOL in our patients. Results A total 36 patients were included in the study. We found 75% patients had no LARS, 25% had minor LARS; no patients had major LARS. 15 patients experienced tenesmus, 11 urgency, 11 accidental leakage of stool, 10 inability to control flatus and 8 frequency. Only 8.33% reported their symptoms affecting their QOL; in this group, accidental leakage of stool was the common symptom. We found no correlation between the incidence of LARS and post-operative time period. None of our LARS patients had had pre-op radiotherapy; only 10% patients who had post- op chemo developed LARS. Conclusion In our cohort of Anterior resection patients, most had no LARS; none had major LARS. Though some patients had some symptoms, QOL was affected in only 8.33%. Those who had symptoms were directed to our LARS clinic in Lower GI physiology for further management.

Pelvic Floor Physical Therapy Prehabilitation (PrePFPT) for the prevention of low anterior resection syndrome

Low Anterior Resection Syndrome (LARS) is a syndrome of lifestyle-limiting defecatory dysfunction diagnosed after the treatment of rectal cancer that can afflict 41 % of patients one year after surgery. Currently, the treatment of LARS is reactionary to the development of symptoms, and post-treatment pelvic floor physical therapy (PFPT) is one form of treatment utilized to mitigate the symptoms of LARS and improve patient quality of life. Prehabilitation is the physical and/or lifestyle preparation that improves recovery following surgery. For rectal cancer patients, general prehabilitation while undergoing neoadjuvant chemoradiotherapy is safe and feasible. However, no studies have examined whether pelvic floor physical therapy prehabilitation, which we term “PrePFPT,” could mitigate the development of LARS. In this commentary, we argue that PrePFPT should become an active area of research in rectal cancer to improve functional and quality of life outcomes. We highlight two proposed international trials, which will evaluate pre- and postoperative PFPT as a strategy to reduce the incidence of LARS. We conclude with our own proposed PrePFPT study design.

Nursing Recommendations for Symptom-Specific Self-care of Low Anterior Resection Syndrome: A Systematic, Scoping Review of the Literature.

Low anterior resection syndrome (LARS) is a result of removing part or most of the rectum as a treatment for rectal cancer that negatively impacts quality of life. There is a lack of standardized nursing symptom-specific self-care recommendations for patients suffering from LARS. The aim of this study was to map the existing research regarding nursing guidelines and symptom-specific recommendations for LARS self-care. A systematic scoping review using 4 comprehensive databases (ProQuest, EMBASE, PubMed, and Web of Science) was completed using the PRISMA Extension for Scoping Reviews guidelines. Applying specified search terms, relevant articles were extracted using criteria and entered into an Excel database. Three publications met the study inclusion criteria: 1 randomized controlled pilot study; 1 nonrandomized, retrospective pilot study; and 1 retrospective, comparative, cross-sectional study. No professional nursing guidelines were found, but 3 nurse-led management programs were reviewed. Publications provided self-care nursing recommendations for all LARS symptoms except for repeated painful stools/tenesmus, soiling, or discrimination disorders/flatulence. Combination of nursing self-care recommendations included dietary/lifestyle modifications, fiber supplements/bulking agents, antidiarrheal and laxative over-the-counter medications, and pelvic floor muscle exercises. When mapping the literature, there appears to be nurse-led management programs and recommendations for self-care for patients with LARS for almost all symptoms. Yet, there are no standardized recommendations. Professional nursing practice guidelines for all symptoms are lacking. Nursing recommendations for self-care of LARS exist and need to be expanded and standardized to include all symptoms. Further research regarding comprehensive nursing self-care recommendations and management is warranted.

