00:00:00: Hello everyone, my name is Agle and I'm the host of UG Podcast.

00:00:04: Educational and hopefully fun dive into GI world and beyond!

00:00:08: We are very happy to have you with us for another exciting episode.

00:00:13: So today we're talking about low anterior resection syndrome or LARS for short which affects a large proportion of patients after rectal cancer surgery yet it often goes under-recognized.

00:00:26: In this episode on the consequences of proctology surgery, we are bringing you a roundtable discussion that digs into the practical questions clinicians face.

00:00:35: Who follows up these patients?

00:00:37: When should renal irrigation come in and where its limits?

00:00:42: What's their role as gastroenterologist And when is it time to escalate treatment?

00:00:48: During the discussion is Harold Rosen joined by Peter Christensen Andreas Ringg and Franco Marinello for experts who bring surgical, multidisciplinary and real-world clinical perspectives to the table.

00:01:02: If this episode leaves you wanting more... ...the full course is waiting on gutflicks.eu And there's a link in their show notes.

00:01:10: Case discussions, complete treatment pyramid….

00:01:12: …and evidence behind it all free access!

00:01:16: Now let us join our conversation.

00:01:26: or last.

00:01:28: Today I will be delighted to have an expert faculty dealing with this interesting and demanding topic.

00:01:38: my name is Harold Rosen, i'm professor of surgery at the Sigmund Freud University And I am involved in coloproctology and mainly focusing on sphincter restoration and fecal incontinence problem since many years.

00:01:55: I'm extremely happy today to present you our expert faculty, and we will start with Andreas please.

00:02:04: Yes hello my name is Andreas Rink um...I am from Essen University Hospital in Germany.

00:02:11: i'm a GIN colorectal surgery and professor for minimally invasive oncologic surgery And I mainly interested of course in minimally invasive surgery and everything that has to do with rectal replacement functionally and technically.

00:02:26: Thank you for being with us Peter please.

00:02:31: my name is Peter Christensen.

00:02:32: I'm a professor in correction surgery at Aarhus University Hospital Denmark.

00:02:38: My main focus in research is pelvic floor surgery And we have balancation following cancer treatment Danish Cancer Society National Research Center for Leicester Quillet, and among these topics we research in low anterior section syndrome.

00:02:59: Thank you for coming Peter Franco.

00:03:02: Hello everyone my name is Franco Maranello.

00:03:04: I'm a colorectal surgeon based at the University Hospital of Baldebrone in Barcelona And i basically treat patients with bowel dysfunction um impelled before disorders Among them Low Anterior Section Syndrome And my main focus in research is how can I help these patients with neuromodulation?

00:03:24: Thank you, everyone for being with us.

00:03:27: For this roundtable discussion.

00:03:29: following our course we will try the following minutes to go into more depth of some remaining questions which partially came up to me by watching your presentation and first one is Franco whom i want address too.

00:03:48: Every patient with LAS needs immediately treatment.

00:03:54: Well, that's a great question Harold because as I stated the LASCOR is very good screening

00:04:00: tool

00:04:02: but we have to keep in mind that patients with LASTCOR might not have repercussion on their daily life activities and patients with minor LAS could have a lot of repercussions.

00:04:13: so we had base our decision about on the quality of life at the patient, their daily life symptoms and also there are age under occupation.

00:04:24: And they're assessment of that their whole life not an immediate treatment for everyone.

00:04:30: so it seems to be a very individual patient-to-patient exact decision.

00:04:36: exactly The most important thing is that the patient has to know what larsie's how it impacts their quality of life, and that we can treat them.

00:04:44: That there are options that we could be...that we can give to them?

00:04:49: And after that, we can start assessing the patient and treating

00:04:52: him.".

00:04:54: So this brings up for me a question which I would like to ask everyone one you is who's seeing your patients following surgery in order make together with them decision go-for treatment?

00:05:10: Well,

00:05:12: at my institution it's me.

00:05:14: Okay?

00:05:15: But also our stoma nurses who had the patient before I lost them in closure also seized a patient and start all of the counseling and initial interventions in case they have symptoms.

00:05:28: Peter...

00:05:29: At my institution is definitely best choice to go through the nurses first because we have time and dedication for this job.

00:05:40: They are more patient than I am.

