Rectal cancer is often included under the term colorectal cancer, whereas patients may use the term bowel cancer instead. The rectum is the last part of the digestive system and each year in the UK about 12,000 people in the UK will be diagnosed with a cancer within their rectum (Office for National Statistics [ONS], 2019).  

Rectal cancer can present with fresh, red blood being passed from the anus or a change in bowel habit. The most common treatment for rectal cancer is surgery and this can be in conjunction with chemotherapy and/or radiotherapy. Historically, the operation of choice for a rectal cancer was removal of the rectum as well as the anus, which resulted in a permanent colostomy and was termed an abdominoperineal resection of the rectum. Advances in surgery mean that a permanent stoma can be avoided in many cases. The rectum is still partially or completely removed, but the remaining ends of the bowel are rejoined (anastomosed). This operation is termed an anterior resection. There are variations of the operations, such as a low or ultra-low anterior resection for cancers that are in the lower portion of the rectum. Another variation of an anterior resection is a total mesorectal excision (TME). A TME is undertaken for people with a low rectal cancer and includes removal of not simply the rectum, but also the surrounding tissues which contain the blood supply and lymphatic system (Bunni and Moran, 2019). Excision of the mesorectum means that the tissues that are nearest to the cancer, which might have microscopic spread into either the veins or lymphatics, are also removed, reducing the risk of rectal cancer recurrence (Bunni and Moran, 2019).  

LOW ANTERIOR RESECTION SYNDROME (LARS)  


Surgery, while being an excellent way to physically remove a cancer, is not without subsequent consequences which nurses may be asked to help with. There can be problems with urinary, sexual and bowel function. Changes in bowel function are common, occurring in up to 80% of people after an anterior resection (Martellucci, 2016) and are collectively termed low anterior resection syndrome or LARS, the focus of this article. 

WHO IS AT RISK OF LARS?  


There are several potential risk factors that may result in LARS. The most common are thought to be: 
  • Radiotherapy  
  • Low rectal tumours  
  • Having a temporary ileostomy (Ye et al, 2021).  
Women are thought to be more at risk (Battersby et al, 2018) due to having a physically shorter anal canal. Radiotherapy is thought to cause nerve damage, in addition to the nerve damage caused by having surgery. Radiotherapy also makes the tissues within the rectal wall less flexible due to fibrosis (Ye et al, 2021). Low rectal cancers result in a physically reduced storage capacity for faeces, as most of the rectum is removed (Ye et al, 2021). The reasons behind a stoma formation potentially causing more problems include a stoma being formed for lower cancers as well as the duration being increased if a complication occurs for example (Vogel et al, 2021). A temporary stoma might also result in changes in the bacteria within the colon and rectum. Understanding these risks will enable nurses to have a greater understanding of who is more likely to encounter problems after their anterior resection.  

BOWEL SYMPTOMS AFTER RECTAL CANCER TREATMENT  


The number of potential bowel symptoms that occur after an anterior resection are broad. When assessing bowel symptoms, it is important to exclude red flag symptoms that might indicate that the cancer has recurred, such as rectal bleeding. There are eight common bowel changes that occur after an anterior resection (Keane et al, 2020):  
  • Variable, unpredictable bowel function  
  • Difficulty emptying the bowels  
  • Altered consistency of faeces  
  • Bowel urgency  
  • Bowel frequency  
  • Anal, flatus or faecal incontinence  
  • Repeated painful stools  
  • Soiling.  
These bowel symptoms might also occur at night. Additionally, patients may not be able to determine the difference between flatus and faeces. What is important to realise is that patients may not discuss these bowel changes due to embarrassment, or because they think that these are consequences of having their cancer removed (Taylor and Morgan, 2011). Thus, nurses need to actively enquire about bowel dysfunction. 