Uncovering the Secret Clues: Using Stool Calprotectin to Improve Low Anterior Resection Syndrome after Surgery

Abstract Background: A majority of patients who undergo low rectal resection experience a frequent complication of low anterior resection syndrome (LARS). It is characterized by distressing bowel dysfunction such as urgency, frequency, and incontinence. Despite the high prevalence of LARS, its management remains challenging due to the lack of reliable diagnostic and monitoring tools. Objectives: This study investigates the relationship between stool calprotectin levels and LARS severity and evaluates the effectiveness of mesalamine treatment. Design: This prospective study involved 48 patients with low rectal cancer who had undergone resection with temporary ileostomy. The patients subsequently presented with LARS for over four weeks after ileostomy closure. Patient and Methods: LARS diagnosis was based on the LARS score, and stool calprotectin levels were measured at baseline and one month and six months post-ileostomy closure. Patients with elevated calprotectin levels received mesalamine treatment and dietary modifications. Statistical analyses were performed to determine the correlation between calprotectin levels and LARS scores using Pearson correlation analysis, linear regression analysis, paired t-test, and ANOVA. Main Outcome Measure: The predictive capacity for stool calprotectin for LARS was the main outcome variable. Sample Size: Forty-eight patients who underwent low rectal cancer resection were enrolled. Results: Among the study group, 28 were males and 20 were females. The mean age was 50 (9.998) years, 95% confidence interval CI = [17–78]) in both groups. The predictive value of calprotectin levels for LARS severity was high with β = 0.72, P-value < .001, and R² 0.55. The mean (SD) stool calprotectin level was 360 (6.282) mcg/g, which correlated with severe LARS symptoms (mean [SD] LARS score = 35 [2.449]). After six months, 60% of patients showed significant improvement (LARS scores <20), 30% had minor improvement (LARS scores 29–30), and 10% showed no improvement. Correlation analysis revealed a strong positive correlation between calprotectin levels and LARS scores (r = 0.75, P < .001). Conclusion: Stool calprotectin is demonstrated to be a promising biomarker for diagnosing and monitoring LARS. The findings highlight the association between LARS and high levels of stool calprotectin. However, the study had limitations of being a single-center study, comprising a small sample size, and not using a randomized clinical trial to evaluate the effectiveness of mesalamine. Conflicts of Interest: None.

Functional outcomes following anterior resection for colorectal cancer: a needs assessment and proposal of a nurse-led remote management algorithm.

With the rise of structured, remote follow-up of colorectal cancers, there is the potential risk of underdiagnosing and undermanaging low anterior resection syndrome (LARS). This cohort study aims to determine the rate of LARS and its patterns of care, with the aim of generating a risk-stratified management algorithm that can be employed for nurse-led follow-up. Patients who underwent elective anterior resection for the management of colorectal cancer between 1 January 2017 and 31 December 2021 were sent quality-of-life questionnaires (EORTC-QLQ-CR29 and LARS score) and surveyed for LARS symptoms and management utilized. Out of 70 patients who completed questionnaires, 71.4% had LARS and 42.9% had major LARS. The international Delphi consensus definition identified more patients (n = 50) with LARS than the LARS score (n = 41). Tumours located <8 cm from the anal verge, ULAR, and temporary stoma were predictive of major LARS on univariate analysis. However, only temporary stoma was predictive for LARS (OR 7.89 (1.15-53.95), P = 0.035) and majors LARS (8.14 (1.79-37.01), P = 0.007) on multivariate analysis. Forty-four percent of patients with LARS did not have input from any health professional for this condition. Consultation with specialist allied health and/or colorectal surgeons ranged from 4% to 22%. Our study highlights that with the current remote follow-up system focused on cancer outcomes a significant proportion of patients with LARS are overlooked, resulting in the underutilization of relevant health professionals and management options. We propose a nurse-led management algorithm to address this issue while still minimizing surgical outpatient load.

Effect of melatonin in patients with low anterior resection syndrome (MELLARS): a study protocol for a randomised, placebo-controlled, crossover trial

IntroductionAfter rectal cancer surgery, a majority of patients suffer from sequelae known as low anterior resection syndrome (LARS). It is a collection of symptoms consisting of flatus and/or stool incontinence,...

Organ preservation and total neoadjuvant therapy for rectal cancer: Investigating long course chemoradiation versus short course radiation therapy.

