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Management of the anterior resection syndrome

02 July 2013

Mhairi Collie and Wendy McFarlane, Edinburgh Presented at ACPGBI Liverpool 2013, 3 July

Anterior resection syndrome is defined as a miserable combination of: “Increased number of daily bowel movements, erratic defecatory patterns, urgency, tenesmus, obstructed defaecation and minor faecal leakage”. Symptoms can certainly be so bad that life with a stoma can seem preferable. There are treatments to try, however, before settling for a stoma. It is important to note from the literature that symptoms in many patients reduce significantly by one year post-operatively. Risk factors for developing anterior resection syndrome include low level of anastomosis, having radiotherapy to the pelvis, and perhaps having a straight anastomosis rather than a pouch. It may be possible to reduce the incidence of anterior resection syndrome by meticulous nerve preservation, minimising the use of diathermy and altering the type of anastomosis. Clearly the level of anastomosis and need for radiotherapy are unlikely to be negotiable from a cancer clearance perspective. The mainstay of treatment is medical, including judicious dietary advice, use of loperamide, stool bulking agents, amitriptyline and smooth muscle relaxants. Other treatment modalities include biofeedback, rectal irrigation and sacral nerve stimulation. Biofeedback can improve coordination of a more effective defaecatory mechanism and can be used to induce sphincter muscle strengthening. Rectal irrigation allows the patient to actively manage their defaecation in a controlled fashion, significantly reducing the daily inconvenience from frequent urgent and uncontrolled motions. Sacral nerve stimulation has been reported in case studies to be effectual in reducing incontinence, clustering and frequency of defaecation. We have a series of 20 patients from Edinburgh in whom sacral nerve stimulation has successfully treated their incontinence from anterior resection syndrome. Comparing these types of patients with those incontinent from obstetric aetiology, we found no difference in the efficacy of SNS. In summary, many patients can achieve a reasonable quality of life with various treatments for anterior resection syndrome, and hopefully the need to resort to a stoma may be confined to a small minority.
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