Low anterior resection syndrome, or “LARS,” is a recognized problem worldwide that can occur secondary to rectal cancer treatment. This resource has been created to help support patients who are at risk of developing LARS. It contains information describing LARS, management options and available support.

Understanding LARS

Your Digestive System

Understanding your digestive system can help you prepare for and recover from rectal cancer surgery.

Your digestive tract forms a pathway from your mouth to your anus. As food moves down, it is processed and changed to waste.

After you swallow food, it moves down your esophagus (food pipe) and into your stomach, where it mixes with stomach acids and becomes liquid. The food begins to break down, and then moves into the small intestine, where nutrients are absorbed. Whatever is not absorbed is waste, which travels down to your colon. Water is absorbed from the liquid waste in the colon, converting it to solid waste. Your rectum serves as a storage area for the waste until it leaves your body through your anus.

Low Anterior Resection (LAR)

LAR is a surgery for rectal cancer in which part or all of the rectum is removed. The remaining portion of your rectum is reconnected to your colon. Once this connection has healed, you will be able to have bowel movements per rectum. The place where the two ends of bowel are connected (with staples or sutures) is called an anastomosis.

Ileostomy

An ileostomy is when a section of small intestine is brought out onto the surface of the skin on your abdominal wall to allow feces to pass. You may need to have an ileostomy for a short duration after LAR surgery. This prevents stool from moving through your colon and rectum where the anastomosis is, allowing it to heal.

What is LARS?

LARS is a collection of symptoms that people who have undergone removal of part or all of their rectum often develop. As the reservoir to store feces is now smaller, bowel movements are usually smaller and more frequent.

Patients with rectal cancer may also undergo radiotherapy. Following radiotherapy, the walls of the rectum can become scarred. This can also affect bowel function and lead to symptoms of LARS.

Following surgery or radiotherapy, nerves that supply your bowels can also be affected. This means the signals that control your bowels may not work as well, leading to LARS symptoms.

Some patients report improvement in their symptoms over time, while others experience persistent LARS symptoms. Each patient is unique.

The symptoms of LARS are different for everyone, but often include:

• Frequency or urgency of stools

• Clustering of stools (lots of bowel movements over a few hours)

• Fecal incontinence

• Constipation followed by numerous bowel movements

• Increased gas or having trouble telling the difference between a bowel movement and passing gas

• Rectal pain

How can you manage LARS?

It is important to discuss LARS with your surgeon or cancer nurse specialist before starting treatment for rectal cancer. For most patients with LARS, nonsurgical therapies are the mainstay of treatment. With treatment, your bowel movements can become predictable, regular and nonpainful. The choice of treatment depends on the type of symptoms you have, the severity and the duration.

Your LARS severity will be evaluated by a LARS score, and your treatment options will be tailored according to this score.

Depending on your symptoms and LARS severity, your doctor may recommend:

• Specific nutrition and lifestyle instructions

• Medications

• Physical therapy to help strengthen your pelvic floor muscles

• Additional procedures such as transanal irrigation, sacral nerve stimulation and colostomy formation

Lifestyle

Bowel dysfunction symptoms can be overwhelming, but with time, you can begin to develop certain lifestyle changes that can help you adapt. You can consider carrying a “survival” pack, consisting of wet wipes, protective ointments (e.g., Calmoseptine or other barrier ointments) and Imodium.

Cleaning after multiple bowel movements can irritate the perianal skin. Using soft or wet cloths rather than dry toilet paper can often be helpful with this. Using a sitz bath or bidet reduces rectal discomfort.

Your cancer nurse specialist or surgeon can help guide you with lifestyle changes you can make to improve LARS symptoms.

Nutrition

Dietary modification is considered first-line therapy for LARS. Your health-care provider can refer you to a nutritionist who can help regulate your diet.

Patients often find that certain foods trigger their bowel symptoms, and many will alter their diet to help improve these symptoms. It is generally recommended that patients avoid foods that lead to softer stools (e.g., caffeine, alcohol, spicy food and fatty foods).

Eating a high-fiber diet can help make stools more solid in consistency, decreasing urgency, clustering and soilage. Soluble fiber is generally well-tolerated, however, it can lead to bloating and increased stooling. Determining the optimal amount of fiber intake can therefore be tricky. If you are unsure of what to do, your health-care provider can refer you to a dietician, who can provide expert advice and help you find the right balance.

Some helpful hints:

• Chew food thoroughly.

• Try small, frequent meals (five to six) per day. Skipping meals may worsen watery stools and cause increased gas.

• Add new foods one at a time to determine the effect it has on your bowel movements.

• Drink plenty of fluids. Sip fluids slowly and drink either between meals or at the end of a meal.

• Avoid caffeine and/or alcohol. This can worsen stool output.

• Eat foods high in soluble fiber and use fiber supplements.

• Milk and milk products contain lactose and can worsen diarrhea for some people. Try lactose-free milk.

Medication

Your health-care provider can prescribe you certain medications to help with individual symptoms.

• Loperamide and lomotil are constipating agents that can help with symptoms of diarrhea.

• Ramosetron (a serotonin receptor antagonist) can help with the feeling of urgency after meals.

• Antibiotics, such as rifaximin or neomycin, can help with bacterial overgrowth, particularly gas or bloating.

• Enemas are medications inserted anally. They are injections of fluids used to cleanse or stimulate emptying of your bowel. They can help prevent accidents by keeping your lower bowel empty.

Patients with major LARS (LARS score greater than 30) will often require a few different types of therapies rather than medical treatment for individual symptoms. Additional therapies can include pelvic floor rehabilitation, transanal irrigation and sacral nerve stimulation.

Physical Therapy

Pelvic Floor Muscle Training

The pelvic floor is a connection of muscles, ligaments, tissues and nerves arranged to form a hammock at the bottom of your pelvis.