00:05:42: More patients that my corrective colleagues and they can take the time to with empathy go into.

00:05:50: this is a patient's situation.

00:05:52: set patience expectations for them, And also start these educational process within because the patients need to understand what it's going on before they can do some changes in their lives.

00:06:09: And to have our nurses do this, you need to delegate the responsibility of them.

00:06:15: You also need to back them up so they are not on their own.

00:06:19: So every time they face a hard decision with patients They can always consult back to physicians.

00:06:27: This is an important way that you should dedicate but be there for them.

00:06:32: Andreas

00:06:33: I try and keep in contact all the patient i did surgery on but I know that we definitely have the problem in Germany, many patients are lost because the centres where they do their surgery.

00:06:44: They're often not allowed to take care of the patient for a longer period and then many patients on last week go to primary care colleagues who don't know much about Larson or treatment options.

00:06:58: so my major aim is inform them exactly what Franco said therapy if they have this symptom.

00:07:09: So I tried to have the patients in contact and then know that can't contact me whenever they need help.

00:07:16: OK

00:07:16: thank you.

00:07:17: I mean a similar observation like you in Austria that sometimes people who had been perfectly operated technically of course technically excellently being operated did drop out or follow up.

00:07:35: the last problem gets completely lost.

00:07:38: And I think this is a big dilemma in which we have to overcome, hopefully with causes like these.

00:07:45: So watching and listening to your presentations...I really had that impression that trans-analyrigation.

00:07:56: I would like to ask you one by one, what are your experiences in terms of how do you use it?

00:08:09: Which pitfalls and problems do you see with this method.

00:08:13: And where is still a way to go until we have the full picture?

00:08:18: We'll do that one-by-one.

00:08:19: Franco please start.

00:08:20: Well yeah definitely transhandle irrigation has been game changer for these patients.

00:08:28: Transylvanidation was born for neurogenic problems and we translated those results into our patients.

00:08:35: And one of the biggest pitfalls or disadvantages that I see is some patients are not comfortable doing their therapy, just you know getting a catheter in to an anal canal then flushing the colon it's not very seductive option but still with Counseling and explaining the patient, setting expectations I think that we can manage to help a lot of patients with this technique.

00:09:07: Peter?

00:09:08: But on the other hand... This treatment actually allows patients to regain control over their lives And all their bowels.

00:09:15: Many last-patients experience that Their bowel has taken control over life.

00:09:22: They cannot live social life go to work, and they need to bring back control into their lives.

00:09:31: And with the therapy when it works actually you can decide when to go to the toilet and not being afraid that you will experience an accident.

00:09:43: Of course this is not a treatment for but...and You NEED TO ADAPT THAT.

00:09:49: YOU SHOULD DO THIS EVERYDAY or every second day in the way you want too and you need to continue doing so because this is not something, if your stopped using it then will go back into a bad situation.

00:10:06: One of the things we stress alot that you choose are your taught treatment.

00:10:13: So This Is Not An Over The Counter thing for last patients.

00:10:16: There's Something That Needs Instruction And Needs Adaption.

00:10:20: So you always need to decide the right volume, that type of catheter.

00:10:26: Should we use a balloon catheter?

00:10:27: Should I use a cone shaped catheter?

00:10:30: there are different pros and cons for both but in an individualized treatment pathway for and with support from their treating nurses.

00:10:41: very important when you use transient ligation for last patients.

00:10:47: Thank You Andreas.

00:10:49: Yes, I also agree that irrigation is the major player in the amaterium we have for treatment of lars.

00:10:55: This why i talk to patients first time with pre-operative counseling and say there might be a necessity do this.

00:11:04: if somebody says no way!

00:11:06: There's no chance... No way that i do transient irrigation.

00:11:09: If patient has high risk developing lars then maybe estomers are better alternative.

00:11:16: so it has very early position When I talk to the patients, but then.

00:11:21: I do store my closure first and then see if the patient develops last before or for us.

00:11:26: so i Do not do it immediately after still more closer with also some colleagues?

00:11:30: I think you'd do in many cases.

00:11:32: yeah

00:11:33: II agree with you that preoperative information about the possibility is So important thing I always say to the patient because there are other concern Is Immediately as your know when they come To You They Say Will I have a stoma?

