Article

The Watford low anterior resection syndrome pathway for pre- and post-stoma reversal patients

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Abstract

There is increasing awareness of the high incidence of bowel dysfunction experienced by patients after sphincter-preserving rectal resection, termed low anterior resection syndrome (LARS); there remains no agreement on effective methods of treatment or effective management strategies. In West Hertfordshire Hospitals NHS Trust, there were no set protocols in place prior to the development of a nurse-led LARS clinic, which has ensured that all patients undergoing anterior resection surgery are monitored, encouraged and empowered to take an active role in their own care. While being the first point of contact for these patients, the nurse works as part of a wider multidisciplinary team (MDT) and the surgical consultants continue to have overall responsibility for patient care. The Watford LARS pathway is a guide with a method of how best to approach management of patients prior to stoma reversal and in preventing symptoms of LARS. In spite of only being set up in 2018, the pathway and clinics are already showing great success.

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Background Transanal irrigation (TAI) is a long-term treatment for obstructive defaecation syndrome, slow transit constipation and faecal incontinence. Aim This study aimed to assess the efficacy of TAI on treating these conditions. Method Data were collected using two standard follow-up questionnaires. Pre- and post-treatment symptom perception scores were compared. A Wilcoxon matched-pairs signed rank test was performed. A p value of <0.05 was considered significant. Findings Of 54 patients who were referred for TAI to a regional pelvic floor centre, 29 agreed to participate. All used one of the four Qufora IrriSedo TAI systems (MacGregor Healthcare). Symptom perception scores were reduced by 48.3% in patients with faecal incontinence (p<0.05) and 33.8% in those with constipation (p<0.0001). Symptom severity decreased, with reductions of 34.8% in St Mark's Faecal Incontinence score (p=0.0249) and 28.6% in Cleveland Clinic Constipation score (p=0.03). Conclusion TAI was shown to be an effective treatment for functional bowel problems.
Article
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Article
Low anterior resection syndrome (LARS) is a collection of symptoms that can occur as a result of a low anterior resection for bowel cancer. Transanal irrigation (TAI) can be used to manage these symptoms. This article describes a retrospective audit of 15 patients who were using TAI to manage symptoms of LARS. The aim of the audit was to ascertain whether the use of TAI improved outcomes for these patients. The data suggest that TAI has reduced both the frequency of bowel movements and episodes of faecal incontinence. Those patients using higher volumes of water seem to have experienced more benefit than those patients using lower volumes of water. These findings are consistent with current literature around TAI for LARS and suggest research into optimum volume of water would be beneficial.
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Introduction Rectal cancer affects more than 600 patients per year in Wales, with a 5-year survival rate of around 60%. A recent report demonstrated that 19% of patients with bowel cancer had difficulty controlling their bowels after surgery, and these patients were twice as likely to report lower quality of life than those who had control. Nearly all patients will experience bowel dysfunction initially following surgery and up to 25% will experience severe bowel dysfunction on a long-term basis. The aim of this study is to test the feasibility of introducing a simple intervention in an attempt to improve bowel function following surgery for rectal cancer. We propose the introduction of an educational session from specialist nurses and physiotherapists prior to surgery and a subsequent physiotherapy programme for 3 months to teach patients how to strengthen their pelvic floor. Methods and analysis All patients with rectal cancer planned to receive an anterior resection will be approached for the study. The study will take place in three centres over 12 months, and we expect to recruit 40 patients. The primary outcome measure is the proportion of eligible patients approached who consent to and attend the educational session. The secondary outcomes include patient compliance to the pelvic floor rehabilitation programme (assessed by patient paper or electronic diary), the acceptability of the intervention to the patient (assessed using qualitative interviews) and preoperative and postoperative pelvic floor tone (assessed using the Oxford Grading System and the International Continence Society Grading System), patient bowel function and patient quality of life (assessed using validated questionnaires). Ethics and dissemination Ethics approval was granted. This feasibility study is in progress. If patients find the intervention acceptable, the next stage would be a trial comparing outcomes after anterior resection in those who have and do not have physiotherapy. Trial registration number ISRCTN77383505; Pre-results.