CONSEQUENCES OF LARS  


Bowel symptoms can be severe for up to two-thirds of people (Pape et al, 2021). Bowel problems can result in reduced quality of life due to patients becoming dependent upon knowing where the toilet is. It is hard to function physically, particularly if people have severe bowel symptoms. Patients with urgency may only have a very short time to get to the toilet once they get the sensation to defecate, sometimes this can be seconds rather than minutes, meaning leaving the house can be difficult. Other patients report that they are unhappy with their bowel function and are preoccupied with their problems, and that they are constantly thinking of ways to manage day-to-day activities, for example. Patients also report that they need to take drugs such as loperamide to give them more confidence to leave their house: ‘When I go outside, I usually take some medicines’ (Tsui and Huang, 2021).  

It is not uncommon for patients to report that they go to the toilet so often that their perianal skin is painful and bleeding, particularly in the first few weeks after surgery. In the author’s clinical experience, simple skin care and barrier creams are usually effective to ameliorate perianal skin damage. Other effects of bowel dysfunction include a negative impact on emotional wellbeing. Patients report that they have needed to make changes to their daily lives — be that work, in their relationships, their occupations or with their partner (Burch et al, 2023). To travel to work some people do not eat for fear of needing to use the toilet while travelling (Landers et al, 2012). Thus, bowel dysfunction can have many negative consequences and impacts on patients’ lives. It is important, therefore, for nurses to understand potential problems so that they can help patients find coping strategies to have a good quality of life.  

ASSESSMENT  


When undertaking a nursing assessment, it may be noticed that the patient has not left the house since their operation. Discussion can establish the reasons behind this. Additionally, the nurse can assess the patient’s bowel function. This might include questions about how their bowels are functioning, for example, has their bowel function improved since surgery and how the changed bowel function is affecting them. It is important to establish not only what is the worse bowel symptom, but also what is the patient’s goal. Although this article is only focusing on bowel, it is of course important to undertake holistic assessment to determine if patients have other issues, such as urinary dysfunction, after their rectal cancer treatment.  

It is vital to recognise that many patients do not understand the mechanisms behind their bowel changes. This can be an important place to start, i.e. explaining:  
  • To the patient about the storage role that the rectum undertook  
  • That storage is no longer possible now the rectum has been removed  
  • That reduced storage facilities for faeces can result in needing to go to the toilet more often to pass small amounts of faeces.  
Understanding why changes happen is often important to patients (Burch et al, 2023). It is normal for improvements in bowel function to occur in the first three months after surgery. After which time smaller, gradual improvements can occur, most within the first two years after surgery. However, patients often need nursing or medical intervention to try and resolve or improve bowel issues.  

INTERVENTIONS  


Interventions will depend upon the bowel symptoms reported. Nurses are experienced in medications that might be useful, for example, anti-motility drugs. People passing frequent loose motions may benefit from thickening the stool with medications such as loperamide, with or without bulking agents (Christensen et al, 2021). Loperamide can also help reduce faecal incontinence. For people who pass small frequent stools, especially when the bowel movements cluster in the morning for example, bulking agents can be useful (Bradshaw, 2022).  

Another intervention is to alter the diet to include more foods that are low in fibre. This can include changing wholemeal versions of bread and cereal for plain versions.  

Caution is needed to ensure that the patient does not miss out on any important food groups and if they have additional needs, such as diabetes, it is important to involve a dietitian. Patients often want to have an information sheet to serve as a reminder, which may be available from the local dietitian. Patients who have difficulty evacuating their bowel motion may benefit from some toilet training, such as the correct position to adopt when using the toilet, which is knees higher than hips (using a small stool if needed), being relaxed, leaning forwards with elbows on knees and bulging out the abdomen, as this helps to position the rectum for defecation. Pelvic floor exercises are also potentially useful for all patients to undertake (Vogel et al, 2022). 

