What is Low Anterior Resection Syndrome?
Low Anterior Resection Syndrome is a series of ongoing life altering symptoms that individuals may experience after undergoing treatment and surgery for rectal cancer. It has been proven to be a prevalent problem for rectal cancer patients, in fact suggesting that all patients receiving a Low Anterior Resection should be screened for LARS - as noted in scientific literature:
“Given that LARS is such a common problem that often leads to poor quality of life (QOL), all patients should be routinely screened for LARS after sphincter-preserving surgery, and the level of anorectal function should be systematically recorded for benchmarking and quality improvement purposes. Consequently, routine and widespread assessment of LARS is called for.”
Source: Chen, Emmertsen, Laurberg (2015) What Are the Best Questionnaires To Capture Anorectal Function After Surgery in Rectal Cancer?
What is a Low Anterior Resection?
LAR involves surgical removal of a majority portion of, or the entire rectum and the sigmoid colon, while hooking up the remaining rectum with the end of the colon. This hookup is referred to as an "Anastomosis" and achieved during the LAR procedure by the colon and rectum being sewn or stapled back together. The goal of a LAR procedure is curative removal of a malignant rectal tumor.
Symptoms of LARS
If your treatment requires a Low Anterior Resection, you may be at risk for LARS. What symptoms should you expect after surgery?
LARS symptoms are unique for everyone, and the speed in which symptoms subside after are dependent upon your unique situation. The most common noted symptoms of LARS include:
Extremely increased frequency of bowel movements
Increased and often immediate urgency of stools
Clustering of stools - high number of bowel movements in a short period of time (hours)
Fecal incontinence or reduced control over bowel movements
Extreme sensitivity to foods high in insoluble fibers
Constipation for a period of days, followed by clustering days later
Increased gas, sometimes uncontrollable
Rectal pain (near site of anastomosis and/or radiation)
Rectal tissue swelling
Not everyone who has a low anterior resection experiences LARS, and incidence of symptoms are related to confluence of anatomy, radiation treatment sites, and surgical location.
LARS Patient Survey - Do you have a suggested technique? Please consider completing our LARS Patient Survey. In this survey, which should take about 10-15 minutes - we invite you to share your thoughts and experiences with LARS so we can improve how we can better assist patients looking for information or guidance.
Mitigating the Symptoms of LARS
LARS has a very real impact on the day to day life for patients. Even a small reduction in the experience of LARS symptoms can lead to significant improvement in a patient’s quality of life. While every patients situation and symptoms are unique, below is an expanding and evolving list of some of the most notable possible therapies.
The below sections briefly highlight some of the techniques used by LARS patients everywhere. We hope some or all of them help you in your LARS journey.
(1) Low Residue Diet [4, 5, 6, 7]
Managing your intake of soluble vs. insoluble fibers can be a helpful way of reducing LARS symptom flare-ups.
Leafy vegetables are often problematic for patients with Low Anterior Resection Syndrome.
The concept of eating a low-fiber and/or high-fiber diet can be confusing for many patients. Depending on the type of fiber ingested, it may create more problems than it helps with resulting soft stools and frequent evacuation. Multiple studies₆ showed₇ that supplementation with soluble dietary fiber can greatly improve the bulking and hydrated capacity of stool solids₄, the consistency of stools as well as issues related to fecal incontinence. Conversely, insoluble fiber may exacerbate diarrhea and bloating₅, also often increasing inflammation and pain in and around the rectum.
A low residue diet limits high amounts of insoluble fiber foods.
On a low residue diet, foods you would want to avoid are:
Whole-grain breads and cereals
Nuts and seeds
Raw or dried fruits
Some vegetables, particularly leafy vegetables like spinach and lettuce
"Residue" in this diet refers to undigested food products that makes up portions of stool. In many cases, insoluble fiber foods tend to prevent proper stool bulking, and instead promote faster bowel motility and more bowel movements per day.
The objective of this diet is to have fewer bowel movements each day, which will in turn ease many of the symptoms described in the symptoms section of this page.
(2) Incorporate Bulking Foods or Bulking Agents [4, 8]
Incorporate bulking foods (soluble fibers) into the low residue diet. Although the primary focus of a low residue diet is to reduce stool overall, increasing the bulk of stool can further help in reducing the number of bowel movements per day₄.
Foods to include that can help in bulking stool:
Potatoes
White breads and plain crackers that are low grain and do not contain seeds
Cooked cereals
Cold cereals including puffed rice and corn flakes
Noodles, pasta and white rice, noodles
Any other soluble fiber foods
In addition to food, some medications or over the counter products can be incorporated to further assist in bulking stools.₈
As examples, Psyllium Husk (Metamucil) and Normacol (Sterculia) are bulking agents. These can be a useful addition, particularly if you are experiencing extensive clustering. These agents can also be used in conjunction with medications like Loperamide but it is advised that techniques such as these are discussed with your medical team.
(3) Bidet, Enema or Bowel Irrigation
Leveraging of one or more of these options is essential for many suffering from LARS. Each technique has pros and cons in terms of cost, preparation and effectiveness, but all of them appear to have a significant impact on LARS management.
There are multiple reasons why these are effective methods. The primary function for each is in their function to help to empty the rectum of remaining fecal matter which could otherwise irritate the skin or rectal tissue, as well as a significant reduction in bowel movements per day.
Here is a helpful video prepared by Nick Kirton around usage of Warm Water Enemas.
(4) Pelvic Floor Exercises
A series of studies have demonstrated that pelvic floor rehabilitation can be useful for improving bowel functional after low anterior resection. Pelvic floor and anal sphincter muscles often become weakened as a result of low anterior resection surgery.
