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Patients who undergo surgery for rectal cancer are often faced with a "new normal." Colorectal surgeon Dr. Marylise Boutros of Cleveland Clinic Florida joins Butts & Guts to discuss Low Anterior Resection Syndrome (LARS), a group of symptoms patients may experience after treatment. Listen to learn more about how to recognize triggers and take control of symptoms.

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Low Anterior Resection Syndrome

Podcast Transcript

Dr. Scott Steele: Butts and Guts, a Cleveland Clinic podcast, exploring your digestive and surgical health from end to end. Hi again everyone, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the chair of colorectal surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today, I'm very pleased to have Dr. Marylise Boutros, who is a colorectal surgeon in Cleveland Clinic Florida's Weston Hospital and the regional Digestive Disease Institute Director of Research. Marylise, welcome to Butts and Guts.

Dr. Marylise Boutros: Thanks for having me.

Dr. Scott Steele: So, it's absolutely so good to talk to you today. And we're going to talk a little bit about something called low anterior resection syndrome, and we'll get to that in just a bit. But first, for all of our listeners who know, we always start out by asking you to tell us a little bit about yourself, where you're from, where'd you train, and how did it get to the point that you're here at the Cleveland Clinic?

Dr. Marylise Boutros: Amazing. I trained at McGill University. I'm born and raised in Montreal, Canada and I did my general surgery training there. And after finishing training, I came to Cleveland Clinic Florida here to learn colorectal surgery, where I stayed for two years. Following that time I went back to Montreal, Canada at McGill University where I worked as a colorectal surgeon, and led an active research program for 12 years, and then came back to beautiful Florida and the beautiful Cleveland Clinic to lead research here and work as a colorectal surgeon.

Dr. Scott Steele: Well, welcome back home and we are extremely excited to have you back. And so today we're going to talk a little bit about low anterior resection syndrome, otherwise known as LARS. So at a very high level to start, what is LARS? Can you explain it to our listeners?

Dr. Marylise Boutros: Yes, absolutely. So low anterior resection syndrome is a group of symptoms that patients experience after having treatment for rectal cancer, most typically. And the most common operation is a low anterior resection, which is removal of the entire rectum or part of it, and connecting the colon to the anus. So patients don't need a permanent bag with this operation, which is great, but the ensuing bowel function afterwards is definitely a new normal. So it's the disturbance of bowel function and that's what low anterior resection syndrome is.

Dr. Scott Steele: So, can you talk a little bit more about the symptoms of LARS and then more specifically, is there something that is a diagnostic test specifically for LARS or is it just more this constellation of symptoms altogether?

Dr. Marylise Boutros: Yes. So the symptoms of low anterior resection syndrome are frequent bowel movements, sometimes urgency to have the bowel movements, and then this phenomenon of clustering where the patient feels like they need to go to the bathroom, they go, they have a small bowel movement, they come back out, oh, and a few minutes or an hour later back in the bathroom again. And in out in of the bathroom for several hours, most often, which is called clustering. The other symptoms are, could be incontinence of some gas, incontinence of liquid stool.

And things that aren't typically talked about but are also part of this low anterior resection syndrome are a feeling that you need to go, and then you go to the bathroom and there's nothing there, or pain upon evacuation, or just difficulty getting the stool out when you go to evacuate. So all the symptoms together make up low anterior resection syndrome. There is no one test to define low anterior resection syndrome and often people don't know the name of the symptoms they're having. They may find that they have a complication or something went wrong with their surgery, when in fact more than half of people who have a low anterior resection will have these symptoms. So it is the constellation of symptoms and there's a score to calculate and measure it, but there is no one specific test.

Dr. Scott Steele: So, a lot of listeners may come to this podcast as they are embarking on a journey that might unfortunately lead them down to the road where they need to have a surgical removal of their rectum. And knowing now that there is the potential for LARS syndrome, are there steps that a patient can take prior to a surgery that may result in LARS that could prevent this from occurring post-op?

Dr. Marylise Boutros: Well, first and foremost is learning about it. I find that a lot of patients don't really know what's going on in their body. And so the fact that you're listening to this and you know, and can expect some of these symptoms, help guide the management afterwards. So I would say there is not too much one can do to prevent LARS except take care of themselves and be physically well. The reason being that when we cut bowel and we connect it back together, there is a small chance that the connection doesn't heal and that's called a leak. And leak has been shown to create like concrete in our pelvis where the new connection is supposed to sit and thus it doesn't function as well.

Things that can increase your risk of leak are smoking, excessive alcohol, being overweight. Things like that are things in our control that we can be healthier. So eating a good diet, being physically fit, avoiding smoking and alcohol, especially as you're entering an operation of removal of the rectum for a tumor, will decrease the chance of leak and that will also decrease the chance of LARS. More than that, the rest of the things are in our control with the way we treat rectal cancer and then we also work together to manage LARS.

Dr. Scott Steele: So, what are the best ways to manage lower anterior resection syndrome?

Dr. Marylise Boutros: Firstly, recognizing what's going on. So when patients feel like, "Oh, my bowel movements are very disordered," I would say keep an eye on what things are triggering it. Some foods and drinks can trigger LARS for different people and they're different for each person, but some very common things is like roughage, like salad and drinking things like alcohol, caffeine and sugary drinks. Those are common aggravating factors. So I would say keep an eye on your symptoms for the first couple of weeks and see what things are aggravating you, and try to eliminate some of them or monitor when you take them, knowing that your bowel movements will be connected to that.