As said, people who are going to the toilet frequently might quickly have perianal skin damage. There are several measures that might be useful. Skin can be protected using a cream such as a barrier cream. If pain is an issue, sitting in a shallow warm bath can help soothe the skin damage. Using soft or moist tissue can help prevent skin damage. There are some simple interventions that nurses can suggest. Sometimes people will try without healthcare professional assistance to introduce interventions such as loperamide. However, they might need guidance on how best to take medication for greatest efficacy (Pape et al, 2022a). For optimal effect if used regularly for someone with LARS, it can be ideal to take loperamide 30–60 minutes before meals and/or bed to slow the bowels rather than wait for an episode of loose stool. Nurses are in an invaluable position to be able to help with some of these management strategies.  

PRACTICE POINT 


It is important to recognise that without intervention some bowel dysfunction will improve within three months. However, for many patients, even with interventions, their symptoms might persist in the long term. Nurses should ask about bowel dysfunction and how it is affecting the patient. This is because patients will often not volunteer information without being asked, out of embarrassment or not wanting to be a burden to their family or healthcare professionals (Pape et al, 2022b). The LARS score is a simple five-question questionnaire that can guide nurses (Emmertsen and Laurberg, 2012).  

Questions cover:  
  • ● Flatus incontinence  
  • ● Liquid stool incontinence  
  • ● Stools passed in 24-hours  
  • ● Stool clustering  
  • ● Urgency. 
There are a number of given responses, and these are weighted, and scores categorised into three groups: no LARS (0–20), minor LARS (21–29), and major LARS (30–42). For patients scoring the highest score, most will need specialist intervention. However, nurses can offer initial advice, such as about diet, exercise and medication. 

Further interventions


If these interventions are not working to the satisfaction of the patient, onward referral might be necessary. In the author’s clinical experience, for additional dietary needs a dietitian is invaluable — one with an interest in bowels is advantageous. For exercises and mechanisms to assist with bowel control biofeedback or pelvic floor, specialists are useful. Other treatments, such as transanal irrigation, may also be offered. There is growing evidence that interventions for faecal incontinence and constipation are also beneficial for people with LARS, including percutaneous tibial nerve stimulation (PTNS) (van der Heijden et al, 2022). For more complex medication, gastroenterologists might undertake additional tests looking for a differential diagnosis such as small intestinal bacterial overgrowth (SIBO) or bile salt malabsorption (Christensen et al, 2021). There are also surgical options to improve bowel function, such as antegrade irrigation via an ACE (antegrade continent enema). Another alternative is sacral neuromodulation, also termed sacral nerve stimulation, to try and stimulate nerves that may have been damaged to improve bowel function. It is also possible to have a stoma formation, a permanent colostomy, if problems are not resolved with other strategies (Christensen et al, 2021).

CONCLUSION  


Treatment for rectal cancer can result in bowel dysfunction. Nurses need to ask about symptoms and what is most bothersome for the patient. This assessment can guide simple interventions, such as medication to slow the bowel, and improve faecal incontinence. Perianal skin damage can be prevented using a barrier cream, or pain improved by sitting in a warm bath. If the nurse is not able to resolve problems, referral to a specialist may be needed. The appropriate specialist will need to be carefully considered and will depend on individual assessment. 

KEY POINTS 

  • ● The common treatment for rectal cancer is surgery, such as an anterior resection which may also be combined with chemoradiation. Treatment for rectal cancer, however, is likely to cause subsequent problems with bowel function 
  • ● Changes in bowel function are common, occurring in up to 80% of people after an anterior resection (Martellucci, 2016) and are collectively termed low anterior resection syndrome or LARS 
  • ● Bowel problems can result in reduced quality of life 
  • ● It is important for nurses to understand potential problems so that they can help patients find coping strategies to have a good quality of life 
  • ● It is vital to recognise that many patients do not understand the mechanisms behind their bowel changes 
  • ● If the nurse is not able to resolve problems, referral to a specialist may be needed.  
Jennie Burch is head of gastrointestinal nurse education, St Mark’s Hospital 
This piece was first published in the Journal of General Practice Nursing. To cite this article use: Burch J (2023) Rectal cancer and low anterior resection syndrome. J Gen Practice Nurs 9(2): 54–57

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