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Background: The purpose of this research is to identify the bowel symptoms and self-care strategies for rectal cancer survivors during the recovery process following low anterior resection surgery. Methods: A total of 100 participants were investigated under the structured interview guide based on the dimensions of "symptom management theory". Results: 92% of participants reported changes in bowel habits, the most common being the frequent bowel movements and narrower stools, which we named it finger-shaped consistency stools. The 6 most frequently reported bowel symptoms were excessive flatus (93%), clustering (86%), urgency (77%), straining (62%), bowel frequency (57%) and anal pendant expansion (53%). Periodic bowel movements occurred in 19% participants. For a group of 79 participants at 6 to 24 months post-operation, 86.1% reported a significant improvement of bowel symptoms. Among 68 participants of this subgroup with significant improvements, 70.5% participants reported the length of time it took was at least 6 months. Self-care strategies adopted by participants included diet, bowel medications, practice management and exercise. Conclusions: It is necessary to educate patients on the symptoms experienced following low anterior resection surgery. Through the process of trial and error, participants have acquired self-care strategies. Healthcare professionals should learn knowledge of such strategies and help them build effective interventions.
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Aim: Up to 80% of patients after low anterior resection, experience (low) anterior resection syndrome (ARS/LARS). However, there is no standard treatment option currently available. This systemic review aims to summarize treatment possibilities for LARS after surgical treatment of rectal cancer in the medical literature. Methods: Embase, PubMed, and the Cochrane Library were searched using the terms anterior resection syndrome, low anterior resection, colorectal/rectal/rectum, surgery/operation, pelvic floor rehabilitation, biofeedback, transanal irrigation, sacral nerve stimulation, and tibial nerve stimulation. All English language articles presenting original patient data regarding treatment and outcome of LARS were included. We focused on the effects of different treatment modalities for LARS. The Jadad score was used to assess the methodological quality of trials. The quality scale ranges from 0 to 5 points, with a score ≤ 2 indicating a low quality report, and a score of ≥ 3 indicating a high quality report. Results: Twenty-one of 160 studies met the inclusion criteria, of which 8 were reporting sacral nerve stimulation, 6 were designed to determine pelvic floor rehabilitation, 3 studies evaluated the effect of transanal irrigation, 2-percutaneous tibial nerve stimulation, and the rest of the studies assessed probiotics and 5-HT3 receptor antagonists for LARS in patients who had undergone rectal resection. All except one study were poor quality reports according to the Jadad score. Conclusions: LARS treatment still carries difficulties because of a lack of well-conducted, randomized multicenter trials. Well-performed randomized controlled trials are needed.
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PurposeThis is a retrospective analysis including all of the patients that have undergone anterior resection for rectal cancer from January 1998 to December 2005 in two tertiary referral centers. The study aims to evaluate the long term functional results after low anterior resection and to identify the risk factors of postoperative bowel disorders. Method Data were collected from the clinical records, and then the low anterior resection syndrome score which is a specific questionnaire to investigate the symptoms after surgery was submitted to the selected patients. Exclusion criteria were intra-abdominal rectal cancer, partial mesorectal excision, permanent stoma, recurrent local disease, and patients who declined the questionnaire. ResultsA total of 93 patients were included in the analysis with a median age at the diagnosis of 66 years. The median follow-up was 13.7 years, and low anterior resection syndrome was reported in 44 patients (47.5 %), with major manifestations in 19 patients (20.5 %), and minor symptoms in 25 patients (27 %). Age more than 70 years, tumor distance from the external anal verge, neoadjuvant treatment, and interval time of closing stoma are independent prognostic factors of functional disorders after surgery. Conclusions Because of its great impact on the quality of life of these patients, it is necessary to early identify the syndrome trying to reduce its manifestations. Moreover, the symptoms seem to remain stable 1 year after surgery; hence, it is important to have an exhaustive, preoperative counseling and an integrated post-operative functional and rehabilitational follow-up in association with the oncologic pathway.
