"Prophylactic" transanal irrigation (TAI) to prevent symptoms of low anterior resection syndrome (LARS) after rectal resection: results at 12-month follow-up of a controlled randomized multicenter trial

The patient perspective on transanal irrigation treatment for low anterior resection syndrome after rectal cancer surgery - a qualitative and quantitative study

PURPOSE

The aim of the study was to explore long-term experiences of transanal irrigation (TAI) in patients with major low anterior resection syndrome (LARS).

METHODS

The study included a qualitative and quantitative analysis of patients who developed major LARS after rectal cancer surgery between 2016 and 2019 and have undergone treatment with TAI. The patients received questionnaires. Mean scores were calculated with time-to-deterioration. Individual semi-structured interviews were performed and analyzed, according to Graneheim and Lundman with patients who performed TAI regularly for more than one year.

RESULTS

In total 28 out of 39 patients responded to the questionnaires and 16 patients participated in the interviews. At mean 6-years follow-up, a 9.4 points difference in mean LARS score was obtained, (21.2 vs. 30.7) indicating less LARS symptoms in favor of the TAI treatment. Patients in the TAI group used less loperamide compared to the control group (36% vs. 79%). The use of bulky agents was similar. The interview text rendered into three main categories: regaining control in everyday life, need for structure and planning and becoming familiar with the procedure.

CONCLUSIONS

Treatment with TAI showed the potential to improve the quality of life of patients with major LARS. The improvements in their general well-being were valued over adjustments and time spent on TAI.

IMPLICATIONS FOR CANCER SURVIVORS

Bowel dysfunction remains after 6-years with lower LARS scores favoring the TAI treatment. In the absence of a definitive treatment, survivors of rectal cancer coping with LARS have shown appreciation of the TAI treatment.

Systematic review of the management options available for low anterior resection syndrome (LARS)

BACKGROUND

Rectal cancer incidence is increasing. Low anterior resection is currently the gold standard surgical management. Postoperatively, patients may present with symptoms indicative of low anterior resection syndrome (LARS). LARS can be debilitating and is difficult to treat with low efficacy of treatment modalities. This systematic review aims to highlight the current evidence regarding LARS management.

METHODS

Systematic review of Medline, Cochrane and Embase used the following terms: "low anterior resection syndrome" AND "management", "low anterior resection syndrome" AND "treatment". Articles that focus solely of low anterior resection syndrome management in patients > 18 years were included. Bias risk was assessed via the Newcastle-Ottawa quality assessment scale for cohort studies and the JBI critical appraisal tool for randomized controlled trials. Due to heterogeneity of methodology, no statistical analysis was performed.

RESULTS

Thirty-eight articles with a total of 1914 patients were included in this review. Ninety-five per cent underwent surgery for malignancy. Treatment options included pharmacology, pelvic floor rehabilitation (PFR), transanal irrigation (TAI), sacral nerve modulation (SNM), percutaneous tibial nerve stimulation (PTNS) and "treatment programs" starting from the least invasive procedures escalating to more invasive treatments upon failure. The most common published medical therapies report Ramoestron use; however, studies are low impact. PFR showed significant improvement in LARS mostly in those with symptoms of faecal incontinence. However, long-term outcomes are inconsistent. TAI supplies pseudo-continence with its greatest benefit reported in those with incomplete evacuation. TAI has significant short-term effects on LARS but little long-term effect. TAI is also associated with a significant drop-out rate. SNM's hypothesised benefit is extrapolated from non-LARS associated FI. Results show improvements in FI but a high rate of explantation. PTNS evidence suggests little if any significant LARS improvement. A single "stepwise programme" study reported that 77 per cent did not progress further than diet and medication. Little evidence suggests benefit regarding diet or acupuncture.

DISCUSSION

There is no consensus as to the optimal treatment strategy for LARS. LARS is multifactorial and requires sensitive discussion between patient and surgeon to address the most prominent symptom. It requires physical and psychological input. No single treatment option provides superior results. Treatment is based on symptom control and patient acceptance.

