AGA's new update urges caution before surgical treatment of refractory constipation

A new update from the American Gastroenterological Association (AGA) is calling for greater caution before surgery is considered for patients with refractory constipation, a severe, chronic form of constipation that does not respond to standard treatments. 

Chronic constipation affects 8–12% of Americans. While most patients improve with conventional treatments, a small but challenging subset remains refractory. These patients often undergo extensive testing, repeated treatments, and, in some cases, surgery. The update, published in Clinical Gastroenterology and Hepatology, emphasizes that surgery should be viewed as a last resort and pursued only after a comprehensive, individualized evaluation. 

For patients whose symptoms persist, colectomy - surgical removal of part or all of the colon - is often considered. AGA warns that this approach carries significant risks and does not consistently lead to symptom relief. 

Studies show that colectomy for constipation is associated with high rates of complications, including bowel obstruction, persistent abdominal pain, bloating, recurrent constipation, and continued reliance on laxatives. As a result, the new guidance encourages clinicians to exhaust all appropriate non-surgical options and confirm the underlying cause of symptoms before considering surgery. 

The update outlines 14 best-practice advice statements to help clinicians accurately diagnose and manage refractory constipation and to identify which patients, if any, may benefit from surgical intervention. 

Key insights: 

• Refractory constipation is uncommon, and clinicians should first rule out treatable secondary causes, such as medication side effects, neurologic conditions, or defecatory disorders. 

• Patients should undergo adequate trials of over-the-counter and FDA-approved medications, as well as non-drug therapies, before surgery is considered. 

• Surgery should only be discussed after confirming slow colonic transit and excluding problems with pelvic floor function. 

• Conditions such as upper gastrointestinal dysmotility, untreated psychiatric illness, or symptoms dominated by bloating and abdominal pain may predict poor surgical outcomes and are considered relative contraindications to surgery. 

• Psychological factors can significantly affect symptom severity and recovery, making pre-operative psychological evaluation an important part of decision-making. 

• In complex or uncertain cases, a temporary ostomy may help determine whether a patient is likely to benefit from permanent surgery. 

• Colectomy with ileorectal anastomosis should only be offered to carefully selected patients without ongoing defecatory disorders. 

Ultimately, the new guidance emphasizes that decisions about surgery should be made on a case-by-case basis, informed by experienced clinicians and the totality of available evidence - not by a one-size-fits-all approach. 

The update reinforces a critical message for patients and providers alike: In refractory constipation, thorough diagnosis and thoughtful planning can help prevent unnecessary surgery and improve long-term outcomes.