WCET® Webinar on Low Anterior Resection Syndrome After ... sfter stoma closure webi… · A world...

10/11/2019

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WCET® Webinar on

Low Anterior Resection Syndrome After Stoma Closure

Denise Hibbert

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In Celebration of World Ostomy Day


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Low Anterior Resection Syndrome After Stoma Closure

Denise Hibbert, RGN, MSc(WHTR), BSc, DipHE, ONC, STN, FSSCRS

Consultant in Colorectal & OWC NursingEditorial Board Annals of Saudi MedicineSaudi ArabiaWCET® Education Chair 2016‐2020

In Celebration of World Ostomy Day

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Goals & Objectives

• Describe normal defaecation process & continence mechanisms

• Discuss definition of low anterior resection syndrome (LARS) & patient reported symptoms

• Describe anatomical & functional changes following rectal resection

• Identify patient & treatment related risk factors

• Discuss assessment & management in relation to current practice


LARS – Definition

Low Anterior Resection Syndrome:

“Disordered bowel function after rectal resection leading to a detriment to quality of life” (Bryant et al 2012)

• Occurs 25‐80% ‐ severity & duration varies

Graphics free public domain

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Background Globally 1.8 million new cases of colorectal cancer 2018

Rectal Cancer accounts for 1/3rd of all colorectal cancers

Sphincter sparing surgery – LAR, now surgery of choice

Advances in treatment – increasing colorectal cancer survivorship – more individuals with LARS

Pathogenesis LARS poorly understood & poorly managed

Common risks ‐ lower anastomosis & radiation

ETs/OWC Nurses, well positioned to assess & manage symptoms

(Kapiteijn et al 2001, Pachler et al 2005 & 2012, Desnoo et al 2006, Cornish et al 2007, Bryant et al 2012, Bleier et al 2013, Pucciani 2013, Martalucci 2016, Chen 2016, Steineck et al 2016, Tenti et al 2018, Croese et al 2018, World Cancer Research Fund 2018, Kupsch et al 2018, Jimenez‐Gomez et al 2018)


Symptoms– Frequency of stool

– Urgency

– Inability to distinguish gas from stool

– Faecal/Gas incontinence

– Clustering of bowel motions within 1st few hours – after meal

– Fragmentation of stool, incomplete emptying

Unpredictable ‐ vary in severity and typeOften combined with urinary & sexual dysfunctionAnxiety exacerbates symptoms

Affect on QOL

(Bryant et al 2012, Bleier et al 2013, Pucciani 2013, Emmertsen et al 2012, Martalucci 2016, Chen 2016, Steineck et al 2016, Keane et. Al 2019)

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Normal Anorectal Anatomy

By Lesion at English Wikipedia, CC BY‐SA 3.0, https://commons.wikimedia.org/w/index.php?curid=32927673

A PuborectalisB Rectum

C Anorectal Angle

D Anal Canal

E Anal Verge

F Internal & External Anal Sphincter

G Coccyx & Sacrum

H Pubic Symphysis

I Ischium

J Pubic bone


Dynamics of Normal Defaecation Mass movement in colon, propagated by gastrocolic reflex

Rectal distention – stretch receptors ‐ urge defaecate

Involuntary relaxation internal anal sphincter (IAS) – rectoanal inhibitory reflex (RAIR) ‐ sampling mechanism

Sensory awareness (cerebral cortex) ‐ gas, liquid, solid (?urgent)

Motor impulses, rectosigmoid contraction, aided by raising intra‐abdominal pressure (pressure gradient)

Relaxation of puborectalis & anal sphincter ‐ defaecation

Closing reflex ‐ IAS

(Sagar 1996, Bharucha et al 2006, Palit et al 2012)

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Anorectum & Continence

Rectum, delay defaecation – capacity, compliance & retrograde movement of stool

Puborectalis – anorectal angle

Transitional zone – sensory receptors – messages cerebral cortex

Length & pressure of anal canal Internal anal sphincter 75‐85% resting pressure – involuntary

External anal sphincter – motor response voluntary squeeze

Delay defaecation several hours (depends stool consistency)

