1. 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

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

3. 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

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

5. Previous Pathway

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

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

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

11. 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), (September 2015)

12. 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)

13. 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( )

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

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

16. 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

17. Thank you Lucy Griffin Clinical Gastrointestinal Physiologist
 Bristol Royal Infirmary