The American Gastroenterological Association (AGA) has issued an updated guideline concerning surgical intervention for patients with refractory constipation. This severe, chronic form of constipation does not respond to conventional treatments.
Chronic constipation affects an estimated 8–12% of the American population. A subset of these patients experiences refractory symptoms, often leading to extensive testing, multiple treatments, and, in some cases, surgical consideration. The updated guidance, published in Clinical Gastroenterology and Hepatology, advises that surgery should be considered a last resort, following a comprehensive, individualized patient evaluation.
Colectomy Risks and Efficacy
Colectomy, the surgical removal of part or all of the colon, is sometimes considered for persistent constipation symptoms. The AGA indicates that this procedure is associated with risks and does not consistently provide symptom relief. Studies have shown that colectomy for constipation can lead to complications such as bowel obstruction, persistent abdominal pain, bloating, recurrent constipation, and continued dependence on laxatives.
Consequently, the new guidance encourages clinicians to prioritize non-surgical options and confirm the underlying cause of symptoms before considering surgery.
Best Practice Advice Statements
The update includes 14 best-practice advice statements to assist clinicians in the diagnosis and management of refractory constipation, and to identify potential surgical candidates. Key recommendations include:
- Refractory constipation is uncommon; treatable secondary causes, such as medication side effects, neurologic conditions, or defecatory disorders, should be ruled out initially.
- Patients should undergo adequate trials of over-the-counter and FDA-approved medications, in addition to non-drug therapies, prior to surgical consideration.
- Surgery should only be discussed after confirming slow colonic transit and excluding issues with pelvic floor function.
- Conditions such as upper gastrointestinal dysmotility, untreated psychiatric illness, or symptoms primarily involving bloating and abdominal pain may indicate poor surgical outcomes and are considered relative contraindications.
- Pre-operative psychological evaluation is identified as an important component of decision-making, given the potential impact of psychological factors on symptom severity and recovery.
- In complex or uncertain scenarios, a temporary ostomy may be used to assess the potential benefits of permanent surgery.
- Colectomy with ileorectal anastomosis should be reserved for carefully selected patients who do not have ongoing defecatory disorders.
Conclusion
The new guidance emphasizes that surgical decisions should be made on a case-by-case basis, informed by experienced clinicians and the totality of available evidence. This approach aims to prevent unnecessary surgery and improve long-term outcomes for patients with refractory constipation.