(Rao et al 2004, Bharucha et al 2006)


Rectal Cancer Treatment

• Early stages – surgical resection or local excision, type depends on distance from anal verge

– APR (permanent stoma) or LAR (sphincter sparing)

• Clinical cancer stage II and above

– Neoadjuvant chemoradiation

– Surgical resection ‐ >50% temporary stoma (ileostomy)

– Adjuvant chemotherapy

– Closure ileostomy (delays are not uncommon)

(Kapiteijn et al 2001, National Comprehensive Cancer Network 2018)

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Low Anterior Resection

16cm ‐ anal verge to sigmoid Colon

Rectum

Dentate Line

IAS

EAS

Sigmoid Colon

Anal Canal 4cmAnal Canal 4cm

12‐16cm upper rectum

8‐12cm Middle rectum

4‐8cm lower rectum Level levator ani

Anal Verge

LAR if tumour within 8cm AV

Graphics by Denise Hibbert


Total Mesorectal Excision (TME)• First described by Heald 1982• Dissection tissue surrounding rectum ‐ containing lymph nodes• Improves oncological outcomes reduces recurrence rates

Mesorectum is dissected down to level of pelvic floor

By Lesion at English Wikipedia, CC BY‐SA 3.0, https://commons.wikimedia.org/w/index.php?curid=32927673

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Mobilisation of Colon



Type of Anastomosis ‐ Pouch

Straight A

Side to end A

Transverse coloplasty

Colopouch


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Defunctioning Ileostomy

Graphics & photograph by Denise Hibbert


Anastomotic Leak Feared

• Occurs in 2‐15% of LAR cases

• More than doubles mortality rate

• Poorer oncological outcomes

• Worse LARS symptoms

• Poorer QOL

(Rullier et al 1998, Lu et al 2016, Bostrom et al 2018)

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Risk Factors LARSTreatment factors not fully understood ‐ multifactorial

Rectal resection

Total Mesorectal Excision

Direct trauma to sphincter

Level of anastomosis

Type anastomosis (neorectum)

Mobilisation colon

Defunctioning stoma ‐ time to stoma closure

Radiation

Anastomotic leak

AgePre‐op continenceDietComorbiditiesSmoking

(Kapitgeijn 2001, Herrmann et al 2003, Pollock et al 2006, Alves et al 2008, Emmertson et al 2013, Lee et al 2008, Bryant et al 2012, Bakx et al 2009, Martellucci 2016, Brown et al 2008, Portier et al 2005, Fazio et al 2013, Bregendahl et al 2013, Wells 2014, Brennan et al 2007, Kennedy et al 2008, Woo et al 2008, Chen et al 2015, Nuytens et al 2018, Haas et al 2018, Croese et al 2018, Son et al 2013, Baek et al 2014, Kupsch et al 2018, Jimenez‐Gomez et al 2018, Bostrom et al 2018, Keane et al 2019)


Patient Experience– Relief surgery over‐fear of recurrence

– Unexpected psychological difficulties after stoma closure

– Loss control/dignity‐uncertainty from day to day

“Not in control of body…Regaining control or managing control…Tied to the toilet” (Taylor et al 2010)

(Worster & Holmes 2009, Taylor et al 2011)


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Health Related Quality of Life

Complex‐multifactorial – individualized Affected culture/spirituality

“No apparent differences in QOL are found in rectal cancer patients with a permanent stoma when compared to non‐stoma patients”

(Kuzu et al 2002 & 2011, Camilleri‐Brennan and Steele 2001, Engel et al 2003, Guren et al 2005, Arndt et al 2006, Cornish et al 2007, Campos‐Lobato et al 2011, Pachler and Wille‐Jorgensen 2005 & 2012)



Patient Reported Outcomes

• 21,802 survivors ‐ 12 and 36 months

• 22% little or no control of their bowels‐ 7% significant diarrhoea

• 38% sexual dysfunction

• 18% significant social distress(DOH 2015)

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Clinical history & exam – symptoms

Patient Reported Outcomes

ARM (sphincter pressures, sensation, capacity, compliance)

Transit studies (time via colon)

MRI defaecography (action of pouch and pelvic floor)