3617 Background: The efficacy of long course chemoradiation (LCRT) vs. short course radiation therapy (SCRT) relative to organ preservation (OP) in rectal cancer (RC) is unknown. We compared OP rates between SCRT and LCRT total neoadjuvant therapy (TNT) strategies. Methods: During the COVID-19 pandemic we established an institutional SCRT mandate with no exceptions. For comparison, we identified RC patients treated with LCRT immediately before and after the mandate period. After completion of TNT, patients were restaged by clinical exam, endoscopy, and MRI. A watch and wait (WW) approach was recommended for patients with a clinical complete response (cCR), defined by the MSK regression schema. Total mesorectal excision (TME) was recommended for non-cCR patients. OP was defined as remaining TME-free with no evidence of disease in the pelvis. We performed survival analysis for: local regrowth rate, OP, disease-free survival (DFS), and overall survival (OS). The validated low anterior resection syndrome (LARS) questionnaire (LARS-Q) was used to determine percentage of patients with major LARS. Results: We identified 332 consecutive patients with non-metastatic rectal adenocarcinoma treated with TNT (Jan. 2018-Jan. 2021). Patient and tumor characteristics were similar in the LCRT (n = 256) and SCRT (n = 76) cohorts. No significant differences in high-risk features were noted. Most patients had clinical stage III disease (82% in LCRT vs. 83% in SCRT). Induction chemotherapy followed by consolidative radiation was the most common treatment order (78% (LCRT) vs. 70% (SCRT)). The median interval from end of TNT to clinical restaging was 8 weeks (LCRT) and 9 weeks (SCRT). The cCR rate was 46% in both cohorts. Among patients with a cCR, the likelihood of WW management was similar (98% (LCRT) vs. 94% (SCRT)). From start of TNT, the median follow-up was 32 and 28 months respectively for LCRT and SCRT. The 2-year OS (95% vs. 92%), DFS (78% vs 70%), and distant recurrence (20% vs. 21%) rates were similar. Among all patients, the 2-year OP rate was 40% (95% CI 35-47%) for LCRT and 29% (95% CI 20-42%) with SCRT. In those patients managed by WW, the 2-year local regrowth rate was 20% (95% CI 12-27%) with LCRT vs. 36% (95% CI 16-52%) with SCRT. Percentage of patients reporting major LARS symptoms were similar among WW patients post TNT: baseline (23% (LCRT) vs. 18% (SCRT)), 6-months (41% (LCRT) vs. 42% (SCRT)), and 12-months (25% (LCRT) vs. 15% (SCRT)). Conclusions: In this nonrandomized comparison, while cCR rates were similar, we observed a numerically higher local regrowth rate with SCRT-TNT than with LCRT-TNT. Rate of major-LARS symptoms were similar with LCRT-TNT than with SCRT-TNT. The ongoing ACO/ARO/AIO-18.1 trial, hypothesizing that LCRT-TNT will increase OP rates relative to SCRT-TNT, will definitively address this question.

Gut microbiome associated with low anterior resection syndrome after rectal cancer surgery

This study aimed to assess the likely association of gut microbiome with low anterior resection syndrome (LARS) symptoms. Postoperative stool samples from patients with minor or major LARS after sphincter-preserving surgery (SPS) for rectal cancer were collected and analyzed using 16S ribosomal RNA sequencing method. The symptom patterns of LARS were classified into two groups (PC1LARS, PC2LARS) using principal component analysis. The dichotomized sum of questionnaire items (sub1LARS, sub2LARS) was used to group patients according to the main symptoms. According to microbial diversity, enterotype, and taxa, PC1LARS and sub1LARS were associated with frequency-dominant LARS symptoms and patients, while PC2LARS and sub2LARS were grouped as incontinence-dominant LARS symptoms and patients. Butyricicoccus levels decreased while overall LARS scores increased. The α-diversity richness index Chao1 showed a significantly negative correlation in sub1LARS and a positive correlation in sub2LARS. In sub1LARS, the severe group showed a lower Prevotellaceae enterotype and higher Bacteroidaceae enterotype than the mild group. Subdoligranulum and Flavonifractor showed a negative and a positive correlation with PC1LARS, respectively, while showing a negative relationship with PC2LARS. Lactobacillus and Bifidobacterium were negatively correlated to PC1LARS. Frequency-dominant LARS had decreased diversity of gut microbiome and showed lower levels of lactic acid-producing bacteria.

