Colorectal cancer is a prevalent malignancy worldwide, ranking third in incidence and second in mortality among all cancers in 2020. Low anterior resection (LAR) is a common surgical approach for treating rectal cancer, but it can lead to a condition known as low anterior resection syndrome (LARS). LARS significantly impacts the quality of life of patients after sphincter-saving surgery, with prevalence rates ranging from 55% to 91.6% and severe LARS affecting 29% to 58.3% of patients. While treatments for relieving LARS are limited, dietary modification plays a crucial role in managing bowel symptoms. This article provides a comprehensive overview of dietary management strategies for LARS, incorporating personal experiences, research findings, and practical tips.
Understanding LARS
Following sphincter-saving surgery, various bowel symptoms can emerge, including fecal incontinence, urgent and frequent defecation, and bowel movements at night. These symptoms are collectively termed LARS. The standard treatment for LARS is currently scarce, making self-management, particularly dietary modification, essential for controlling bowel symptoms. More than 96% of patients report changing their diet to manage bowel symptoms after surgery.
Symptoms of LARS
LARS encompasses several related symptoms that patients may experience post-surgery, including:
- Fecal incontinence
- Urgency
- Increased bowel frequency
- Clustering of bowel movements
- Risk of urinary and/or sexual dysfunction due to nerve damage
These symptoms can interfere with daily living and reduce the quality of life.
The Role of Dietary Management in LARS
Dietary management is an important strategy for controlling LARS after sphincter-saving surgery. However, the specific dietary factors influencing LARS are not completely clear. Many patients resort to trial and error to manage defecation dysfunction, highlighting the need for scientific guidance in dietary modifications.
Read also: Diet and Ogilvie Syndrome
General Dietary Recommendations
- Chew Food Thoroughly: Proper chewing aids digestion and reduces the burden on the digestive system.
- Keep a Food Journal: Tracking food intake can help identify patterns and triggers for LARS symptoms.
- Eat Small, Frequent Meals: Consuming 5-6 small meals per day can prevent watery stools and reduce gas.
- Introduce New Foods Gradually: Add new foods, including fiber and whole grains, one at a time to evaluate their impact on bowel movements.
- Drink Plenty of Fluids: Sip fluids slowly, either between meals or at the end of a meal, to stay hydrated without exacerbating symptoms.
- Limit Caffeine and Alcohol: These substances can worsen stool output.
Specific Dietary Modifications
Fiber Intake
The role of fiber in managing LARS symptoms can be complex. A low-residue diet, which limits high amounts of insoluble fiber foods, may be beneficial for some individuals.
- Soluble Fiber: Can improve stool consistency and reduce fecal incontinence.
- Insoluble Fiber: May exacerbate diarrhea and bloating.
Foods to Avoid (High in Insoluble Fiber)
- Whole-grain breads and cereals
- Nuts and seeds
- Raw or dried fruits
- Some vegetables, particularly leafy greens like spinach and lettuce
Foods to Include (Soluble Fiber)
- Potatoes
- White breads and plain crackers (low grain, no seeds)
- Cooked cereals
- Cold cereals like puffed rice and corn flakes
- Noodles, pasta, and white rice
Bulking Foods and Agents
Incorporating bulking foods (soluble fibers) into a low-residue diet can further help reduce the number of bowel movements per day.
Bulking Foods:
- Potatoes
- White bread and plain crackers
- Cooked cereals
- Cold cereals (puffed rice, corn flakes)
- Noodles, pasta, and white rice
- Soluble fiber-rich foods
Bulking Agents:
- Psyllium Husk (Metamucil)
- Normacol (Sterculia)
These agents can be particularly useful for managing clustering of bowel movements.
Foods That Thicken Stool
Adding foods that thicken the stool can help manage diarrhea.
- Applesauce
- Bananas
- Cheese
- Peanut butter
- Potatoes
- White pasta
- Pretzels
- White rice
- White bread
- Yogurt
- Marshmallows
- Tapioca
Foods That May Cause Gas
Certain foods can cause gas and exacerbate LARS symptoms.
Read also: Understanding Cushing's and Weight
- Cabbage
- Spinach
- Broccoli
- Cauliflower
- Brussels sprouts
- Radishes
- Carbonated beverages
- Onions
- Beans
- Corn
- Cucumbers
- Nuts
- Beer
- Dairy products
Managing Lactose Intolerance
Lactose intolerance can exacerbate LARS symptoms. Cow’s milk, due to its lactose content, can be a dietary irritant for many individuals, leading to bloating, diarrhea, and abdominal pain.
- Eliminate Cow’s Milk: Consider removing cow’s milk from the diet to see if symptoms improve.
- Milk Alternatives: Use milk alternatives such as lactose-free milk, soymilk, or oat milk.
A case series highlighted that patients experienced significant improvement in LARS symptoms after eliminating cow's milk from their diets, suggesting a link between lactose intolerance and LARS.