00:11:51: And then, I can always say, ninety-nine percent you will not need the stoma.

00:11:58: But there might be...might be a price to pay for that.

00:12:02: and this is ...that we'll need transient litigation For certain time or maybe forever.

00:12:12: We've seen these nice treatment pyramid which really reflects the options and the time point when which treatment

00:12:24: should

00:12:24: be involved into management.

00:12:29: And what comes up to me is, this a question for you Peter... at what time-point are the gastroenterologists or should they be involved in the management of last patients?

00:12:44: So our sitting We involve the gastroenterologist for in two specific settings.

00:12:53: If we have a diarrhea dominant last patient, we need to find the cause of the diarrhea because and then treat the course Because if you don't treat that course You will never succeed with any other treatment.

00:13:09: That would be transient legation, sacral nerve modulation or Anything else.

00:13:14: you need to treat the cause of the diarrhea and the gastroenterologist help us doing this.

00:13:21: we could up front predict who would be likely To have these Diagnoses, and these are other patients with radiotherapy very frequent defecations And also pistol stool type six plus seven.

00:13:39: I would advise that Have your gastroenterologist on board for those patients.

00:13:45: Thank you very much.

00:13:47: when I look further at the pyramid Franco of course neuromodulation as we know is the major player in fecal incontinence.

00:13:58: where do you from your experience and your data really see the role of neuro modulation procedures in loss.

00:14:07: That's also a very good question that we're trying to find out because one of the things that do not have clear is when to implement a treatment.

00:14:19: When should the patient start trans-sample irrigation?

00:14:22: When should I escalate the patient to neuromodulation, those are things that haven't been resolved yet.

00:14:29: so... To answer your question i think that neuromidulation can be tried after any after exhausting conservative treatment, after trying to reduce or control the diarrhea.

00:14:43: After setting patient expectations.

00:14:46: but I think that we need to start focusing on treating patterns of symptoms and i do thing those patients with fecal urgency for fecal incontinence that storage pattern was talking about are, or might be better candidates to make a second neuromodulation.

00:15:13: Still other patients are suitable to try it of course but always in very adjusted expectations setting.

00:15:22: Thank you very much.

00:15:24: So when we conclude the therapeutic options and open questions And since we are getting close to Christmas, everyone of you has now a wish free for one study or trial he would like in terms of quality, life and last treatment.

00:16:07: So what is your wish for Christmas?

00:16:09: In terms of the trial...

00:16:11: It's probably a randomized trial on pre-circle or mental flap interposition because data that this Chinese group has showed it so impressive.

00:16:20: but only one group known as randomized.

00:16:24: maybe its nothing if its only fifty percent they have shown potential effect, so that would be a great study.

00:16:32: Thank you Peter!

00:16:33: So

00:16:34: the beauty of being part of family like this is if family members get a present I also get some presents...so i will love those trials to be done.

00:16:46: but my favorite trial it's bit more ambitious and really wants me able to phenotype last patients on the basis symptoms and on pathophysiology to be able design the best treatment options for each phenotype.

00:17:08: And this still needs some small trials, medium-sized trials of different and also in collaboration before we are there.

00:17:19: Okay, let's see if Santa Claus has it in a reindeer carriage for you.

00:17:23: Franco your.

00:17:24: so

00:17:25: I maybe Santa came earlier.

00:17:27: but II am starting the trial because I think that following Peter suggestion Not only we have to start focusing on patterns or phenotypes of large patients But also

00:17:39: timing.

00:17:40: when should we start?

00:17:42: The treatment itself.

00:17:44: So I will start.

00:17:46: We will start at our institution a trial implementing early neuromodulation implantation to see how these patients go after conservative measures fail.

00:17:59: And because I do believe that this pyramid that we see here, it's very important to standardize preoperative counseling and conservative measures in getting on board the gastroenterologists to treat those patients with diarrhea, but then I think the last part of this pyramid should be really dynamic and not one step

00:18:22: approach.

00:18:23: So i think that we should start focusing on that since Lars is so complex.

00:18:29: Thank you very much for all of you being here today For your time and effort in this great course And also your input into online discussion.

00:18:43: So I would like to conclude this and hope that everyone has enjoyed our course.

00:18:49: Thank you so much.