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Colorectal cancer ranks as the third most common type of cancer in the world. One of the most common types of surgery instituted to eliminate cancer lesion in the lower rectum is low anterior resection.1 About one-third patients develop low anterior resection syndrome/ anterior resection syndrome (LARS/ARS) following this surgery, which comprises of painful defecation, stool urgency and frequency, inability to discriminate between flatus and stool, diaper dependency, difficulty holding stools as well as incontinence which leads to extremely poor quality of life.1 Surgery, as well as the radiotherapy, is inflicted in the development of this syndrome since both results in some form of damage to the innervations of the anal sphincter and rectum.2 Neo-rectum produced from surgery cannot also hold stool for long, which also contributes to the symptoms of this syndrome.2 Anterior resection syndrome often fails to remit and becomes a chronic ailment for the colorectal cancer survivors, thus causing significant malfunction and distress to their lives.3 Very little research has focused on the management of LARS/ARS. Symptoms of LARS/ARS seem to resemble that of diarrhoea- predominant irritable bowel syndrome (IBS-D) and studies have shown that these symptoms may be the result of altered expression of serotonin receptors.4,5 Ryohei Itagaki et al. in their clinical trial demonstrated the efficacy of 5-HT3 receptor antagonists in reducing symptoms of LARS/ARS.5 In this small trial a 5-HT3 receptor antagonist, ramosetron was given to the patients for one month and noticed that it produced significant reductions in stool urgency as well as the number of stools per day.5 These results indicate that therapeutic options which have demonstrated efficacy against IBS-D such as 5-HT3 receptor antagonists and opioid receptor agonists may prove efficacious in reducing symptoms of LARS/ARS.6 Loperamide has since long proven to be a potent anti-diarrhoeal agent and has established its efficacy in treating IBS-D in several clinical trials.7 In a double-blind clinical trial conducted by P S Efskind et al, loperamide produced improvement in stool consistency and frequency throughout the five weeks of treatment in patients with IBS-D.7 Continuous...

Serratiopeptidase is a proteolytic enzyme produced by serratia species E15, isolated from the intestine of silkworm. It has become one of the most widely used medications by both physicians and surgeons and is said to have efficacy in reducing inflammation via the breakdown of various inflammatory mediators. [1] Serratiopeptidase is mostly prescribed in inflammatory illnesses and in some non-inflammatory disorders albeit less commonly due to its analgesic effects. It is even used very commonly in the post-operative period to improve healing and to reduce inflammation of the surgical wound. [2] However, an online literature search on Medline, Cochrane library and Google scholar using the search words serratiopeptidase, serrapeptase, serralysin, serratiapeptase and proteolytic enzymes retrieved only small-scale, inadequately structured, studies reflecting some anti-inflammatory effects of serratiopeptidase, but most of these failed to demonstrate significant benefits from the drug.[3] Serratiopeptidase has a lower efficacy as compared to the NSAIDs as an analgesic but demonstrated greater anti-inflammatory effects than the NSAIDs.[4] Therefore, it is still not sufficiently efficacious to be used solely and rather, is almost always used in combination with NSAIDs to reduce pain symptoms. [5] As a matter of fact, one of the authors’ of this letter had significant experience with the drug in treating seronegative spondyloarthropathy. The drug was used for about a week but no improvement was noted in the reduction of symptoms and the person remained severely disabled. Switching to meloxicam significantly showed good response. In the light of above reports and observations, there is a dire need of conducting well-designed clinical trial-based studies for a wider spectrum of conditions and limit its use until its benefits and/or contraindications are substantially proven [3] Continuous...