Diagnosis and Treatment of Low Anterior Resection Syndrome

Defecation disorders following rectal resection have long been overlooked as an inevitable surgical complication due to the lack of established diagnostic criteria or definitions. However, these disorders have been recently termed low anterior resection syndrome (LARS), which is a defecation disorder that occurs following rectal resection and impairs the patient's quality of life (QOL). The LARS score developed by Emmertsen et al., which is a patient-reported outcome measure to evaluate the severity of bowel dysfunction following rectal surgery by scoring the major symptoms of LARS, facilitates the diagnosis and assessment of LARS and enables international comparison and validation through the use of validated scores generated according to the international standards. Based on comparisons with other evaluation instruments, the use of the LARS score is strongly recommended internationally for LARS screening in patients following rectal resection. Recent findings have indicated that multiple pathophysiological changes, including reservoir function and evacuation of the neorectum, anal sphincter function, negative impact of a diverting stoma, autonomic denervation, and radiotherapy, are involved in the etiology of LARS. Due to the lack of established treatments and prevention of LARS, a suggested treatment chart for patients with LARS was presented in the Management Guidelines for Low Anterior Resection Syndrome (MANUEL) project. Future surgical treatment should focus not only on the radical cure of cancer and safety of treatment but also on the maintenance and improvement of QOL, with particular attention to the preservation of function. Particularly for rectal cancer, surgeons must formulate treatment plans that consider the prevention and treatment of LARS.

Consensus-driven protocol for transanal irrigation in patients with low anterior resection syndrome and functional constipation

BACKGROUND

This study aims to establish a consensus-based standard protocol for transanal irrigation (TAI) in patients with low anterior resection syndrome (LARS) and functional constipation.

METHODS

The Delphi method was utilized to reach a consensus among clinicians and nurses expert in the field of colorectal surgery and gastroenterology. To address various uncertainties concerning technical aspects, difficulties, and prescription of TAI, two questionnaires were developed and analyzed in two rounds. A binary approach was employed, setting a consensus threshold of 75% agreement.

RESULTS

In the first round, nurses achieved consensus on all statements, while clinicians required a second round to reach consensus, particularly regarding prescription and technical aspects. Clinicians reached consensus on prescribing TAI as a second-line treatment for LARS and functional constipation, following the failure of conservative measures such as dietary and lifestyle interventions. Timing considerations for patients with LARS encompass avoiding TAI within 1 month of stoma closure and waiting a minimum of 3 months. For functional constipation, TAI is recommended for slow transit constipation, emphasizing its preference over surgical options. Consensus was also reached on the choice of catheter for patients with LARS, training requirements for patients and caregivers, preparation of the patient's intestine before TAI, and recommended irrigations.

CONCLUSIONS

This consensus study successfully developed a standardized TAI protocol for LARS and functional constipation. It provides comprehensive guidelines for prescription and technical aspects, addressing the challenges encountered by healthcare professionals. The protocol aims to enhance patient care, improve treatment outcomes, and contribute to the advancement of TAI.

Is transanal irrigation the best treatment possibility for low anterior resection syndrome? A multicenter, randomized clinical trial: study protocol

Background

Up to 50% of patients who undergo rectal resection suffer from various and partly severe functional problems, despite the preservation of the anal sphincter. These complaints are defined as low anterior resection syndrome (LARS). So far, there are no randomized clinical trials regarding the most effective treatment for LARS. Our aim is to evaluate whether transanal irrigation improves bowel function and quality of life in patients following low anterior resection compared to best supportive care.

Methods

Patients who have undergone low anterior resection will be approached for this study. On patient's visit, complaints regarding the defecation as well as any deterioration in their overall quality of life will be assessed using questionnaires such as the Low Anterior Resection Syndromes score, Wexner score, European Organization for Research and Treatment of Cancer (EORTC) Quality of Life (QOL) CR-29, and Measure Yourself Medical Outcome Profile tool. Few additional target questions will be also asked, such as "Would you recommend the treatment to anybody; did you expect the improvement following the treatment; etc." Questionnaires and scales will be filled on follow-up visits every 3 months for 1 year.

Discussion

This multicenter, randomized controlled trial will lead to a better understanding of LARS treatment. Moreover, it will be a hypothesis-generating study and will inform areas needing future prospective studies.

Clinical Trial Registration

ClinicalTrials.gov, identifier (NCT05920681).

Preventative strategies for low anterior resection syndrome

BACKGROUND

A common and debilitating complication of low anterior resection for rectal cancer is low anterior resection syndrome (LARS). As a multifactorial entity, LARS is poorly understood and challenging to treat. Despite this, prevention strategies are commonly overlooked. Our aim was to review the pathophysiology of LARS and explore current evidence on the efficacy and feasibility of prophylactic techniques.