Second thing that can be done is using fiber and anti-diarrheal like Imodium, which are over the counter. These slow down the bowel movements or help them clump together so that we don't get the clustering symptoms, which can be very bothersome especially initially after having surgery. And I'd say the third thing is to speak to your provider and speak to your doctor about what's going on because oftentimes we feel like the doctor is just interested in our cancer and making sure that the cancer is gone and that we have recovered without complications, but you're treating team really does care about this symptom or this combination of symptoms. And so bringing it up and discussing it so that it can be managed with other adjuncts as well.

Dr. Scott Steele: Truth or myth, truth or myth, LARS symptoms only last six months after surgery?

Dr. Marylise Boutros: Unfortunately, myth, but we can mitigate them. So the first six months are probably where it's roughest and where it's important to speak up about them and seek help for them. And then patients really figure out a new normal that they can live with and can use other things like pelvic physiotherapy, and we have a few other techniques and technologies to treat LARS that can make life very good. But LARS is usually here to stay.

Dr. Scott Steele: Yeah. And that goes into my next question. So I was going to say, is there a cure for LARS?

Dr. Marylise Boutros: Unfortunately, not. There is no cure for LARS as we speak today, but there are very good ways to manage the symptoms and mitigate them. Other than the things that I've discussed, there's irrigation, which is a very cool strategy that a lot of patients feel like their LARS is really under control with it, where the patient can learn to clear out their entire colon, at first every day, then every other day or every two, three days, so that there are controlled bowel movements. You irrigate the colon and then you're done for the day and don't have to worry about your bowel movements, at least for a couple of days. There's also sacral neuromodulation, a pacemaker that we can put in. It's used for fecal incontinence and urinary incontinence and other indications, but it can also help LARS. So we don't have a cure, but we have very good management strategies.

Dr. Scott Steele: So, one of the things you mentioned earlier was that patients should talk to their doctor about this. And so what questions should they ask their doctor when exploring treatments for LARS?

Dr. Marylise Boutros: First I would say, ask if there's a specialized nurse at the institution that can help with these symptoms, or if there is a doctor like myself who's really interested to manage LARS, it often can be someone other than the rectal cancer surgeon, perhaps, that can help. The second thing I would say is if they've already tried diet, fiber and anti-diarrheal to ask if there's an irrigation program that they could use for sacral neuromodulation as well as pelvic floor physiotherapy.

Dr. Scott Steele: So, are there any advancements on the horizon regarding low anterior resection surgery that may lead to the prevention of LARS?

Dr. Marylise Boutros: Yes, there are. And say in overall how we treat rectal cancer. Now people are very aware of LARS and so have it in mind as something that they want to improve as we evolve our rectal cancer treatments. Firstly, minimally invasive surgery is starting to show that it is actually better in terms of preserving nerves and function. And so minimally invasive surgery as it evolves and improves and more people use it, I think will improve our rate of LARS. In addition, the way we treat the rectal cancer, sometimes we give chemotherapy and radiation and we can get it to melt away completely, and just observe and rather than operate for rectal cancer, and that decreases the chances of LARS as well, even though the radiation does cause some LARS, but at least the patient will keep their rectum.

Dr. Scott Steele: Okay, so now it's time for our quick hitters, an opportunity to get to know our guests a little bit better. So first of all, what was your first car?

Dr. Marylise Boutros: My first car was a Nissan Pathfinder.

Dr. Scott Steele: Nice, nice, nice. What color was it?

Dr. Marylise Boutros: Black.

Dr. Scott Steele: Nice. And so what is your favorite meal?

Dr. Marylise Boutros: Oh, sushi.

Dr. Scott Steele: I got to ask you this being a Canadian originally, so is there a favorite Canadian meal, specifically?

Dr. Marylise Boutros: Poutine.

Dr. Scott Steele: There we go. I was hoping it would be that. That's fantastic. And so what's a sport that you like to play?

Dr. Marylise Boutros: I used to play soccer.

Dr. Scott Steele: And so finally for the last question, I normally ask people a little bit about living here in Northeast Ohio, but you traveled back and now live in Florida. Name something that you like about living in the southeast United States.

Dr. Marylise Boutros: Oh, I love that the day has more to it. Coming from the Canadian north, the day has a little bit more to it and the kids can play in the afternoon, I can go for a walk and it's a longer, more beautiful day.

Dr. Scott Steele: Oh, that's fantastic. So give us a final take-home message to our listeners about LARS.

Dr. Marylise Boutros: My take-home for LARS is that it is a group of symptoms that all patients who will undergo rectal cancer treatment will experience to some degree. It's in our control and it's something that is very important to discuss with your provider and get some help with, so that you can overcome it and establish a new normal that is very livable with a good quality of life.

Dr. Scott Steele: Oh, that's fantastic advice. And so to learn more about low anterior resection syndrome or to schedule an appointment for treatment at Cleveland Clinic Florida, please call 833.949.2981. That's 833.949.2981. You can also visit clevelandclinicflorida.org/digestive for more information. That's clevelandclinicflorida.org/digestive. Dr. Boutros, thanks so much for joining us on Butts and Guts.

Dr. Marylise Boutros: Thank you for having me.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.

Butts & Guts

Butts & Guts

A Cleveland Clinic podcast exploring your digestive and surgical health from end to end. You’ll learn how to have the best digestive health possible from your gall bladder to your liver and more from our host, Colorectal Surgeon and President of the Main Campus Submarket, Scott Steele, MD.
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