Low anterior resection syndrome.

Low anterior resection syndrome (LARS) is the distressful defecatory functional problem after sphincter-saving surgery for rectal cancer. Although the symptoms of fecal urgency, frequency, and incontinence may develop in most of the patients after surgery, there is no definitive treatments for LARS. Multifactorial etiologies and various risk factors have been identified, but the reduction of storage capacity in the rectum is one of the main reasons for LARS. Anal sphincter muscle or nerve damage during rectoanal resection or anastomosis construction, and intersphincteric resection for low-lying tumors or hand-sewing anastomosis, are the absolute risk factors for LARS. Preoperative radiotherapy, postoperative complications, such as anastomosis leakage, or longer duration of stoma, are also risk factors. The severity of LARS can be confirmed using the LARS score questionnaire. The questionnaire has been translated to numerous language versions including Korean and have been validated. Diverse empirical treatments, such as loperamide, fiber, probiotics, or enema, have been tried, but the safety and efficacy have not been verified yet. The 5-Hydroxytryptamine (5-HT) receptor antagonist, ramosetron, used for diarrhea-dominant irritable bowel syndrome, is one potential drug for relieving the symptoms of major LARS. A randomized-controlled trial suggested the use of ramosetron could be safe and efficacious for patients who have major LARS after sphincter-saving rectal cancer surgery. Novel techniques or drugs for relieving the symptoms of LARS should be developed more and further studies are necessary.

Cross-sectional study of low anterior resection syndrome in patients who have survived more than 5 years after sphincter-preserving surgery for rectal cancer

Objective: In this study, we aimed to investigate the prevalence of low anterior resection syndrome (LARS) in patients who had survived for more than 5 years after sphincter-preserving surgery for rectal cancer and to analyze its relationship with postoperative time. Methods: This was a single-center, retrospective, cross-sectional study. The study cohort comprised patients who had survived for at least 5 years (60 months) after undergoing sphincter- preserving radical resection of pathologically diagnosed rectal adenocarcinoma within 15 cm of the anal verge in the Department of Gastrointestinal Surgery, Peking University People's Hospital from January 2005 to May 2016. Patients who had undergone local resection, had permanent stomas, recurrent intestinal infection, local recurrence, history of previous anorectal surgery, or long- term preoperative defecation disorders were excluded. A LARS questionnaire was administered by telephone interview, points being allocated for incontinence for flatus (0-7 points), incontinence for liquid stools (0-3 points), frequency of bowel movements (0-5 points), clustering of stools (0-11 points), and urgency (0-16 points). The patients were allocated to three groups based on these scores: no LARS (0-20 points), minor LARS (21-29 points), and major LARS (30-42 points). The prevalence of LARS and major LARS in patients who had survived more than 5 years after surgery, correlation between postoperative time and LARS score, and whether postoperative time was a risk factor for major LARS and LARS symptoms were analyzed. Results: The median follow-up time of the 160 patients who completed the telephone interview was 97 (60-193) months; 81 (50.6%) of them had LARS, comprising 34 (21.3%) with minor LARS and 47 (29.4%) with major LARS. Spearman correlation analysis showed no significant correlation between LARS score and postoperative time (correlation coefficient α=-0.016, P=0.832). Multivariate analysis identified anastomotic height (RR=0.850, P=0.022) and radiotherapy (RR=5.760, P<0.001) as independent risk factors for major LARS; whereas the postoperative time was not a significant risk factor (RR=1.003, P=0.598). The postoperative time was also not associated with LARS score rank and frequency of bowel movements, clustering, or urgency (P>0.05). However, the rates of incontinence for flatus (3/31, P=0.003) and incontinence for liquid stools (8/31, P=0.005) were lower in patients who had survived more than 10 years after surgery. Conclusions: Patients with rectal cancer who have survived more than 5 years after sphincter-preserving surgery still have a high prevalence of LARS. We found no evidence of major LARS symptoms resolving over time.