METHODS

A literature review was performed between [1st January 2000 to 1st October 2023] for studies which investigated preventative interventions for LARS. Mechanisms by which LARS develop are described, followed by a review of prophylactic strategies to prevent LARS. Medline, Cochrane, and PubMed databases were searched, 189 articles screened, 8 duplicates removed and 18 studies reviewed.

RESULTS

Colonic dysmotility, anal sphincter dysfunction and neorectal dysfunction all contribute to the development of LARS, with the complex mechanism of defecation interrupted by surgery. Transanal irrigation (TAI) and pelvic floor rehabilitation (PFR) have shown benefits in preventing LARS, but may be limited by patient compliance. Intraoperative nerve monitoring (IONM) and robotic-assisted surgery have shown some promise in surgically preventing LARS. Nerve stimulation and other novel strategies currently used in treatment of LARS have yet to be investigated in their roles prophylactically.

CONCLUSIONS

To date, there is a limited evidence base for all preventative strategies including IONM, RAS, PFP and TAI. These strategies are limited by either access (IONM, RAS and PFP) or acceptability (PFP and TAI), which are both key to the success of any intervention. The results of ongoing trials will serve to assess acceptability, while technological advancement may improve access to some of the aforementioned strategies.

Clinical Management of Low Anterior Resection Syndrome: Review of the Current Diagnosis and Treatment

BACKGROUND

Low anterior resection syndrome (LARS) is a series of bowel dysfunction symptoms, including altered bowel frequency, irregular bowel rhythms, fecal incontinence, and constipation. LARS occurs in 80% of patients undergoing sphincter-preserving surgery, affecting patients' quality of life along with social avoidance. Different measurements and treatments have been raised to deal with LARS, but no systematic standard has been developed.

OBJECTIVE AND METHODS

To promote the standardization of clinical trials and clinical management of LARS, this review summarizes the latest findings up until 2023 regarding the diagnostic criteria, assessment protocols, and treatment modalities for postoperative LARS in rectal cancer.

RESULTS

The diagnostic criteria for LARS need to be updated to the definition proposed by the LARS International Collaborative Group, replacing the current application of the LARS score. In both clinical trials and clinical treatment, the severity of LARS should be assessed using at least one symptom assessment questionnaire, the LARS score or MSKCC BFI, and at least one scale related to quality of life. Anorectal manometry, fecoflowmetry, endoscopic ultrasonography, and pelvic floor muscle strength testing are recommended to be adopted only in clinical trials. After analysis of the latest literature on LARS treatment, a stepwise classification model is established for the standardized clinical management of LARS. Patients with minor LARS can start with first-line treatment, including management of self-behavior with an emphasis on diet modification and medication. Lamosetron, colesevelam hydrochloride, and loperamide are common antidiarrheal agents. Second-line management indicates multi-mode pelvic floor rehabilitation and transanal irrigation. Patients with major LARS should select single or several treatments in second-line management. Refractory LARS can choose antegrade enema, neuromodulation, or colostomy.

CONCLUSIONS

In clinical trials of LARS treatment between 2020 and 2022, the eligibility criteria and evaluation system have been variable. Therefore, it is urgent to create a standard for the diagnosis, assessment, and treatment of LARS. Failure to set placebos and differentiate subgroups are limitations of many current LARS studies. Randomized controlled trials comparing diverse therapies and long-term outcomes are absent, as well. Moreover, a new scale needs to be developed to incorporate the patient's perspective and facilitate outpatient follow-up. Though the establishment of a stepwise classification model for LARS treatment here is indispensable, the refinement of the guidelines may be improved by more standardized studies.

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

INTRODUCTION

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).

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Transanale Irrigation als Geheimtipp

Funktionelle Störungen nach Rektumresektion, die unter der Definition „low anterior resection syndrome“ (LARS) zusammengefasst werden, beeinträchtigen bei vielen operierten Patienten zum Teil massiv die Lebensqualität. Nachdem die transanale Irrigation (TAI) bei ähnlicher Problematik anderer Genese als erfolgreiche Option zum Einsatz gekommen ist, wurde sie auch bei Patienten mit bereits länger bestehendem LARS angewandt. Als Folge der deutlichen Verbesserung der Rektumfunktion durch diese Therapie wurde auch eine prophylaktische Anwendung unmittelbar nach Verschluss der protektiven Ileostomie diskutiert und im Rahmen einer kontrollierten, randomisierten Studie untersucht. Dabei zeigte sich eine signifikante Reduktion der Anzahl der Defäkationsepisoden (bei Tag und Nacht), des LARS-Scores sowie des Wexner-Inkontinenz-Scores in den ersten 3 Monaten. Obwohl der positive Effekt der TAI eine Empfehlung als Therapieoption bei LARS nahelegt, verbleiben noch offene Fragen (notwendiges Irrigationsvolumen, Intervalle zwischen den Irrigationen, Behandlungsdauer) als Basis für zukünftige Untersuchungen.

