1. Low Anterior Resection Syndrome
David Cotton, Jessie Mansell,
Jon Randall

2. Low Anterior Resection
Curative treatment for low rectal cancer
Avoiding permanent stoma + wound complications of APER
Sphincter preservation as an aim has led to very low tumours being resected
Total Mesorectal Excision
Anastomotic leak + pelvic complications
Neoadjuvant chemoradiotherapy (+ adjuvant treatment for many)
Clinical concentration often on disease/survival

3. Low Anterior Resection Syndrome (LARS)
“Disordered bowel function after rectal resection leading to a detriment in quality of life” 1
In reality this varies and has been said to include urgency, loose stool, frequency, altered stool consistency, obstructed defecation and incontinence
If present at one year after surgery (or stoma closure) then it is likely to be present after 10 years 2

4. Reproduced from Chen et al 3

5. The LARS score Developed by Emmertsen + Laurberg 4 in Denmark
Subsequently validated in English by Juul et al5
Quality of life after rectal cancer surgery is dependent on a number of factors
However it is closely linked to LARS
‘Major’ LARS causes a significant reduction in quality of life compared to no LARS 6

6. Likely risk factors 1, 3, 7 Neoadjuvant chemoradiotherapy
Short/no remnant rectum (<5cm)
Clinical anastomotic leak/abscess/defect
Prolonged presence of defunctioning ileostomy
Nerve dysfunction (pudendal neuropathy)
Older age
Preoperative dysfunction

7. Differential diagnoses
Radiation enteritis
Chemotherapy-induced enteritis
Malabsorption
Anastomotic stricture
Disease recurrence
Primary (pre-operative) dysfunction
Other causes of altered bowel habit

8. Medical (‘traditional’) management
Dietary advice
Loperamide
Bulking agents
Amitriptyline
Buscopan

9. Advanced management Stool training + advanced education Counselling
Biofeedback
Rectal irrigation

10. Sacral Nerve Stimulation
Still an evolving technique for LARS
2015 review article in Colorectal Disease 8 found 43 patients considered for SNS for LARS
In this instance for incontinence + LARS
Median follow-up 15 months
34 implants placed
94.1% improvement in symptoms (74.4% on intention to treat)
PTNS may also have similar efficacy 9

11. References
Bryant CL, Lunniss PJ, Knowles CH, Thaha MA, Chan CL. Anterior resection syndrome. Lancet Oncol. (2012); 13(9): e403-8.
Sturiale A., Martellucci J., Valeri A. Long term functional results after laparoscopic low anterior resection for rectal cancer. Colorectal Disease (2015), Poster Abstracts. 17: 38–101. doi:  /codi.13053
Chen T, Wiltink L, Nout R et al. Bowel Function 14 Years After Preoperative Short-Course Radiotherapy and Total Mesorectal Excision for Rectal Cancer: Report of a Multicenter Randomized Trial. Clin Colorect Cancer (2015); 14(2):
Emmertsen KJ, Laurberg S. Low anterior resection syndrome score: development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer. Ann Surg (2012);255(5):922-8.
Juul T, Battersby N, Christensen P et al. Validation of the English translation of the low anterior resection syndrome score. Colorectal Dis (2015);17(10):908-16
Juul T, Ahlberg M, Biondo S et al . Low anterior resection syndrome and quality of life: an international multicenter study. Dis Col Rectum (2014);57(5):
Ziy Y, Zbar A, Bar-Shavit Y, Igov I. Low anterior resection syndrome (LARS): cause and effect and reconstructive considerations. Tech Coloproctol (2013 );17(2):

12. References
Ramage L, Qiu S, Kontovounisios C et al. A systematic review of sacral nerve stimulation for low anterior resection syndrome. Colorectal Dis. (2015);17(9):
Troncoso P, Vigorita V, Garrido L et al. Preliminary results in the use of posterior tibial nerve stimulation in the treatment of Low Anterior Resection Syndrome. Colorectal Dis. (2015);17(S2):44.