Daily Enemas before Ilio Reversal to prevent LARS?

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Big Jay
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Daily Enemas before Ilio Reversal to prevent LARS?

Postby Big Jay » Mon Dec 11, 2017 11:30 am

I have a TME in my near future and I'm pretty paranoid about LARS. I know it'll be what it'll be and I'll just have to deal w/ whatever is to come. However, I want know what I can do pre/post-op to help prevent, or at least lessen, any future issues.

I was reading up on LARS on "Up to Date" (a sort of clearing house that gathers and summarizes all of the latest/greatest medical info for doctors) and I came across this one sort of throw-away paragraph:

"Additionally, patients who receive a protective stoma as a part of their low anterior resection may be at increased risk of developing LARS. In a follow-up study 12 years after a randomized trial, patients who underwent low anterior resection with a protective stoma reported increased incontinence for flatus and liquid stools and worse overall LARS score compared with patients who underwent low anterior resection without a protective stoma. Thus, patients who have a protective stoma that is not expected to close within one to two months should also receive daily or two- to three-times-per-week enemas or anterograde colonic irrigation via the stoma."

So basically an enema a day keeps the LARS away. Sounds unpleasant but if that's what it takes... For whatever reason the two studies that this paragraph references are about daily enemas for patients w/ LARS after reversal when this clearly says you should have them prior to reversal. So, I don't know where this pre-reversal enema recommendation came from. I would assume the enemas help keep the nerves stimulated and the muscles in shape. Plus, it's probably better to learn how to use your new plumbing w/ a controlled volume of water rather than an uncontrolled volume of poo.

I've asked my two prospective surgeons, at Johns Hopkins and at Memorial Sloan Kettering, about this enema thing and both expressed total ignorance of it and instantly dismissed the idea. Sadly this reinforced my impression that surgeons have little knowledge of, or interest in, LARS

So, to the group, has anyone heard of, or participated in, doing daily enemas prior to Ilo reversal? Is there a good central source for LARS prevention? Any advice on what I should be doing pre-surgery (besides enjoying food while I still can)?

DX at 45yo 6/9/16, 2.4cm tumor, 9cm from Anal Verge, 6/27/16
Clinical staging IIIC, CEA 3.1 7/1/16
30x Chemorad 8/5/16 - 9/16/16
CT/MRI/Scope => CCR 11/1/16... Rolling the dice on Watch & Wait
Snake Eyes: Tiny regrowth at scar 11/1/17

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Re: Daily Enemas before Ilio Reversal to prevent LARS?

Postby MissMolly » Mon Dec 11, 2017 12:53 pm

Big Jay:
An antegrade enema means an enema where water is infused through the mucus stoma (or non-working stoma), effectively flushing the segment of diverted large intestine that is resting and healing from the LARS surgery.

A retrograde enema means an enema where water is infused via the rectum, cleaning the lower digestive tract/rectum. A retrograde enema is what most people think of as an enema.

I would encourage anyone considering antegrade enemas during recovery to discuss the practice with their surgeon before proceeding. The reason for a temporary loop ileostomy is to allow the diverted lower digestive tract and anastomosis to fully heal before allowing fecal output to flow down and through to exit the body via a patent rectum and anus. There would be the possibility of fecal contamination and leakage into the abdomen if the anastomosis is frail and has pin-hole openings.

An antegrade enema makes sense in that it will prevent fecal matter that overflows from the working stoma into the mucus stoma from adhering to the lower intestine and forming a backlog of fecal matter. In essence, with an antegrade enema you are flushing the resting and diverted segment of intestine with warm water. You are keeping the diverted segment of intestine free from fecal matter that may overflow into the mucus stoma. You are keeping the diverted segment of intestine free of accumulated mucus and serous fluids and cellular debris which is naturally occurring (the diverted segment of intestine is a living tissue that continues to produce mucus and serous fluids and sheds cellular debris).

The concern would be in those individuals with a frail anastomosis or fragile tissue integrity. Fecal material with contaminating bacteria could enter the abdomen and result in peritonitis or sepsis - potentially life threatening. This is likely why the practice is not universally practiced.

Bottom Line: Discuss the practice of an antegrade enema fully with your surgeon. Know the possible risks and symptoms of peritonitis or sepsis if you do go forward with the procedure. For anyone with a fragile rectal anastomosis or who is immunocompromised, the practice of regular antegrade enemas would likely be of high risk and not advised.

