Low Anterior Resection Syndrome: Establishing a Treatment Pathway Lucy Griffin – Clinical Gastrointestinal Physiologist Gastrointestinal Physiology Department, Bristol Royal Infirmary Acknowledgements to: Jessie Mansell – 3rd Year Medical Student Jonathan Randall – Consultant Colorectal Surgeon

Background Physiology Department Anorectal disorders Anorectal manometry Bowel management service Anorectal disorders 700 referrals / year Low Anterior Resection Syndrome (LARS) 1 referral / year

Patient Perspective Symptom onset, diagnosis and surgery over short period of time Temporary stoma (absence of symptoms) Sudden onset of symptoms with stoma reversal Patients now fall between care of stoma care nurse/oncologist/surgeon Sometimes without any significant symptoms prior to diagnosis Convinced to have stoma during which absence of symptoms. Desperate to get back to normal life and have stoma reversed Been through a very stressful time, think its over

Patient Perspective (2) Constant worry of disease recurrence Anxiety and low mood Loss of confidence Guilt

Previous Pathway

Proposed Pathway J. Mansell - Medical Student. eSSC 3rd year project

Proposed Pathway J.Mansell – Medical Student. eSSC 3rd year project

Bowel management advice Enable the patient to understand their symptoms Laxative / Imodium use Diet Stool consistency

Biofeedback Method of visualising sphincter function Regain muscle control Poor anorectal function associated with presence of defunctioning stoma Increased risk of LARS with longer duration of stoma Gadan S., Floodeen H., Lindgren R., Matthiessen P. Does a defunctioning stoma affect long term anorectal function following low anterior resection of the rectum for cancer? Colorectal Disease, September 2015, vol./is. 17/(3), 1462-8910 (September 2015)

Irrigation Peristeen Improves bowel emptying Controlled timing of bowel movements Faulkner G., Barrow E., Ryder S., Hill J. The use of rectal irrigation in the management of low anterior resection syndrome (LARS) Colorectal Disease, July 2014, vol./is. 16/(91-92) www.coloplast.co.uk/peristeen-anal-irrigation-system-en-gb.aspx

Sacral Nerve Stimulation Effective treatment for faecal incontinence in LARS patients Similar success rates for LARS as for other forms of faecal incontinence Mege D., Vitton V., Meurette G., Zerbib P., Sielezneff I. Anal incontinence associated with low anterior resection syndrome: Sacral nerve stimulation is-it efficient? Colorectal Disease, September 2015, vol./is. 17/(10) Ramage L., Qiu S., Kontovounisios C., Tekkis P., Rasheed S., Tan E. A systematic review of sacral nerve stimulation for low anterior resection syndrome. Colorectal Disease, September 2015, vol./is. 17/9(762-771)  

Cases so far 8 patients (since April 2015) Average of 3 sessions No. of Patients BMA BFB Irrigation SNS 4  1 3

Ongoing development Questionnaires pre-and post-treatment Develop a clearly defined treatment pathway Fine-tune timing of referral Development of patient information leaflet

What can you do? Use LARS score in clinic Use patient information leaflets Use the services available Do not assume someone else is providing the service

Thank you Lucy Griffin Clinical Gastrointestinal Physiologist  Bristol Royal Infirmary Lucy.Griffin2@uhbristol.nhs.uk