A Randomized Controlled Clinical Trial of Transanal Irrigation Versus Conservative Treatment in Patients With Low Anterior Resection Syndrome After Rectal Cancer Surgery

OBJECTIVE

The aim of the study was to evaluate transanal irrigation (TAI) as a treatment for low anterior resection syndrome (LARS).

BACKGROUND

LARS is a bowel disorder that is common after sphincter preserving rectal cancer surgery. Despite symptomatic medical treatment of LARS many patients still experience bowel symptoms that may have a negative impact on quality of life (QoL). TAI is a treatment strategy, of which the clinical experience is promising but scientific evidence is limited.

MATERIALS AND METHODS

A multicenter randomized trial comparing TAI (intervention) with conservative treatment (control) was performed. Inclusion criteria were major LARS, age above 18 years, low anterior resection with anastomosis and a defunctioning stoma as primary surgery, >6 months since stoma reversal, anastomosis without signs of leakage or stricture, and no signs of recurrence at 1-year follow-up. The primary endpoint was differences in bowel function at 12-month follow-up measured by LARS score, Cleveland Clinic Florida Fecal Incontinence Score, and 4 study-specific questions. The secondary outcome was QoL.

RESULTS

A total of 45 patients were included, 22 in the TAI group and 23 in the control group. Follow-up was available for 16 and 22 patients, respectively. At 12 months, patients in the TAI group reported significantly lower LARS scores (22.9 vs 32.4; P =0.002) and Cleveland Clinic Florida Fecal Incontinence Score (6.4 vs 9.2; P =0.050). In addition, patients in the TAI group also scored significantly higher QoL [8 of 16 European Organisation for the Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) QoL aspects] compared with the control group.

CONCLUSIONS

The results confirm our clinical experience that TAI reduces symptoms included in LARS and improves QoL.

A study on the clinical application of greater omental pedicle flap transplantation to correct anterior resection syndrome in patients with low rectal cancer

INTRODUCTION

Low anterior resection syndrome (LARS) is the most common complication after total mesorectal excision (TME) in patients with low rectal cancer and has been a challenge in colorectal surgery that severely impacts the quality of life of patients. This study aimed to introduce a revised surgical procedure which could effectively maintain rectal compliance and significantly improve LARS after the operation.

METHODS

We performed mesorectal reconstruction after routine Dixon TME using greater omental pedicle flap transplantation in 11 patients with low rectal cancer (5 cases of preoperative neoadjuvant chemoradiotherapy, 5 cases of preoperative neoadjuvant chemotherapy, and 1 case of postoperative adjuvant chemotherapy), thereby simulating the initial anatomical structure of the mesorectum and significantly reducing the postoperative anterior resection syndrome. The lars precision syndrome assessment scale (LARSS) was used to access the LARS.

RESULTS

At 12 weeks after the 11 patients recovered from the anal defecation function, the average score on the LARS questionnaire was 25.5 ± 1.5 (minor). The average time at which anal function began to recover was 6.2 ± 2.6 weeks after surgery. The recovery was rapid, as the rectal and anal function of all patients generally returned to normal levels within 12 weeks, and the quality of life was close to that before surgery.

CONCLUSION

Greater omental flap transplantation can significantly improve LARS after Dixon TME in patients with low rectal cancer.

Low anterior resection syndrome: can it be prevented?

