Teddy Fletcher, General and Colorectal Surgical Registrar and Clinic Research Fellow at Imperial College London
The traditional abdominal perineal resection (APR) with a permanent end colostomy has been superseded by increasingly low sphincter preserving anterior resections. However, these advancements have come with functional consequences: up to 80% of patients undergoing low anterior resection (LAR) will develop a significant degree of bowel dysfunction following their surgery, which persists for up to 15 years post-surgery in 50% of patients.
The above-described incidence of LARS and consequential negative impact on patient QoL means its management must be prioritised and streamlined. Whilst there has been a significant amount of research into its optimal management, there is, to date, no gold standard. As such, the majority of colorectal centres offer no or, at best, ad-hoc treatment for LARS. These patients often return to a conventional outpatient colorectal clinic where management is variable, time consuming and often ineffective. The obstacle to increasingly low resections, therefore, is not oncological clearance, but functional outcome. We therefore hypothesised that a specialised clinic is both an innovative and logical progression in the management of LARS.
In July 2018, WHHT, in collaboration with MacGregor Healthcare, set up a holistic specialised nurse-led LARS clinic with the aim of managing LARS. As far as the authors are aware, WHHT is the only colorectal cancer centre in the United Kingdom to run a dedicated LARS clinic for the management of this syndrome. Following a formal assessment of the clinic (pending publication) we have demonstrated that there is high satisfaction with our LARS clinic, and that patients attending the clinic have lower LARS score and less major LARS than has been previously reported in the literature.
‘The Watford LARS Pathway’ was created in cooperation with Vanash Patel, Consultant Colorectal Surgeon at West Hertfordshire Hospitals NHS Trust (Watford, St Albans and Hemel Hempstead Hospitals), who was the supervising consultant for this project.