February’s Paper of the Month has been simultaneously published in the three most important colorectal journals: Colorectal Disease, ANZ Journal of Surgery and Diseases of the Colon & Rectum. Through sound Delphi methodology, a large patient-provider group reached consensus on how to define the low anterior resection syndrome.
International consensus definition of low anterior resection syndrome. Keane C, Fearnhead NS, Bordeianou L, Christensen P, Basany EE, Laurberg S, Mellgren A, Messick C, Orangio GR, Verjee A, Wing K, Bissett I; LARS International Collaborative Group.
Colorectal Dis. 2020 doi: 10.1111/codi.14957; ANZ J Surg. 2020 doi: 10.1111/ans.15421; Dis Colon Rectum. 2020; 63:274-284. doi: 10.1097/DCR.0000000000001583.
What is known on the subject?
The rising percentage of sphincter-sparing rectal resections and improvement in oncological results after rectal cancer treatment have heightened awareness of survivorship issues, including bowel dysfunction. Consequently, clinicians and researchers have been urged to look beyond survival and recurrence as the sole measures of treatment success.
The term 'low anterior resection syndrome (LARS)' describes 'disordered bowel function after rectal resection, leading to a detriment in quality of life'. Although pragmatic, this definition can incorporate a vast array of symptoms with consequent heterogeneity in reporting that makes it impossible to accurately identify the prevalence of LARS. Development of a validated patient-reported outcome measure, the LARS score, has improved the standardisation of reporting and prevalence of LARS using this tool is reported to be 41%. The LARS score has good psychometric properties and has been validated in multiple languages but it may significantly underestimate the impact of evacuatory dysfunction and may not accurately assess the impact of symptoms on an individual patient's quality of life.
What this study adds
This international patient–provider initiative used robust methodology to reach a consensus definition of LARS. This is the first attempt to define LARS that, from conception, incorporated multiple stakeholders and prioritized patient views. Patients served not only as participants, but also as investigators with active steps taken throughout to ensure that the patient perspective was recognised and amplified. This key factor is likely to have contributed to a broader definition that accurately captures real-world clinical experience. The major finding of this consensus definition is that both symptoms and consequences of LARS are important, identifying eight symptom complexes and eight consequences that are considered to be of the highest priority when defining LARS. The consensus work suggests that the impact of LARS is such an important component that it is necessary to specify the various dimensions that may be impacted by symptoms of LARS.
Implications for colorectal practice
Engagement of the wider patient community through advertising the project via social media and involvement of patient participants active in peer support groups may allow wider dissemination of the proposed definition. Further work is needed to transform the definition presented into a scoring system, but authors suggest that inclusion of specific patient-centred consequences may allow development of a refined tool with greater discrimination of changes that occur over time and with treatment.
The production of an easily recognizable visual aid will hopefully allow for greater awareness of LARS by both patients and clinicians, and may enable more patients to receive professional help for their symptoms. Acknowledging that both symptoms and consequences are important will enable better identification of rectal cancer survivors who experience bowel dysfunction, more accurately assess its severity and enable more precise evaluation of treatment approaches for LARS.