For individuals with permanent loop colostomies, the practice of retrograde enemas is used on a routine basis to keep the diverted lower intestine free of accumulated hardened mucus. This is done with a fully patent and healed lower digestive tract (no healing rectal anastomosis) and is not comparable to a person with a loop ileostomy following a LAR.
Dear friend to Bella Piazza, former Colon Club member (NWGirl).
I have a permanent ileostomy and offer advice on living with an ostomy - in loving remembrance of Bella
I am on Palliative Care for broad endocrine failure + Addison's disease + osteonecrosis of both hips/jaw + immunosuppression. I live a simple life due to frail health.

Big Jay
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Joined: Fri Jun 17, 2016 5:41 pm
Location: Baltimore, MD

Re: Daily Enemas before Ilio Reversal to prevent LARS?

Postby Big Jay » Mon Dec 11, 2017 1:26 pm

I'd definitely want to wait until after I'd passed the gastrografin leak test. That's what, 4-6 wks after surgery?

It's kind of hard to discuss this with my doctor since he has no knowledge of it. I'll keep doin' the research. If things are going they way the Oncologists claim then I won't have chemo. So I'll only have the ilo for a few months and the enemas won't be required. However, I still have the old Boy Scout "Be Prepared" motto ingrained in my brain so I'm planning for contingencies.
DX at 45yo 6/9/16, 2.4cm tumor, 9cm from Anal Verge, 6/27/16
Clinical staging IIIC, CEA 3.1 7/1/16
30x Chemorad 8/5/16 - 9/16/16
CT/MRI/Scope => CCR 11/1/16... Rolling the dice on Watch & Wait
Snake Eyes: Tiny regrowth at scar 11/1/17

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Location: Michigan

Re: Daily Enemas before Ilio Reversal to prevent LARS?

Postby susie0915 » Mon Dec 11, 2017 2:53 pm

I only had my ileostomy for a few weeks as I had a blockage 4 weeks after surgery, needed additional surgery to remove scar tissue so my surgeon decided to reverse the ileo since he was in there as to avoid another abdominal surgery after chemo. I never heard of having to do an enema or irrigate an ileostomy. I have a friend that has a permanent colostomy that irrigates rather than wear a bag. I thought lars severity coincided more with the amount of rectum remaining. In my case my tumor was 5cm above anal verge so I have very little rectum remaining. Once I finished chemo, I never had problems with loose stools or not being able to hold my stool. My issues were more frequency as I didn't have much rectum so I couldn't store much stool as most people do before evacuation. After going to bowel control clinic I chose to begin doing the daily enemas as it evacuated my lower bowel for the day and was done when I chose. I waited almost a year of trying different things, and even though I went through periods of good days there weren't enough. I also met with a dietician, and did pelvic floor therapy which were both helpful as well. This is interesting, I'm just not clear on how it helps to avoid LARS after reversal.
58 yrs old Dx @ 55
5/15 DX T3N0MO/ 2A
6/15 5 wks chemo/rad
7/15 sigmoidoscopy/scar tissue left
8/15 Pet scan NED
9/15 LAR
0/24 nodes
10/15 Bowel blockage. surgery,early ileo rev, c-diff inf :(
12/15 6 rds of xelox
5/16 Clear CT lung scarring/inflammation
9/16 clear colonoscopy
4/17 CT 4mm lung nod onc feels scar tissue
7/17 no change lung nodule
10/17 Clear pel/abd CT
11/17 CEA<.5
1/18 CT/Lung no change in 4mm nodule or scarring/inflammation

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Re: Daily Enemas before Ilio Reversal to prevent LARS?

Postby ozziej » Mon Dec 11, 2017 8:00 pm

I also belong to a Facebook group for people living with LARS. The vast majority of us had a low or ultra low rectal resection however not all had a temporary ileostomy. Many only had their stoma for up to the recommended 12 weeks but they still have LARS. This is not surprising given that LARS has multiple causal factors: pre surgery radiotherapy, height of the anastomosis, skill of your surgeon, pre-treatment functioning. LARS is also not static. It occurs along a continuum and can be impacted by other post op factors such as diet and stress. I would be wary of accepting the results of one study. There are others which show no relationship between a defunctioning stoma and LARS. I would encourage you to do pre op pelvic floor exercises as these will help with any post reversal incontinence. However it's important to note that a significant proportion of people with LARS (including me) never experienced incontinence. I wish you all the best for your upcoming surgery. You might like to join our Facebook group if you find you have ongoing bowel dysfunction but please give yourself at least 6 months for things to settle. I was still seeing improvement at the 2 year post reversal mark.
F 56 dx 11/14 Stage 1 RC (post EMR)
No neo-adjuvant or adjuvant chemo/RD
3/15 ULAR (open) temp loop ileo
5/15 ileo reversal
NED and hoping to stay that way!! : )

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