What is Low Anterior Resection Syndrome (LARS)?

For people who have had surgery that involves removing part of the rectum or lower bowel, living with the resulting change in bowel function can be quite challenging. The rectum can be removed for various reasons, often (but not always) this is as the result of cancer treatment.  Removal of the lower part of the rectum and re-joining the remaining ends of bowel back together, is called a low anterior resection.

Some people who undergo a low anterior resection will have had a stoma formed, to divert the flow of faeces (poo) away from the area that has been joined back together and allow it time to rest and heal. Others may also go on to have chemotherapy and/or radiotherapy. All of these factors can affect the function of the bowel long after surgery and treatment have finished.

Many people expect things to go back to normal after their surgery and for some this will be the case. Remember, you have lost a portion of bowel that cannot be replaced and things are likely to be ‘different’. As a general rule, your bowel should start to settle down within a few weeks or months following your surgery (or stoma reversal for those who have had one). However, for others it can take longer and their bowel function may never go back to how things were before they became ill. If symptoms are persisting and not settling, it is important to speak with your colorectal or stoma care nurse as there is lots that can be done to help.

Many people experience feelings of guilt around seeking help for these symptoms, expecting to have to put up with the consequences of treatment as a ‘trade off’ for being cured of their cancer. This can result in people living with poor bowel control and/or function, which in turn can have a huge impact on their quality of life. In severe cases, it can prevent people from doing all the things they enjoy, such as sport and exercises, eating out with family and friends or being intimate with their partner.

However, it is important to know that there are things that can be done to help manage these symptoms and enable you to live a full and active life.

Low Anterior Resection Syndrome (LARS) Symptoms

The term syndrome simply means a collection of symptoms. For people with LARS they may have some or all of the following symptoms, to a lesser or greater degree:

• Bowel urgency – having the sudden need to open your bowels which can lead on to ….
• Bowel leakage – the involuntary passage of flatus (wind), liquid or solid stool from the back passage
• Bowel frequency – having to open your bowels several times a day, often with loose stools
• Clustering or fragmentation of stool – passing small stools frequently. Having to return to the toilet several times due to being unable to empty completely in one go
• Tenesmus – the feeling of wanting to open your bowels even if there is nothing there to pass
• Constipation – straining to open your bowels. This can happen even if your stools are loose or soft.

If any of these symptoms are affecting your quality of life, it is important to speak with your colorectal or stoma care nurse specialist. If you are no longer in contact with them, ask your GP to refer you to a specialist bladder and bowel clinic, who are experienced in dealing with this condition.

Hints and tips for managing LARS

Managing LARS symptoms is often a case of trial and error, as what works for one person may not work for another! Very often, a combination approach is required and it is important to take things step by step, rather than introducing lots of changes at once.

Following a thorough assessment, your healthcare professional may suggest any of the following:

• Dietary adjustments
• Anti-diarrhoeal medication to slow the bowels down
• Bulking agents – to firm the stools up and help with clustering
• Management of stress and anxiety
• Bowel retraining tips
• Pelvic floor exercises and techniques to help with bowel emptying
• Skin care advice
• Use of anal plugs or inserts to help with leakage
• Transanal irrigation

If your bowel control has still not become more manageable after trying all of these ideas, ask to speak with your colorectal surgeon to discuss what other options may be available:

1. Some patients benefit from sacral neuromodulation (often called sacral nerve stimulation or SNS). A trial is carried out first, to check that you will work for you. A thin wire is temporarily inserted under the skin in your lower back and attached to a small external stimulator. The surgeon adjusts the stimulator until the best level is found for you. If your symptoms are improved during the trial, you would be offered a permanent, implanted stimulator.
2. Posterior tibial nerve stimulation is helpful for some. This involves inserting a very fine wire just above the ankle, through which a mild electric current is passed. This stimulates the nerves that control the lower bowel and rectum.
3. For people with severe LARS symptoms not responding to treatment, it is not uncommon for people to voice how much better things were when they had their stoma. People can live full and healthy lives with a permanent stoma and some people with LARS may opt to have a new stoma formed rather than living with their poor bowel control.

The main thing to remember is that whatever the reason for your surgery, regaining quality of life afterwards is really important. If you are having ongoing symptoms that are affecting your ability to do the things you enjoy, there is help out there and don’t be afraid to talk to your doctor or nurse!