Functional outcomes after transanal total mesorectal excision (TaTME): a random forest analysis to predict patients' outcomes.

Anorectal, sexual, and urinary dysfunction are common issues after rectal cancer surgery, although seldom explored. The primary aim of this study was to investigate postoperative anorectal functional results. Patients with mid/low-rectal cancer treated with transanal TME (TaTME) with primary anastomosis with/without diverting stoma between 2015 and 2020 were reviewed and selected if they had a minimum follow-up of 6months (from the primary procedure or stoma reversal). Patients were interviewed using validated questionnaires and the primary outcome was bowel function based on Low Anterior Resection Syndrome (LARS) scores. Statistical analyses were performed to identify clinical/operative variables correlated with worse outcomes. A random forest (RF) algorithm was computed to classify patients at a greater risk of minor/major LARS. Ninety-seven patients were selected out of 154 TaTME performed. Overall, 88.7% of the patients had a protective stoma and 25.8% reported major LARS at mean follow-up of 19.0months. Statistical analyses documented that age, operative time, and interval to stoma reversal correlated with LARS outcomes. The RF analysis disclosed worse LARS symptoms in patients with longer operative time (> 295min) and stoma reversal interval (> 5.6months). If the interval ranged between 3 and 5.6months, older patients (> 65years) reported worse outcomes. Finally, no statistical difference was documented when comparing the rate of minor/major LARS in the first 27 cases versus others. One-quarter of the patients developed major LARS after TaTME. An algorithm based on clinical/operative variables, such as age, operative time, and time to stoma reversal, was developed to identify categories at risk for LARS symptoms.

Management of Low Anterior Resection Syndrome (LARS) Following Resection for Rectal Cancer.

A total of 60-80% of patients undergoing rectal resection (mostly as a treatment for rectal cancer) suffer from a variety of partly severe functional problems despite preservation of the anal sphincter. These patients are summarized under the term low anterior resection syndrome (LARS). Preoperative radiotherapy, vascular dissection and surgical excision of the low rectum and mesorectum lead, alone or all together, to a significant impairment of colonic and (neo-) rectal motility. This results in a variety of symptoms (multiple defecation episodes, recurrent episodes of urge, clustering, incontinence, etc.) which are associated with severe impairment of quality of life (QOL). This narrative review summarizes the present state of knowledge regarding the pathophysiology of LARS as well as the evidence for the available treatment options to control the symptoms resulting from this condition. A review of the literature (Medline, Pubmed) reveals a variety of treatment options available to control symptoms of LARS. Medical therapy, with or without dietary modification, shows only a modest effect. Pelvic floor rehabilitation consisting of muscle exercise techniques as well as biofeedback training has been associated with improvement in LARS scores and incontinence, albeit with limited scientific evidence. Transanal irrigation (TAI) has gained interest as a treatment modality for patients with LARS due to an increasing number of promising data from recently published studies. Despite this promising observation, open questions about still-unclear issues of TAI remain under debate. Neuromodulation has been applied in LARS only in a few studies with small numbers of patients and partly conflicting results. LARS is a frequent problem after sphincter-preserving rectal surgery and leads to a marked impairment of QOL. Due to the large number of patients suffering from this condition, mandatory identification, as well as treatment of affected patients, must be considered during surgical as well as oncological follow-up. The use of a standardized treatment algorithm will lead to sufficient control of symptoms and a high probability of a marked improvement in QOL.

