>AGA Updates: Rethinking Surgery for Chronic Constipation

Key takeaways:

• AGA guidance urges careful diagnosis and stepwise care for refractory constipation before surgery.
• Surgical decisions should follow objective testing, phenotyping and strict patient selection.

An expert review on refractory constipation established 14 best practice statements addressing key clinical issues for the condition, including a “much more detailed and cautious framework for surgical decision-making.”

Commissioned by AGA and published in Clinical Gastroenterology and Hepatology, the review was “prompted by a persistent and important gap in clinical guidance,” according to lead author Kyle Staller, MD, MPH, gastroenterologist and director of the Gastrointestinal Motility Laboratory at Massachusetts General Hospital.

“While chronic constipation is common and well covered in existing guidelines, refractory constipation is not,” Staller, who is also an associate professor of medicine at Harvard Medical School, told Healio. “These patients represent a relatively small but highly complex group who often cycle through tertiary care, undergo repeated testing and are sometimes steered toward irreversible interventions without a consistent physiologic framework.

“The AGA commissioned this update to provide practical, expert-driven guidance for clinicians facing these challenging scenarios — particularly where the stakes are highest, such as decisions around surgery.”

Healio spoke with Staller about the updated guidance, including why refractory constipation is especially difficult to define and treat, how the 14 best practice advice statements were decided and how gastroenterologists can use this guidance to inform care.

Healio: Why is it so difficult to define refractory constipation?

Staller: Refractory constipation is difficult to define because constipation itself is not a single disease. It reflects the interplay of colonic transit, anorectal function, medications, diet, activity and psychological factors — many of which are at least partially reversible. In addition, patients describe and experience constipation very differently, and there is wide variability in what constitutes an “adequate” therapeutic trial before labeling someone refractory. Without objective testing and a shared framework, the term can easily be applied too early or imprecisely.

A major goal of this update was to move the definition away from symptom frustration alone and toward demonstrated failure of appropriately targeted therapy.

Healio: How did you decide which key clinical issues to address?

Staller: We focused on the clinical decision points that most often determine downstream outcomes — particularly those where missteps can lead to harm. These include confirming the diagnosis, excluding defecatory disorders, objectively documenting slow colonic transit, ensuring adequate trials of medical and nonpharmacologic therapies, and carefully selecting patients for surgery.

Many of these issues are not controversial in isolation, but they are inconsistently applied in practice. The best practice advice statements were designed to address these high-impact moments in a clear, sequential and clinically usable way.

Healio: How do these recommendations differ from previous guidance?

Staller: Previous guidance has largely addressed constipation broadly, with limited attention to what to do when standard therapies fail.

This update is different in that it is refractory constipation-specific and explicitly addresses a sequential pathway based on pathophysiology. It places greater emphasis on anorectal physiology and biofeedback before labeling patients refractory, on objective documentation of slow transit before escalating care, and on structured escalation of both pharmacologic and nonpharmacologic therapies. Perhaps most importantly, it provides a much more detailed and cautious framework for surgical decision-making, reflecting what we have learned about poor long-term outcomes for surgery for constipation.

Healio: What do you consider the most significant piece of advice given?

Staller: If I had to choose one, it would be the emphasis on not labeling a patient as refractory until defecatory disorders have been identified and treated when present. Dyssynergic defecation is common, frequently overlooked and fundamentally changes management. Failure to address it early is one of the most common reasons patients appear “refractory” when, in fact, they are not.

Healio: These best practices involve a lot of caution surrounding surgical treatment — why was this so important?

Staller: Because colectomy is irreversible, high-risk and associated with variable long-term satisfaction. While surgery can be transformative for carefully selected patients, outcomes are consistently worse when key prerequisites — such as confirmed slow transit, absence of defecatory disorders and exclusion of regional dysmotility or major psychological comorbidity — are not met.

The literature makes clear that poor patient selection, rather than the procedure itself, is often the driver of disappointing outcomes. Our intent was not to discourage surgery, but to protect patients by ensuring it is used only when the likelihood of benefit clearly outweighs the risk.

Healio: What should gastroenterologists take home from this update?

Staller: The central take-home message is that true refractory constipation is uncommon, but refractory symptoms are not. Before escalating care — especially toward surgery — clinicians should slow down, confirm the underlying physiology and ensure that therapies are being matched to mechanism. A systematic, stepwise approach not only improves outcomes but also helps set realistic expectations for patients and clinicians alike.

Healio: As new research becomes available, how often should these best practices be revisited?

Staller: These recommendations should be revisited as the evidence base evolves—particularly as we gain more long-term data on newer pharmacologic agents, device-based therapies and predictors of surgical outcomes. That said, many of the core principles outlined here — objective testing, careful phenotyping and thoughtful patient selection — are unlikely to change and should remain foundational to care.

Healio: Is there anything else you would like to emphasize?

Staller: One of the recurring themes in managing refractory constipation is the importance of expectation-setting — for patients and clinicians. Constipation is often a chronic condition rather than a problem with a definitive cure, and success is frequently measured in meaningful improvement rather than perfection.

Approaching these patients with rigor, humility and a willingness to revisit assumptions is just as important as any specific test or therapy.

For more information:

Kyle Staller, MD, MPH, can be reached at [email protected].

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Sources/Disclosures

Source:

Healio Interviews

Reference:

Disclosures:
Staller reports research support from Ardelyx and consulting for AbbVie, Ardelyx, Atmo, Laborie, Mindset Health, Salix and Takeda.

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