May's 'Paper of the Month' looks at a study which aimed to evaluate transanal irrigation (TAI) as a treatment for low anterior resection syndrome (LARS).

A Randomized Controlled Clinical Trial of Trans-anal Irrigation Versus Conservative Treatment in Patients with Low Anterior Resection Syndrome After Rectal Cancer Surgery
Pieniowski, Emil H.A. MD; Bergström, Charlotta M. BS; Nordenvall, Caroline A.M. PhD; Westberg, Karin S. PhD; Johar, Asif M. MSc; Tumlin Ekelund, Susanne F. PhD; Larsson, Kristina R. MSc; Pekkari, Klas J. PhD; Jansson Palmer, Gabriella C. PhD; Lagergren, Pernilla PhD; Abraham-Nordling, Mirna PhD.
Annals of Surgery 277(1):p 30-37, January 2023. | DOI: 10.1097/SLA.0000000000005482

What is known about the subject?

Low anterior resection syndrome (LARS) is a bowel disorder that is common after sphincter preserving rectal cancer surgery. LARS is categorised as minor or major LAS and includes symptoms such as incontinence, urgency, problems with emptying the bowel and frequent bowel movements. These can be very distressing for patients, causing a significant impact on their quality of life. A validated LARS score can be used to assess the impact on patients’ quality of life, however, there is no existing consensus on the definition of LARS. In 2020, an international consensus definition was published, drawn up in conjunction with clinicians and patients. [1]

Trans-anal irrigation (TAI) is one treatment option available to patients with LARS, which can help to reduce symptoms and improve quality of life.

What the study adds?

This study randomised 45 patients from 3 centres in Sweden, diagnosed with major LARS following rectal cancer surgery. Twenty-two patients were randomised to the intervention, TAI, and 23 to the control group (standard of care). The primary outcome of the study was difference in bowel function at 12 month follow up as measured by the LARS score; secondary outcomes included the Cleveland Clinic Incontinence score, and four study-specific questions on bowel function (general bowel function, impact on daily life, urgency, fragmentation). Quality of life measured via the EORTC QLQ-C30.

The study showed that at 12 months follow up, patients in the TAI group reported significantly lower LARS scores (22.9 v 32.4) and had significantly improved quality-of-life compared to the control group.

Implications for colorectal practice

This study shows that TAI is a good option for patients with major LARS following rectal cancer surgery, it reduces symptoms and improves quality of life. This is the first RCT to evaluate TAI as a treatment for LARS. While TAI can be time consuming for the patient, and needs to be taught by a clinician, it can significantly improve LARS symptoms, and in turn improve patients’ quality of life. Clinicians should consider discussing TAI with their patients, giving them time to discuss any worries before trialling TAI.


  1. International consensus definition of low anterior resection syndrome. Keane C, Fearnhead NS, Bordeianou L, Christensen P, Basany EE, Laurberg S, Mellgren A, Messick C, Orangio GR, Verjee A, Wing K, Bissett I; LARS International Collaborative Group. Colorectal Dis. 2020 doi: 10.1111/codi.14957; ANZ J Surg. 2020 doi: 10.1111/ans.15421; Dis Colon Rectum. 2020; 63:274-284. doi: 10.1097/DCR.0000000000001583.