The Role of Oil and Livestock/Poultry Meat Intake
Research indicates that the intake of oil and livestock/poultry meats can influence LARS. A study found that both the intake of oil before surgery and at 6 months after surgery were significantly associated with the improvement of LARS. The relationship between the intake of livestock and poultry meats and oil and the improvement of LARS was also significant.
- Oil Intake: Higher oil intake may be associated with improved LARS outcomes.
- Livestock and Poultry Meat Intake: Lower intake of livestock and poultry meat may be associated with better LARS outcomes.
The rate of improvement of LARS at 6 months was higher among patients who consumed less livestock and poultry meat (less than 33.10 g/day) compared to those who consumed more (more than 44.18 g/day). Additionally, the rate of LARS at 6 months was higher among patients with the lowest oil intake (less than 26.67 g/day) compared to those with the highest oil intake (more than 30.01 g/day).
Other Management Strategies
In addition to dietary modifications, other strategies can help manage LARS symptoms.
Read also: Nutrition for Sjögren's
Pelvic Floor Exercises (Kegels)
Pelvic floor exercises, such as Kegels, can help strengthen the muscles of the pelvic floor. To perform Kegels, tighten the muscles as if trying to hold back a bowel movement, hold for 5-10 seconds, release, and rest. Repeat this exercise regularly.
Bowel Irrigation
Some patients with LARS find that bowel irrigation helps decrease daily distress and LARS symptoms. Irrigation should be done carefully and under the advisement of a doctor.
Medications and Probiotics
- Anti-diarrheal Medications: Imodium can help with clustering of bowel movements.
- Fiber Supplements: Metamucil can be used as a fiber supplement.
- Probiotics: Some patients find that taking a probiotic pill or consuming probiotic-rich foods like yogurt, kombucha, or kefir helps.
Stool Training and Biofeedback
These non-surgical therapies can retrain muscles to manage bowel dysfunction, such as fecal incontinence and constipation.
Counseling
Talking about the challenges of LARS can help ease stress and shift focus to other aspects of life.
Survival Pack
Carry a survival pack consisting of wet wipes, protective ointments, and anti-diarrheal medication.
Addressing Specific Concerns
For a 59-year-old female who had a lower anterior resection surgery for rectal cancer followed by chemotherapy and stoma reversal, the current diet of only mashed white rice and banana is suboptimal. It is crucial to address the nutritional deficiencies and gradually reintroduce other food groups.
Is This a Serious Situation?
Yes, the current diet is not nutritionally adequate and can lead to serious health issues if continued long-term. The lack of protein, fats, vitamins, and minerals can result in malnutrition, muscle wasting, and impaired immune function.
Do I Need to Take Any IV Drip to Cover This Suboptimal Nutrition?
Consult with a healthcare provider or a registered dietitian to determine if IV nutrition (parenteral nutrition) or other nutritional support is necessary. They can assess the severity of the nutritional deficiencies and recommend the most appropriate course of action.
Reintroducing Foods
Start Slowly: Introduce one new food at a time to monitor tolerance.
Wait Three Days: Allow three days to observe any negative reactions before introducing another food.
Prioritize Protein: Protein is essential for healing and maintaining muscle mass. Try small amounts of easily digestible protein sources like:
- Well-cooked, shredded chicken: Start with a very small portion (1-2 tablespoons).
- Soft tofu: If dairy is an issue, tofu can be a good alternative.
Add Healthy Fats: Incorporate small amounts of healthy fats to aid in nutrient absorption and provide energy:
- Avocado: A small portion of mashed avocado can be easily digestible.
- Olive oil: Use a small amount of olive oil for cooking or as a dressing.
Introduce Cooked Vegetables: Cook vegetables thoroughly to make them easier to digest:
- Well-cooked carrots: Start with a small portion of mashed carrots.
- Pureed sweet potatoes: Sweet potatoes are a good source of vitamins and fiber.
Consider Lactose-Free Dairy or Alternatives: If dairy was previously an issue, try lactose-free options or alternatives like:
- Lactose-free yogurt: Yogurt can be a good source of probiotics.
- Almond milk or oat milk: Use these as alternatives to cow's milk.
Continue Multivitamin and Calcium Supplements: Ensure continued intake of multivitamin and calcium supplements to address potential deficiencies.
Sample Meal Plan
Breakfast:
- Small portion of mashed white rice with a few slices of banana.
- Lactose-free yogurt (if tolerated).
Lunch:
- Small portion of mashed white rice with 1-2 tablespoons of shredded, well-cooked chicken.
- Mashed carrots.
Dinner:
- Small portion of mashed white rice with soft tofu.
- Pureed sweet potatoes.
Snacks:
- Banana (twice a day).
Monitoring and Adjustments
Keep a detailed food journal to track tolerance and symptoms. Work closely with a registered dietitian or healthcare provider to adjust the diet as needed.
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