Pelvic floor physiotherapists are experts in the muscles and function of the pelvic floor. They can help train your muscles to restore strength, coordination and control. Patients often find working with a physical therapist helpful to gain better control of their bowels. Muscle training can help reduce leakage by improving structural support, timing and strength of muscle contractions.

Biofeedback Training

Your physical therapist may also suggest biofeedback training. Biofeedback uses electrical sensors that help you receive information about your body. This feedback can be helpful if you have problems locating the right muscles during your therapy. It can help you synchronize your muscle contractions to empty your bowels.

Rectal Balloon Training

Rectal balloon training involves inserting a small, soft balloon into the rectum. This is attached to a syringe that injects either water or air into the balloon, causing it to expand. This provides feedback on rectal sensation and allows patients to practice expelling the balloon, training and coordinating bowel function.

Peristeen

Peristeen is an irrigation system that uses a catheter to introduce water through the anus and lower colon to “clean out” and evacuate feces. This empties the lower bowel for a prolonged period of time, reducing clustering and frequency of bowel movements.

Patients have found Peristeen very helpful, as they can control the timing of their bowel movements. You can speak to your health-care provider to see if you are a candidate for Peristeen. The process of using Peristeen does require some training, and you will be supported by a specialist until you are able to use it independently.

Sacral Nerve Stimulation

Sacral nerve stimulation, or “SNS,” is performed by surgically inserting a small device into the tailbone area. SNS works by stimulating the nerves that supply the muscles of the rectum and anus to help improve bowel control. It is usually performed to improve fecal incontinence and help patients regain more control over their bowel movements.

SNS is a two-stage surgical procedure. The first stage consists of a two- to four-week trial period. If there is a good response, a second procedure to insert a permanent wire is performed. SNS is a safe procedure that is typically performed under local anesthesia or sedation.

Colostomy

If the methods described above do not provide adequate relief of LARS symptoms, a colostomy can be performed. A colostomy is different than the temporary ileostomy you may have had. It involves a surgical procedure to bring a part of your colon out of your abdominal wall. It allows formed feces that would otherwise come out of your anus to pass into a bag each day. This is typically a permanent solution after other techniques have failed.

It is important to remember that everyone is different. Some therapies may work for you and others may not. You may need to try different therapies simultaneously. Treatments should typically be trialed for at least four weeks to determine efficacy.

What is the LARS score?

The LARS score is an easy-to-use tool for assessment of bowel dysfunction following rectal cancer surgery. The aim of the questionnaire is to assess your bowel function.

It contains five questions. Scores from each question are added up to form a final LARS score. This score can be interpreted as:

• 0-20: No LARS

• 21-29: Minor LARS

• 30-42: Major LARS

Your health-care provider will offer you treatments depending on your LARS score. They will also use your LARS score as a way to monitor your progress.

The LARS score is available in 24 different languages at present.

What is my LARS tracker?

About Your LARS Tracker

At your first visit, you may be contacted regarding our LARS tracking system. Many patients may experience some symptoms of LARS during your treatment. To help us care for you, we will regularly send you a LARS questionnaire so that we can track and treat your symptoms. Your responses will help us understand how you are feeling and whether we need to undertake any interventions to help you.

What will happen to my responses?

Your responses will be sent to your rectal cancer team. Based on your responses, someone may contact you or you may be asked to attend our clinic to provide more information.

Your information is private and confidential — only your health-care team at Johns Hopkins will see it.

Support Groups

Your surgeon and cancer nurse specialist will provide guidance and support throughout your rectal cancer care. Please do not hesitate to reach out if you need advice or help. There are also a variety of support groups available for patients with LARS; these can be invaluable, and it is important to remember that you are not alone in this journey. Available support groups will be listed on this page. 

Important Contact Information

Pelvic Floor Physical Therapy with Biofeedback

Try to find a physical therapist that uses biofeedback to treat pelvic floor dysfunction. You can make an appointment with the pelvic floor physical therapy group at Hopkins, however, the wait can be several months.

Alternatively, there is a website — aptapelvichealth.org/ptlocator — that you can use to find therapists closer to home that may have shorter wait times. You can either use the main PT locator directory by entering your ZIP code and selecting the specialty you are looking for, or you can look under the general PT locator and click on the link under “additional directories” that says “find a physical therapist – CAPP Pelvic Certificate” to look for someone with confirmed certification in pelvic floor therapy. Either way, once you have identified a therapist, you should call their office and ask if they specifically treat “dyssynergic defecation/pelvic floor dysfunction with biofeedback.”

For your convenience, below is a list of physical therapists in Baltimore who may be close to home. Since therapists often change locations, please call the facility and ask if they specifically treat “dyssynergic defecation/pelvic floor dysfunction with biofeedback” before booking your appointment.

Johns Hopkins Bayview Rehab Services
4940 Eastern Ave., Baltimore, MD 21224
Phone: 410-550-0414

Johns Hopkins Outpatient Center
600 N. Wolfe St., Meyer 1-130, Baltimore, MD 21287
Phone: 410-614-3234

Claudette Cole, DPT; Kim Keller, PTA
Greater Baltimore Medical Center
6701 N. Charles St., Suite 4377, Baltimore, MD 21204
Phone: 443-849-6210

Vernise Burs, PT
Burs & Garrett Physical Therapy, Inc.
2530 N. Charles St., Suite 102, Baltimore, MD 21218
Phone: 410-889-7872

Samantha DuFlo, PT
Physiotherapy
2000 Girard Ave., Baltimore, MD 21211
Phone: 410-279-8231

Laura Keyser, PT
Metta Integrative Wellness Center
720 W. 36th St., Baltimore, MD 21221
Phone: 415-699-0984