Graphics free public domainPossible investigations


Measures

Faecal Incontinence scores

• Faecal incontinence severity index (FISI)

• Wexner scale (Cleveland Clinic)

• St Marks Continence Score (Vaizey Score)

LARS Score – internationally validated

+ QOL

MSKCC‐BFI – for pelvic radiation – lengthy

– EORTC module CR30 & CR29

– FACT‐C

– FIQL

– B‐QOL(Emmertsen et al 2012, Ihn et al 2014, Keane et al 2019)

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Emmertsen KJ, Laurberg S


• Sex stratified random sample ‐ 3440 Danish population (Civil Reg)

Aged 20‐89 years – F 50%

• Postal / electronic survey including LARS Score

Response rate all 54.5% ‐ F=54%; aged group 50‐79 = 70.5%

18.8% F and 9.6% M had LARS score >30 p=0.001

Statistically more likely physical disease

• LARS common Danish community

• Normative data now available comparison after LAR

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Treatment

• No one treatment for all patients

• Management is in accordance with individuals’ symptoms

• Based on knowledge ‐ management of faecal incontinence & defaecatory disorders


General Guidance Preoperative information & counseling

Pre‐stoma closure advise, education, counseling, exercises

Clinical Nurse Specialist –follow‐up (telephone advise)

QOL measurement (Bowel QOL)

Accurate measurement & documentation symptoms‐LARS score

Bowel management program

Psychosexual / social counselingGraphics free public domain

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Management

Empower knowledge – changed anatomy & new function

Proper position toilet – squatting

Dietary manipulation‐bowel diary

Medication manipulation‐stool consistency

Containment‐skin care

Exercises, retraining, biofeedback

Bowel management – suppositories, enemas

Coping‐waiting

Promote positive attitude

Stoma‐last resort

(Gosselink et al 2005, Koch et al 2009, Marris et al 2013, Bazzel et al 2016)



Diet• Eat regularly – do not over eat

Increase soluble fibre Reduce insoluble fibre

Oatmeal and oat bran

Apples, citrus fruits, and strawberries

Barley

Rice bran

• Avoid sugar, artificial sweetener, fructose

• Avoid alcohol and caffeine

• Avoid hot spicy & fatty foods

• Avoid dairy if lactose intolerant

• Avoid gas making foods & activities

Wheat bran, whole grains & cereals Whole‐wheat breads & wheat branSeedsSkins fruits and vegetables

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Diarrhoea ‐ Foods that Thicken Stool

• Starchy carbohydrates

– Potatoes

– White bread, rice & pasta

• Bananas

• Apples & pears skin removed

• Jelly products

• Marshmallows

• Smooth peanut butter


Medications

• Loperamide (Imodium) 2‐16 mg per day, titrate ‐ stool soft formed

– Start once per day & increase (30 mins before breakfast)

– 1‐2 capsules 30 mins before meals and at night if necessary, or

– Liquid 5ml = 1mg (easier titrate)

• Psyllium once a day at bedtime (soluble fibre)

• Codeine – may cause sleepiness

• Probiotics may help some patients

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Sphincter Exercises

Performed minimum 5 sets, 5 x per day

• Strength – squeeze as hard as you can

• Endurance – squeeze as long as you can

• Speed of recruitment – squeeze as quickly as you can

Number and type individualised to patient


Retraining / Biofeedback

• Behavioral therapy‐ greater awareness of physiological functions – improve condition

• Explain normal anatomy & function – changes

• Sphincter isolation, identification

• Exercises – Strength – Endurance – Speed recruitment

• Brace procedure‐ oblique muscle recruitment

• Sensitivity & balloon volume training

• Develop healthy coping mechanisms

• Therapeutic relationshipGraphics & photograph free in public domain

Audio/visual instrumentation

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Pelvic floor rehabilitation & biofeedback

125 identified, 5 studies met criteria, 321 patients

4 studies included biofeedback

FI scores, QOL scores, ARM in 3 studies

“PFR useful improving functional outcome after a LAR… studies of limited quality… available evidence points to the effectiveness of the procedure”