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Background: Restorative anterior resection is considered the optimal procedure for most patients with rectal cancer and is frequently preceded by radiotherapy. Both surgery and pre-operative radiotherapy impair bowel function, which adversely affects quality of life. Objective: This study aimed to report symptoms associated with bowel related quality of life (BQoL) impairment and identify risk factors that predict BQoL impairment. Design: Cross-sectional cohort study Settings: Multicentre study from twelve UK centres Patients: 578 rectal cancer patients underwent a curative restorative anterior resection between 2001-2012 (median 5.25 years post surgery) Main Outcome Measures: Patients completed outcome measures that assessed bowel dysfunction (Low Anterior Resection Syndrome score), incontinence (Wexner score) and quality of life (EORTC QLQ-C30), plus a BQoL anchor question – “overall how does bowel function affect your quality of life?” Results: Responses were provided by 462 patients (80% response rate). Overall 391/462 (85%) patients reported BQoL impairment, with 187/462 (40%) reporting major BQoL impairment. A large difference in global quality of life (22points, p<0.001) was reported for “none” versus “major” BQoL impairment, with greatest symptom severity for diarrhoea (25points,p<0.001), insomnia (24points,p<0.001) and fatigue (20points,p<0.001). Regression analysis identified major BQoL impairment in 60% and 45% of patients with low rectal cancer treated with and without pre-operative radiotherapy, compared with 47% and 33% of mid/upper rectal cancers with and without pre-operative radiotherapy respectively. Limitations: Advances in delivery of radiotherapy and improvements in post-treatment symptom management, though currently of limited efficacy, imply that the content of the consent aid should be reevaluated in 5-10 years time. Conclusions: Anterior resection patients should be informed that bowel related quality of life impairment is common. The key risk factors are low tumour height and neoadjuvant therapy. This study provides quality of life and functional outcome data, plus a newly developed consent aid, that will enhance this pre-operative discussion.
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To understand how patients experience compassion within nursing care and explore their perceptions of developing compassionate nurses. Compassion is a fundamental part of nursing care. Individually, nurses have a duty of care to show compassion; an absence can lead to patients feeling devalued and lacking in emotional support. Despite recent media attention, primary research around patients' experiences and perceptions of compassion in practice and its development in nursing care remains in short supply. A qualitative exploratory descriptive approach. In-depth, semi-structured interviews were conducted with a purposive sample of 10 patients in a large teaching hospital in the United Kingdom. Interviews were digitally recorded and transcribed verbatim. Thematic networks were used in analysis. Three overarching themes emerged from the data: (1) what is compassion: knowing me and giving me your time, (2) understanding the impact of compassion: how it feels in my shoes and (3) being more compassionate: communication and the essence of nursing. Compassion from nursing staff is broadly aligned with actions of care, which can often take time. However, for some, this element of time needs only be fleeting to establish a compassionate connection. Despite recent calls for the increased focus compassion at all levels in nurse education and training, patient opinion was divided on whether it can be taught or remains a moral virtue. Gaining understanding of the impact of uncompassionate actions presents an opportunity to change both individual and cultural behaviours. It comes as a timely reminder that the smallest of nursing actions can convey compassion. Introducing vignettes of real-life situations from the lens of the patient to engage practitioners in collaborative learning in the context of compassionate nursing could offer opportunities for valuable and legitimate professional development.
