2 Appendices:
Appendix A: Flowchart of the protocol for the screening and treatment for LARS.
3 Appendix B: The screening and treatment protocol for LARS (translated from Dutch).
Title document
Low Anterior Resection Syndrome (LARS) Keywords
Low Anterior Resection Syndrome; LARS Purpose of treatment
Every patient who underwent a low anterior resection (LAR) or sigmoid resection receives an appointment with the colorectal care nurse within 2-3 weeks post-operative or after reversal of the stoma. During this appointment, an explanation of the low anterior resection syndrome will be given. Also, the most common self-management strategies will be discussed with the patient. Both written and verbal Information is provided.
In case of a high LARS score, the colorectal care nurse conducts an extensive interview to map the existing clinical problems. Possible interventions and information provision is aimed at the complaints that mostly affect the patient.
Comments in advance
- This post-operative care track is carried out by colorectal care nurses.
- The effects of complaints on daily life and functioning are one of the main aspects in this post- operative care track.
- Important in this are daily activities, work and the ability to fit the interventions in this daily pattern.
- Motivation and patient-needs play an important role.
- All interventions and scores are being reported in the electronic patient registry.
- An interventions needs to be evaluated after two weeks, with oral feedback and the LARS and Bristol Stool scores.
Indications
The post-operative care track starts after a patient undergoes a low anterior resection (LAR) or sigmoid resection without stoma placement. In case of a temporarily stoma, this care track will start after reversal of the stoma.
Methods
Post-operative, during clinical admission.
- Patients will receive the flyer “lifestyle advices for a healthy stool” with additional explanation.
Especially toilet posture must be trained with the patient.
- In case of faecal incontinence, provision of incontinence material will be ordered for use at home.
- A total of two appointments need to be scheduled at discharge from the hospital:
o 2-3 days after hospital discharge: telephonic appointment with the colorectal care nurse.
o 2-3 weeks after hospital discharge: outpatient appointment with the colorectal care nurse.
Telephonic appointment, 2-3 days after discharge.
- Conduct the LARS score.
- Ask for the Bristol Stool score.
- Ask for incontinence and the necessity for incontinence materials, including ordering these in case of need.
- Ask for anal complaints (itch, pain, chapped anus). Advise by complaints.
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- Ask for the use of laxation. Advise to stop in case the stool is active.- Ask for the stool, complaints?
- Point out the flyers “lifestyle advices for a healthy stool”. Give advices with respect to nutrition and fluids in case of high frequency stool and high score on the Bristol Stool chart.
- Point out the possible ways to contact the Colorectal care nurses in case of need.
- In case of need: bring the next control appointment forward (colorectal care nurse or surgeon).
First outpatient control appointment, 2-3 weeks after discharge.
- Conduct the LARS score.
- Ask for the Bristol Stool score.
- Explanation of the low anterior resection syndrome.
- Written flyer about LARS.
In case of LARS, irrespectively the score:
Optimize the Bristol score.
- Bristol 1-2: start Macrogol/Movicolon (Sachet, powder for drinks, 1-3/day, 1 sachet) + advice on fluids and nutrition.
- Bristol 3-4: no action.
- Bristol 5-7: Psyllium fibers (psyllium fibers, 3.6 gr sachets/Plantago Ovata Sachets 3.6 gr) + advice on fluids and nutrition.
In case of very high frequency (15-20 times/day) and a Bristol score 5-7: consider the direct start of loperamide. The combined use of psyllium fibers with lopermide has proven to be more effective.
In case of evacuation problems: aim to keep the stool smooth (Bristol score 4). Be aware of the possibility of anastomotic stricture/stenosis/narrowing: ask for pencil thin stool.
In case of actual anastomotic narrowing, make sure to keep the consistence of the stool smooth. This facilitates the passage of the anastomosis.
Referral to Pelvic Floor Rehabilitation training in case of the following complaints:
- Incontinence.
- Urgency complaints.
- High frequency.
- Suspicion of bad toilet behaviour/posturing, excessive squeezing or pushing.
In case of fragmentation:
- Optimize the Bristol Stool score.
- Pay attention to toilet behaviour and posturing.
In case of skin problems: prescribe the use of protective products (i.e. Proshield, Sudocreme, Zinc oxide, Bepanthen). In case of poignant feelings and severe complaints of pain around the anal area, prescribe lidocaine crème (1 mg/gr, tube 25 mg). Always ask for other complaints with the stool which impedes the patient in daily life. Interventions need to be aimed at these complaints.
Telephonic evaluation, 2 weeks after start intervention - Conduct the LARS score.
- Ask for the Bristol Stool score, and optimize following the schedule below.
- Evaluate the effect of pelvic floor rehabilitation training.
- Evaluate the interventions and their effect on daily functioning of the patient.
Optimize Bristol Stool score
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- Bristol 6-7: in case the maximal dose of psyllium fibers (3x/day, 1 sachet) doesn’t improve theconsistence of the stool, start with loperamide (loperamide 2 mg, 1-4/day, 1-2 capsules). The use of psyllium fibers in combination with loparamide shows favourable effects on the stool compared to loparamide alone.
Advice for the use loperamide: Start with 1x/day 1 capsule, 30 min before a meal. Slowly dose increasing till correct stool form is achieved. Pay attention to the possibility of obstipation. Try to reduce the dose if possible.
Evaluate and advice on nutrition and fluids intake (flyer).
- Bristol 5: increase the dose of psyllium fibers to maximal 3 x/day 1.
Evaluate and advice on nutrition and fluids intake (flyer).
In case a patient shows good comprehension, the use of loperamide can be considered: Start with 1x/day 1 capsule, 30 min before a meal, increase the dose slowly till correct stool form is achieved. Pay attention to the possibility of obstipation, and reduce the dose if possible.
- Bristol 3-4: no action.
Bristol 1-2: Consider increasing the dose of Macrogol/movicolon.
Evaluate and advice on nutrition and fluids intake (flyer).
Telephonic evaluation, 2 weeks after start intervention
If a patient desires a wish for an outpatient control appointment, this is possible after 6 weeks.
A persistent high burden of disease after 3 months always results in an outpatient control appointment, see below.
Outpatient control appointment, 3 months post-operative - Conduct the LARS score.
- Ask for the Bristol Stool score.
- Evaluate complaints and burden of disease. Evaluate the taken interventions.
- Verbal check of knowledge and provide additional information in case of a critical gap in knowledge.
- Discuss the option for trans-anal irrigation (note: start of irrigation after Pelvic Floor Rehabilitation training is finished).
In case of no LARS:
- Explanation LARS.
- Provide the flyer of LARS.
- Advice to retour in case of complaints.
Post-operative care track
- A routine and systematic evaluation with electronic registration of the LARS score during every control appointment in the hospital will follow during a period of 5 year post-operative. All surgical medical specialists, case managers and colorectal care nurses need to be involved.
All patients with high LARS scores will be reffered directly to the colorectal care nurse.