Transanal Irrigation

Quantitative studies of function

Transanal irrigation 250cc water (1000) may be useful

Generates colonic mass movements ‐?? rehabilitative effect on colonic motility or pseudo continence

(Koch et al 2009; Gosselink et al 2004, Rosen et al 2011)

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• Qualitative study ‐ Single Center, UK – LARS score > 20N=21 Diagnosed LARS ‐ irrigation n=12Minimum 3 months > stoma closureM=93%; age 36 ‐79y40% neoadjuvent radiation, 20% defunctioning stoma87% major LARSFU 1, 2 & 6 months

Results:• Decrease mean LARS from 35.93 to 17.73• Decrease FI score from 9.73 to 3.20• Pts perceiving major symptoms benefitted most‐ Improved QOL


• Single center ‐ Italy – n=331 month after surgery ‐ Major LARS score (early LARS)6 months after surgery if Major LARS score (Chronic LARS)Transanal irrigation 6 months crossed over enemas 3 months

Results: • 19 early LARS, 8 chronic LARS completed• Decrease median number daily BM ‐ 7 to 1 at 6m & 4 at 9m• Decreased median LARS score 35.1 to 12.2 at 6m and 27 at 9m• No difference between early and chronic LARS• QOL improved – irrigation SF 36

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• Single center – France

24% LAR ‐ 72% CAA ‐ 4% perineal colostomy

N=25 ACE

Reported

• Improved LARS 33 v 4 p=<0.001 &

• QOL‐GIQI 73 vs 104 p=<0.001

• 12% failure rate catheter problems


Functional differences – hand‐sewn CAA & ultralow stapled A Single‐surgeon series – 11 stapled, 9 hand‐sewn

Mean FU 2.95 years

ARM testing, Wexner FIS, (LARS) Score; SF36 HRQOL

Reported stapled anastomosis – better function no difference ARM or global QOL

Small sample, slightly more irradiated in hand‐sewn group

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• Single Center Study – Netherlands

• N=54 ‐ Laparoscopic LAR 50% ‐ TaTME 50%

• Single Surgeon experience

• FU at least 6.6 months

• Surveys included EORTC C30 and CR29 and LARS

• Reported no Sig Diff ‐ LARS Scores or QOL,

• Non‐sig higher FI scores TaTME

• Conclude TaTME still evolving ‐ may be safe alternative


8 studies identified included 1‐9 patients – most looking at faecal incontinence

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N=12 SNS Median, FU 34 monthsMedian improvement - faecal incontinence 90% & QoL 80% Small study looking at faecal incontinence


• Pilot study Single center – Spain

N=21 – LARS

12 session PTNS (30 minutes)

Decreased median LARS score from 32 to 27 p=0.009

• Small numbers, treatment only 30 mins ?? QOL & cost benefit

Photograph free in public domain

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• 117 websites, 25 met criteria

“Current online information on LARS is suboptimal

“Websites are highly variable, important content is often lacking and material is too complex for patients”.


• Focus group session, Danish population – post LARn=16, F=50%

• Audiotaped sessions x 3 – over 5 yearsInductive content analysisThemes: illness perception – preoperative care – postoperative support

Identified: • Need better screening LARS• Extension pre‐operative counseling• Social support• Better postoperative FU, contact & support

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• 242 health‐care professionals participated ‐ survey.

Most estimated prevalence major LARS is 20–40% after LAR

Only 10% of surgeons use LARS screening tools

Fewer than half surgeons use LARS scores before or after a LAR

“Majority of surgeons indicated more information & patient counselling would improve the quality of life of their patients”


Pre‐op LARS Score – predict individual risk

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ConclusionPatients should be well informed on what to expect before surgery

Information reinforced after surgery

Validated measurement instruments – used in clinical practice

PROMS ‐ QOL

ETs (OWC) nurses ideally positioned as knowledgeable experts

Advocacy, navigation, education, empathy, counseling

Prepare patients psychologically & physically

Manage chronic symptoms

Support adaptation & coping


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© WCET® 2019 www.wcetn.org

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WCET® Webinar on Low Anterior Resection Syndrome After ... sfter stoma closure webi… · A world...

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