Surgery remains the cardinal treatment in colorectal cancers but changes in bowel habits after rectal cancer surgery are common and disabling conditions that affect patients' quality of life. Low anterior resection syndrome is a disorder of bowel function after rectal resection resulting in a lowering of the QoL and recently has been defined by an international working group not only by specified symptoms but also by their consequences. This review aims to explore an extensive bibliographic research on preventive strategies for LARS. All "modifiable variables," quantified by the LARS Score, such as type of anastomosis, neoadjuvant therapy, surgical strategy, and diverting stoma, were evaluated, while "non-modifiable variables" such as age, sex, BMI, ASA, preoperative TMN, tumor height, and type of mesorectal excision were excluded from the comparative analysis. The role of defunctioning stoma, local excision, neoadjuvant radiotherapy, and non operative management seems to significantly affect risk of LARS, while type of anastomosis and surgical TME approach do not impact on LARS incidence or gravity in the long term period. Although it is established that some variables are associated with a greater onset of LARS, in clinical practice, technical difficulties and oncological limits often make difficult the application of some prevention plans. Transtomal irrigations, intraoperative neuromonitoring, pelvic floor rehabilitation before stoma closure, and early transanal irrigation represent new arguments of study in preventive strategies which could, if not eliminate the symptoms, at least mitigate them.

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 quality of life. While the pathophysiology of LARS is poorly understood, its underlying cause 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.

Transanal Irrigation for Neurogenic Bowel Disease, Low Anterior Resection Syndrome, Faecal Incontinence and Chronic Constipation: A Systematic Review

Transanal irrigation (TAI) has received increasing attention as a treatment option in patients with bowel dysfunction. This systematic review was conducted according to the PRISMA guidelines and evaluates the effect of TAI in neurogenic bowel dysfunction (NBD), low anterior resection syndrome (LARS), faecal incontinence (FI) and chronic constipation (CC). The primary outcome was the effect of TAI on bowel function. Secondary outcomes included details on TAI, quality of life (QoL), the discontinuation rate, adverse events, predictive factors for a successful outcome, and health economics. A systematic search for articles reporting original data on the effect of TAI on bowel function was performed, and 27 eligible studies including 1435 individuals were included. Three randomised controlled trials, one non-randomised trial, and 23 observational studies were included; 70% of the studies were assessed to be of excellent or good methodological quality. Results showed an improvement in bowel function among patients with NBD, LARS, FI, and CC with some studies showing improvement in QoL. However, discontinuation rates were high. Side effects were common, but equally prevalent among comparative treatments. No consistent predictive factors for a successful outcome were identified. Results from this review show that TAI improves bowel function and potentially QoL; however, evidence remains limited.

Management guidelines for low anterior resection syndrome - the MANUEL project

AIM

Little is known about the pathophysiology of low anterior resection syndrome (LARS), and evidence concerning the management of patients diagnosed with this condition is scarce. The aim of the LARS Expert Advisory Panel was to develop practical guidance for healthcare professionals dealing with LARS.

METHOD

The 'Management guidelines for low anterior resection syndrome' (MANUEL) project was promoted by a team of eight experts in the assessment and management of patients with LARS. After a face-to-face meeting, a strategy was agreed to create a comprehensive, practical guide covering all aspects that were felt to be clinically relevant. Eight themes were decided upon and working groups established. Each working group generated a draft; these were collated by another collaborator into a manuscript, after a conference call. This was circulated among the collaborators, and it was revised following the comments received. A lay patient revised the manuscript, and contributed to a section containing a patient's perspective. The manuscript was again circulated and finalized. A final teleconference was held at the end of the project.

RESULTS

The guidance covers all aspects of LARS management, from pathophysiology, to assessment and management. Given the lack of sound evidence and the often poor quality of the studies, most of the recommendations and conclusions are based on the opinions of the experts.

CONCLUSIONS

The MANUEL project provides an up-to-date practical summary of the available evidence concerning LARS, with useful directions for healthcare professional and patients suffering from this debilitating condition.

Changes to gastrointestinal function after surgery for colorectal cancer

Bowel function is increasingly considered as an important outcome for patients undergoing surgery for colorectal cancer. Increasing technical skills and technological advances have meant fewer patients require a long-term stoma but this comes at the cost, often, of poor function. With a larger range of treatment options available for a given cancer, both function and oncology should be considered in parallel when counselling patients before surgery. In the perioperative phase, bowel function can be improved with minimally invasive surgery and enhanced recovery after surgery protocols, with limited evidence for targeted medical therapies. Early detection and sound management of surgical complications such as anastomotic leak and stricture can mitigate their adverse effects on bowel function. Long-term gastrointestinal dysfunction manifests as diarrhoea and low anterior resection syndrome for colon and rectal cancer respectively. Multi-modal strategies for low anterior resection syndrome are emerging to improve significantly quality of life after restorative rectal cancer surgery.