Low Anterior Resection Syndrome: Pathophysiology, Risk Factors, and Current Management

Low anterior resection syndrome (LARS) is a condition of anorectal dysfunction that occurs frequently following anal sphincter-preserving surgery for rectal cancer and can reduce the quality of life. In this review, we summarize the main symptoms and pathophysiology of this syndrome and discuss the treatment approaches. Early evaluation and initiation of appropriate treatment postoperatively are crucial. The most frequently used tool to evaluate the severity of LARS is the LARS score, and an anorectal manometer is used for objective evaluation. LARS is believed to be caused by multiple factors, and some of its causes include direct structural damage to the anal sphincter, damage to the innervation, loss of rectoanal inhibitory reflex, and decreased rectal volume and compliance. Diet modifications, medications, pelvic floor muscle training and biofeedback are the primary treatments, and rectal irrigation can be added as a secondary treatment. If LARS symptoms persist even after 1 to 2 years and significantly reduce the quality of life, antegrade irrigation, sacral nerve stimulation or definitive stoma may be considered. High-quality evidence-based studies on LARS treatment are lacking, and randomized controlled trials aimed at developing severity-based treatment algorithms are needed.

Prevalence and Risk Factors of Low Anterior Resection Syndrome in Epithelial Ovarian Cancer Surgery.

BackgroundIn this study, we aimed to determine the prevalence and risk factors of low anterior resection syndrome (LARS) in epithelial ovarian cancer (EOC) surgery.MethodologyA descriptive cross-sectional study was conducted at the Gynecologic Oncology Section of the Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore, Pakistan. Using non-probability consecutive sampling technique, all patients who underwent cytoreductive surgery involving low anterior resection for EOC between January 2016 and January 2021 were included. Patients were assessed for LARS symptoms using the LARS score, along with its risk factors. Descriptive statistics, that is, continuous variables were expressed as the median and interquartile range, while categorical variables were expressed as frequencies and percentages. The LARS score was categorized according to a two-tier model with “no or minor LARS” and “major LARS.” Univariate analyses were performed by the chi-square tests providing odds ratios and 95% confidence intervals to identify risk factors for major LARS.ResultsOverall, 95% of cases had LARS scores that fell in “no or minor LARS,” while only 5% of cases had “major LARS.” Univariate analyses relieved no statistically significant association between the occurrence of major LARS and any of the risk factors.ConclusionsThe prevalence of LARS was 5%, and no risk factors were associated with major LARS in our study population.

Bowel Dysfunction after Low Anterior Resection for Colorectal Cancer: A Frequent Late Effect of Surgery Infrequently Treated

The development of major low anterior resection syndrome (LARS) after low anterior resection is severely detrimental to quality of life, yet awareness of it by clinicians and patients and the frequency of treatment of LARS is unclear. Patients who underwent low anterior resection for sigmoid or rectal cancer at a tertiary center between 2007 and 2017 (n = 798) were surveyed in 2019 to assess LARS symptoms and report medications or treatment received for LARS. LARS scores were calculated (score range 0-42) and normalized to published data on LARS prevalence in the general population in Europe, stratified by age (<50 or ≥50) and sex. Of the 594 patients (74%) who returned the survey, 255 (43%) were identified as having major LARS (LARS score ≥30). This prevalence was significantly higher than published normative data from Denmark and Amsterdam when stratified by age greater than or less than 50 and sex. Patients with major LARS infrequently reported current use of first-line therapies (antidiarrheal medications 32%, fiber supplements 16%, and both 13%). Only 3% reported receiving second-line therapy of transanal irrigations and/or pelvic floor rehabilitation, and only 1% had undergone third-line therapy of sacral nerve stimulator implantation. Major LARS is common yet seemingly underrecognized by clinicians because less than half of patients are on first-line therapy and practically none are on second- and third-line therapies. Long-term follow-up of patients after low anterior resection, improved preoperative and postoperative education, and continued symptom assessment is necessary to improve treatment of major LARS.

