Aim Low anterior resection syndrome (LARS) is pragmatically defined as disordered bowel function after rectal resection leading to a detriment in quality of life. This broad characterization does not allow for precise estimates of prevalence. The LARS score was designed as a simple tool for clinical evaluation of LARS. Although the LARS score has good clinical utility, it may not capture all important aspects that patients may experience. The aim of this collaboration was to develop an international consensus definition of LARS that encompasses all aspects of the condition and is informed by all stakeholders. Method This international patient–provider initiative used an online Delphi survey, regional patient consultation meetings, and an international consensus meeting. Three expert groups participated: patients, surgeons and other health professionals from five regions (Australasia, Denmark, Spain, Great Britain and Ireland, and North America) and in three languages (English, Spanish, and Danish). The primary outcome measured was the priorities for the definition of LARS. Results Three hundred twenty‐five participants (156 patients) registered. The response rates for successive rounds of the Delphi survey were 86%, 96% and 99%. Eighteen priorities emerged from the Delphi survey. Patient consultation and consensus meetings refined these priorities to eight symptoms and eight consequences that capture essential aspects of the syndrome. Sampling bias may have been present, in particular, in the patient panel because social media was used extensively in recruitment. There was also dominance of the surgical panel at the final consensus meeting despite attempts to mitigate this. Conclusion This is the first definition of LARS developed with direct input from a large international patient panel. The involvement of patients in all phases has ensured that the definition presented encompasses the vital aspects of the patient experience of LARS. The novel separation of symptoms and consequences may enable greater sensitivity to detect changes in LARS over time and with intervention.

Consensus abstractBackground: The management of primary rectal cancer beyond total mesorectal excision planes (PRCbTME) and recurrent rectal cancer (RRC) is challenging. There is global variation in standards and no guidelines exist. To achieve cure most patients require extended, multivisceral, exenterative surgery, beyond conventional total mesorectal excision planes. The aim of the Beyond TME Group was to achieve consensus on the definitions and principles of management, and to identify areas of research priority. Methods: Delphi methodology was used to achieve consensus. The Group consisted of invited experts from surgery, radiology, oncology and pathology. The process included two international dedicated discussion conferences, formal feedback, three rounds of editing and two rounds of anonymized web- Executive summaryThe executive summary supports the need for standardization of care and a collaborative, cross-discipline consensus statement. Burden of disease:There are 14 000 new rectal cancers per year in the UK, 40 000 in the USA and under half a million new cases per year globally. Of these, 5-10 per cent have invaded adjacent organs at presentation and 10 per cent recur following primary surgery. Complexity of surgery:Major, exenterative, multivisceral resections require specialist multiprofessional care. The surgical procedures are time-consuming (up to 12 h) and are associated with prolonged length of hospital stay (between 10 and 30 days). Long-term 5-year survival rates vary between 30 and 50 per cent. Adverse event rates have been reported in up to 50 per cent of patients. Superspecialist training of surgeons within a multidisciplinary team is required. Inappropriate worldwide variation in practice:There is a wide range of practice from non-specialist and specialist centres, with unequal access to care across global settings. These include differing referral selection criteria, where patients are often denied potentially curative treatment. When surgery is offered, the outcome is neither captured by the national databases nor audited locally. * Collaborating members are shown at the end of the article. 1010The Beyond TME Collaborative Standardization of definitions: Definitions for the rectum, for primary rectal cancer beyond conventional total mesorectal excision planes, and for recurrent rectal cancer have been defined heterogeneously in the literature and between different institutions, leading to a clear requirement for standardization of the exact definition of these terms.The need for policy: Delay in diagnosis is common and inequalities exist in referral patterns based on geography, with no clear clinical guidelines. No current guidelines exist for these patients, despite the significant burden, cost of surgery, morbidity and national variations in care.Resource impact: The cost-effectiveness of the complex assessments and interventions requires further research. The quality of life and morbidity from non-operative management are unknown. There is a need for specialist training of the mul...

Awareness of the surgical options and a willingness to consider more aggressive options may result in more patients being considered for potentially curative resection.

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The consensus process has provided guidance for the management of patients with PRC-bTME or RRC, taking into account global variations in surgical techniques and technology. It has further identified areas of research priority.