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Between 25 and 80 % of patients undergoing a low or very low anterior resection will suffer postoperatively, from a constellation of symptoms including fecal urgency, frequent bowel movements, bowel fragmentation and incontinence, collectively referred to as the low anterior resection syndrome (LARS). The etiology of LARS is multifactorial with the potential of sphincter injury during anastomosis construction, alterations in anorectal physiology, the development of a pudendal neuropathy, and a lumbar plexopathy with exacerbation of symptoms if there is associated anastomotic sepsis or the use of adjuvant and neoadjuavnt therapies. The symptoms of LARS may be obviated in part by the construction of a neorectal reservoir which may take the form of a colonic J-pouch, a transverse coloplasty, or a side-to-end anastomosis. This review outlines the factors contributing to LARS symptomatology along with the short- and medium-term functional results of comparative trials with the different types of neorectal reconstructions.
Article
Introduction Substantial progress has been made in the treatment of rectal cancer in the past two decades. Low anterior resection is a cornerstone in current treatment, combined with neo-adjuvant (chemo-) radiation in selected cases. However, side effects such as increased frequency, urgency and incontinence are seen in a majority of patients postoperatively. These symptoms, referred to as low anterior resection syndrome (LARS), have a severe impact on quality of life. Management of LARS is complex, and surgeons seem to underestimate and misinterpret the impact of symptoms associated with LARS. Aim and methods We investigated the awareness and management of LARS in The Netherlands, conducting a national survey in which colorectal surgeons and colorectal care nurses were asked for their views on this complex syndrome. Results 242 health-care professionals participated in the survey. Most participants estimate the prevalence of major LARS is 20–40% after low anterior resection (LAR); a severe underestimation of actual prevalence - around 70%. Only 10% of surgeons use LARS screening tools in the preoperative period, and fewer than half of surgeons use LARS scores before or after a LAR. Although most surgeons inform their patients preoperatively about the changes in bowel function that they may experience after rectal cancer treatment, a majority of these surgeons indicate more information and patient counselling would improve the quality of life of their patients. Discussion Impact and prevalence of LARS is underestimated by their physicians. Uniform clinical guidelines should be developed to guide physicians in adequate management of patients with LARS.
Article
Background: Transanal irrigation(TAI) has been reported to be an inexpensive and effective treatment for low anterior resection syndrome(LARS). The aim of the present prospective study was to evaluate the use of TAI in patients with significant LARS symptoms at a single medical center. Methods: Patients who had low anterior resection for rectal cancer between April 2015 and May 2016 at the Careggi University Hospital were assessed for LARS using the LARS and the Memorial Sloan-Kettering Cancer Center Bowel Function Instrument (MSKCC BFI) questionnaires 30-40 days after surgery or ileostomy closure (if this was done). Quality of life was evaluated using a visual analog scale and the Short Form-36 Health Survey. All patients with LARS score of 30 or higher were included (early LARS) as were all patients with a LARS score of 30 or higher referred 6 months or longer after surgery performed elsewhere (chronic LARS) in the same study period. Study participants were trained to perform TAI using the Peristeen™ System for 6 months, followed by 3 months of enema therapy following a similar protocol. Results: Thirty-three patients were enrolled in the study. Six patients stopped the treatment. The 27 patients (19 early LARS and 8 chronic LARS) who completed the study had a significant decrease in the number of median daily bowel movements [baseline 7 (range 0-14); 6 months 1 (range 0-4); 9 months 4 (range 0-13)]. The median LARS Score fell from 35.1 (range 30-42) (baseline) to 12.2 (range 0-21) after 6 months (p < 0.0001) and then rose to 27 (range 5-39) after 3 months of enema therapy. There was no difference in LARS score decrease at 6 months between the patients with early and chronic LARS (22.5 and 23.9 respectively; p=0.7) and there were no predictors of score decrease. Four components of the SF-36 significantly improved during the TAI period. The MSKCC BFI score significantly improved in several domains. Twenty-three patients (85%) asked to continue the treatment with TAI after the study ended. Conclusions: TAI appears to be an effective treatment for LARS and results in a marked improvement of continence and quality of life. Patients may be assessed and treated for LARS early after surgery since the treatment benefit is similar to that observed in patients with LARS diagnosed 6 months or longer after surgery. The potential rehabilitative role of TAI for LARS is promising and should be further investigated.