Low Anterior Resection Syndrome: Predisposing Factors and Treatment

Bowel dysfunction after restorative proctectomy, commonly referred to as Low Anterior Resection Syndrome (LARS), is a common long-term sequela of rectal cancer treatment that has a significant impact on a patient's quality of life. While the pathophysiology of LARS is poorly understood, its underlying cause that it is likely multifactorial, and there are numerous patient, tumor, and treatment-level factors associated with its development. In accordance with these risk factors, several strategies have been proposed to mitigate LARS postoperatively, including modifications in the technical approach to restorative proctectomy and advancements in the multidisciplinary care of rectal cancer. Furthermore, a clinically applicable pre-operative nomogram has been developed to estimate the risk of LARS postoperatively, which may help in counseling patients before surgery. The management of LARS begins with identifying those who manifest symptoms, as postoperative bowel dysfunction often goes unrecognized. This goal is best achieved with the systematic screening of patients using validated Patient-Reported Outcome Measures. Once a patient with LARS is identified, conservative management strategies should be implemented. When available, a dedicated LARS nurse and/or multidisciplinary team can be an invaluable resource in engaging patients and educating them regarding LARS self-care. If symptoms of LARS persist or worsen over time despite conservative measures, second-line interventions such as transanal irrigation or pelvic floor rehabilitation, can be initiated. A small proportion of patients will ultimately require an intervention such as sacral neuromodulation or permanent colostomy for refractory, major LARS symptoms.

Using transanal irrigation in the management of low anterior resection syndrome: a service audit.

Low anterior resection syndrome (LARS) is a collection of symptoms that can occur as a result of a low anterior resection for bowel cancer. Transanal irrigation (TAI) can be used to manage these symptoms. This article describes a retrospective audit of 15 patients who were using TAI to manage symptoms of LARS. The aim of the audit was to ascertain whether the use of TAI improved outcomes for these patients. The data suggest that TAI has reduced both the frequency of bowel movements and episodes of faecal incontinence. Those patients using higher volumes of water seem to have experienced more benefit than those patients using lower volumes of water. These findings are consistent with current literature around TAI for LARS and suggest research into optimum volume of water would be beneficial.

Analysis of presacral tissue structure in LARS and the prevention of LARS by reconstruction of presacral mesorectum with pedicled greater omentum flap graft.

The greater omentum has played a unique biological role in regenerative surgery. The aim of our study was to alter the anterior sacral structure by filling the anterior sacral space with the greater omentum and evaluate its effect on the low anterior resection syndrome (LARS) after total mesorectal excision (TME) surgery for low rectal cancer. We retrospectively collected clinical data of patients with primary low rectal cancer who underwent TME and ileostomy closure in our hospital from March 2018 to March 2020. Spearman correlation analysis was conducted to analyze the correlation between postoperative mesorectal fascia (MRF) thickness and LARS score. Subsequently, we prospectively used a tipped greater omental flap graft to reconstruct the anterior rectal sacral structures (MRF reconstruction) in 17 patients and compared LARS scores and rectal compliance (RC) at week 12 after closure of the ileostomy in both groups. There were 47 patients with No-MRF reconstruction (31 males, mean age 60.68 ± 9.21years) and 17 with MRF reconstruction (10 males, mean age 49.82 ± 14.74years). Correlation analysis indicated that MRF thickness and RC were negatively correlated with LARS severity (p < 0.05). The LARS score of patients with MRF reconstruction at 12weeks was significantly better than that of those with No-MRF reconstruction (32.97 ± 2.65 vs. 26.94 ± 1.52, p = 0.001), and the RC of MRF reconstruction were lower (2.80 ± 0.55 vs. 3.67 ± 0.38, p = 0.001). In addition, MRF reconstruction and No-MRF reconstruction have the similar incidence of postoperative complications (p = 0.156). No hemorrhage or necrosis of the greater omentum flap was observed in any of the patients. Greater omentum flap transplantation can significantly improve the symptoms of LARS at 12weeks after ileostomy closure and we expect it to become a new surgical procedure for the treatment of low rectal cancer.