Most people with a temporary ostomy are so happy that it is only temporary and dream of the day they will be free from the bag and have their old bodies back. But all too often, they have the reversal surgery and are then plagued by a life of running to the toilet, chronic diarrhea, and unrelenting flatus. Socializing becomes extremely difficult, especially dining out as they are now in constant search of a toilet or live in fear that they will have an “accident”. While body image may be restored, quality of life deteriorates due to altered bowel function.
Low anterior resection syndrome (LARS) is a collection of symptoms patients suffer from after having undergone an ostomy reversal, following an ostomy from a Low Anterior Resection surgery. The Low Anterior Resection surgery removes part of the colon and rectum resulting in a temporary colostomy. Reversal surgery, often referred to as a “Take Down” is typically done 3 -6 months later. Most people anticipate that their bowel patterns will return to normal, but that does not always happen.
LARS symptoms may include the following:
- Frequency and urgency of stools
- Clustering of stools (numerous bowel movements over a few hours)
- Fecal incontinence (which also includes gas)
- No stool for a day or two, or more, and then numerous bowel movements another day and/or increased gas.
- Inability to determine if they are going to pass gas or stool.
Not all patients experience every symptom. However, 30-70% of patients experience some form of bowel dysfunction and fecal incontinence.[1] A LARS Score is 5 questions related to defecation that helps clinicians to determine the severity of this condition. Some patients may notice that their symptoms resolve over time (6 – 12 months) while others may continue to have symptoms indefinitely.[2] Patients with temporary stoma reversals from diverticulitis or other maladies are also noted to experience similar bowel dysfunction.
The exact etiology of LARS is not known due to the multifactorial mechanisms involved. There may be pelvic nerve injury, colonic dysmotility, reduced rectal reservoir capacity, and loose stools due to the shorter colonic transit time. Pelvic floor muscle weakness from childbirth or obstetrical trauma may also increase risk. Radiotherapy of the pelvic region is noted to be the highest risk factor. [3] Other risk factors include tumor height, age at time of surgery, and total versus partial mesorectal excision.[4]
Surgeons typically advise patients that there may be some bowel control issues after reversal. Some recommend physical therapy specializing in Pelvic Floor Muscle Exercises (PME) preoperatively. In a brief online survey of patients, 80% did not receive any education on what to expect. There is a gamut of ongoing conversations in private social media groups among patients who are truly suffering and feel abandoned and helpless. Focus is on diet, as well as encouragement that it gets better with time – sometimes 6 months, sometimes 2 years. But their lives are on hold and tied to the toilet.
Treatment of LARS is based on individual symptoms of fecal incontinence and defecation disorders. In general, treatments include diet, antidiarrheal medications, improving complete evacuation, and pelvic floor rehabilitation. Diet suggestions are to increase intake of foods high in soluble fiber, chew well, eat small frequent meals, avoid lactose products, avoid caffeine and alcohol, and drink plenty of fluids. Medication recommendations typically include daily doses of Loperamide, fiber supplements of psyllium husk such as Metamucil®, and probiotics.
Pelvic Floor Rehabilitation is usually the first line of treatment for fecal incontinence. The goal is for the patient to identify the sphincter and improve strength, endurance, and speed of recruitment of the muscles necessary for continence.[5] Biofeedback and E-stim are also described as effective in decreasing fecal incontinence and leakage.
Toileting hygiene is taken to another level as well; moistened flushable wipes and use of zinc barrier creams to protect the perineal skin from acidic loose stools are compulsory. Individuals complain of severe incontinence associated dermatitis with terrible burning pain around the anus. Pieri and Patton (2020) note that educating the patient on the correct seating position (squatting) to enhance the anorectal angle and eliminate straining has been noted to be one of the most effective interventions to assist with complete evacuation. Trans-anal irrigation (Peristeen®) is noted to be one of the most effective management tools but has low compliance due to the complexity of the procedure. Incontinence briefs and/or pads are often necessary to manage fecal incontinence.
Percutaneous endoscopic cecostomy is an option for refractory severe LARS in which the individual performs an antegrade enema through a stoma on the abdomen to evacuate their bowels. If all else fails, the patient may opt for a permanent colostomy.
Preoperative assessment should include a preoperative LARS score to predict bowel dysfunction severity. Counseling should include information regarding the risk for bowel incontinence and dysfunction after reversal. Some people do return to a semi-normal bowel function, but a large portion of patients do not. Aftercare may require psychological services to learn new coping mechanisms.
[1] Lin, Y, Chen, H, Liu, K. (2015). Fecal incontinence and quality of life in adults with rectal cancer after lower anterior resection. Journal of Wound Ostomy and Continence Nursing, 42(4); 395-400.
[2] Washington University School of Medicine in St. Louis. https://colorectalsurgery.wustl.edu/patient-care/low-anterior-resection-syndrome/
[3] Pieri, C. and Patton, V. (2020). Clinical nursing management of low anterior resection syndrome- a practical guide to understanding and managing symptoms. Journal of Stomal Therapy Australia, 40(2): 8-13.
[4] Battersby, N, Bouliotis, G, Kemmertsen, K. etal. (2018). Development and external validation of a nomogram and online tool to predict bowel dysfunction following restorative rectal cancer resection: the POLARS score. Gut. 67: pg 688-696
[5] A.J. Kalkdijk-Dijkstra, J.A.G. van der Heijden, H.L. van Westreenen, P.M.A. Broens, M. Trzpis, J.P.E.N. Pierie, B.R. Klarenbeek, & FORCE Trial Group. (2020). Pelvic floor rehabilitation to improve functional outcome and quality of life after surgery for rectal cancer: study protocol for a randomized controlled trial (FORCE trial). Trials, 21(1), 1–12. https://doi.org/10.1186/s13063-019-4043-7
Can you tell me of any medication or pills I can take that eliminate or lessen odor? It seems to be worse in the mornings. I am going on vacation with friends and it can be very embarrassing.
I had a colostomy 2 years ago and have been considering a reversal.
I met with 2 surgeons and didn’t get this information. Go figure.
This is a well researched and excellent paper for ostomates considering a take-down.