Carrying out pelvic floor strengthening exercises may also help in keeping the sphincter shut and the stool from coming out. Stronger muscle strength will mean that when you feel urgency you can consciously tighten your sphincter to prevent leakage of gas, liquid or even solid stool. Like any other muscles in the body, the more you use and exercise them, the stronger the sphincter muscles will be.
(5) Anti-Inflammatory Therapies
Anti-inflammatory drugs such as NSAIDs like Ibuprofen/Advil or steroids during extreme flare-ups seem to help,
Zinc oxide cream can also be helpful, but in general, usage of anti-inflammatory medications may be an indicator that management of LARS hasn't been fully effective.
(6) Neurotransmitter Supplements. Especially Melatonin and 5-HTP [9-13]
Chjnacki et al (2011) showed that long term ingestion of melatonin for group 1 study participants led to a steady level of C-reactive protein (“CRP” which is a common marker for inflammation) compared against the control group receiving placebo for which CRP rose significantly month over month.
Melatonin has been identified in numerous studies as a potential adjuvant treatment for ulcerative colitis₉, inflammatory bowel disease₁₀, and others₁₁ that are associated with colonic or rectal tissue. Among other benefits, this makes it a good candidate to try if you are struggling with painful inflamed rectal tissue that is otherwise unmanageable.
There is a lack of data in literature from the randomized studies on the therapeutic effectiveness of melatonin in IBD. Nevertheless, considering the antiinflammatory action of this enterohormone, some researchers, among them Terry and colleagues suggest the potential therapeutic usage of melatonin in the treatment of IBD. The results of our study also support this opinion. Source: Chojnacki et al (2011) Evaluation of Melatonin Effectiveness in the Adjuvant Treatment of Ulcerative Colitis
5-HTP is the immediate precursor of serotonin, and is easily synthesized into serotonin. There are studies that indicate usage of 5-HTP in cases of diverticulitis or IBD, particularly when the colonic issues are arising due to serotonin depletion₁₂.
The serotonergic system is compromised in diverticular disease (DD). Altered expression of 5HT-4R at mRNA and protein levels may contribute to intestinal motor disturbances reported in patients with DD. The findings support the hypothesis that DD is associated and possibly promoted by an enteric neuromuscular pathology. Source: Böttner et al, (2012) The enteric serotonergic system is altered in patients with diverticular disease
But the research also indicates that 5-HTP should be avoided for chronic long term usage due to its direct connection to serum serotonin levels, among other issues₁₃.
Should you take Melatonin or 5-HTP? As always, we recommend speaking to your doctor if they are helping manage your LARS or related pain. But from our experience and research, both of these supplements are well tolerated and regarded as generally safe, and melatonin in particular has been noted to have many benefits for current and past cancer patients.
On a personal note - these two might sound like surprising suggestions, but these are two back pocket options that have sometimes been the only way to bring me back to normalcy after a longer lasting round of days or weeks of more intense flare-up of rectal inflammation and other LARS symptoms.
(7) Other Medications [5]
Other Medications or Health Products such as Loperamide (Immodium), Medilac-Vita₅ and others can assist with slowing bowel motility and reducing clustering. Many of these options do come with side effects, such as stomach and cramping pains, which need to be weighed against the benefits that are provided.
Additional Resources:
Another helpful resource for many of us has been a Facebook group called "Living with Low Anterior Resection Syndrome". The group has a lot of helpful information shared frequently and certainly are a good group to answer questions about LARS.
If you are interested in participating or learning more about research studies around treatment for LARS, see: LARS related Clinical Trials that are currently recruiting
Low Anterior Resection Syndrome - Techniques in Coloproctology's Podcast
In this podcast Giuseppe Gagliardi, Co-Editor-in Chief of Techniques in Coloproctology, interviews Nicola Fernhead and Jacopo Martellucci on the definition and treatment of low anterior resection syndrome. 2 patients with the syndrome are also interviewed. In this conversation patients and experts share their tips and insights. Some of the discussion is based on a recent article published on the journal "Role of transanal irrigation in the treatment of anterior resection syndrome" which you can view on this link
References:
Chen, Emmertsen, Laurberg (2015) What are the best questionnaires to capture anorectal function after surgery in rectal cancer?
Chen et al. (2015) Bowel function 14 years after preoperative short-course radiotherapy and total mesorectal excision for rectal cancer: report of a multicenter randomized trial.
Sturiale et al. (2017) Long-term functional follow-up after anterior rectal resection for cancer.
UCSF Medical Center (2011) After Low Anterior Resection for Treatment of Rectal Cancer.
Yin et al. (2018) Bowel symptoms and self-care strategies of survivors in the process of restoration after low anterior resection of rectal cancer.
Nikoletti et al. (2008) Bowel problems, self-care practices, and information needs of colorectal cancer survivors at 6 to 24 months after sphincter-saving surgery.
Sloots et al. (2009) Practical strategies for treating postsurgical bowel dysfunction.
Coloplast - Walker, et al. (2015) Managing your bowel function after Rectal Cancer Surgery Patient Information Booklet.
Chojnacki et al. (2011) Evaluation of Melatonin Effectiveness in the Adjuvant Treatment of Ulcerative Colitis.
Jun-Hua Li el al. (2005) Melatonin Reduces Inflammatory Injury Through Inhibiting NF-κB Activation in Rats with Colitis.
Mozaffari et al (2011) Melatonin, a Promising Supplement in Inflammatory Bowel Disease: A Comprehensive Review of Evidences.
Mawe, Hoffman (2013) Serotonin signalling in the gut — functions, dysfunctions and therapeutic targets.
Hinz, Stein, Uncini (2012) 5-HTP efficacy and contraindications.