Article
Aim: Sacral nerve stimulation has become a preferred method for the treatment of faecal incontinence in patients who fail conservative (non-operative) therapy. In previous small studies, sacral nerve stimulation has demonstrated improvement of faecal incontinence and quality of life in a majority of patients with low anterior resection syndrome. We evaluated the efficacy of sacral nerve stimulation in the treatment of low anterior resection syndrome using a recently developed and validated low anterior resection syndrome instrument to quantify symptoms. Method: A retrospective review of consecutive patients undergoing sacral nerve stimulation for the treatment of low anterior resection syndrome was performed. Procedures took place in the Division of Colon and Rectal Surgery at two academic tertiary medical centres. Pre- and post-treatment Cleveland Clinic Incontinence Scores and Low Anterior Resection Syndrome scores were assessed. Results: Twelve patients (50% men) suffering from low anterior resection syndrome with a mean age of 67.8 (±10.8) years underwent sacral nerve test stimulation. Ten patients (83%) proceeded to permanent implantation. Median time from anterior resection to stimulator implant was 16 (range 5-108) months. At a median follow-up of 19.5 (range 4-42) months, there were significant improvements in Cleveland Clinic Incontinence Scores and Low Anterior Resection Syndrome scores (P < 0.001). Conclusion: Sacral nerve stimulation improved symptoms in patients suffering from low anterior resection syndrome and may therefore be a viable treatment option.
Article
Outcomes for rectal cancer surgery have improved significantly over the past 20 years with increasing rates of survival and recurrence, specifically local recurrence. These gains have been realized during a period of time in which there has been an increasing emphasis on sphincter preservation. As we have become increasingly aggressive in avoiding resection of the anus, we have begun accepting bowel dysfunction as a normal outcome. Low anterior resection syndrome, defined as a constellation of symptoms including incontinence, frequency, urgency, or feelings of incomplete emptying, has a significant impact on quality of life and results in many patients opting for a permanent colostomy to avoid these symptoms. In this article, we will highlight the most recent clinical and basic science research on this topic and discuss areas of future investigation.
Article
Bowel dysfunction after sphincter-preserving surgery for rectal cancer is a common complication, with the potential to affect quality of life (QoL) strongly. The aim of this study was to examine the extent of bowel dysfunction and impact on health-related QoL after curative sphincter-preserving resection for rectal cancer. QoL was assessed using the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire, and bowel function using a validated questionnaire, including the recently developed low anterior resection syndrome (LARS) score. Assessments were carried out at the time of diagnosis, and at 3 and 12 months after surgery. A total of 260 patients were included in the study. At 3 months, 58·0 per cent of patients had a LARS score of 30 or more (major LARS), which declined to 45·9 per cent at 12 months (P < 0·001). The risk of major LARS was significantly increased in patients who received neoadjuvant therapy (odds ratio 2·41, 95 per cent confidence interval 1·00 to 5·83), and after total versus partial mesorectal excision (odds ratio 2·81, 1·35 to 5·88). Global health status was closely associated with LARS, and significant differences in global health status, functional and symptom scales of QoL were found between patients without LARS and those with major LARS. Bowel dysfunction is a major problem with an immense impact on QoL following sphincter-preserving resection. The risk of major LARS was significantly increased after neoadjuvant therapy and total mesorectal excision.
Article
Up to 80% of patients with rectal cancer undergo sphincter-preserving surgery. It is widely accepted that up to 90% of such patients will subsequently have a change in bowel habit, ranging from increased bowel frequency to faecal incontinence or evacuatory dysfunction. This wide spectrum of symptoms after resection and reconstruction of the rectum has been termed anterior resection syndrome. Currently, no precise definition or causal mechanisms have been established. This disordered bowel function has a substantial negative effect on quality of life. Previous reviews have mainly focused on different colonic reconstructive configurations and their comparative effects on daily function and quality of life. The present Review explores the potential mechanisms underlying disturbed functions, as well as current, novel, and future treatment options.