AGA Urges Caution Around Surgery for Refractory Constipation in Clinical Practice Update

The American Gastroenterological Association (AGA) has released a clinical practice update on the evaluation and management of refractory constipation.1,2

The document, published in Clinical Gastroenterology and Hepatology, on January 7, 2025, outlines 14 best-practice advice statements to help clinicians accurately diagnose and manage refractory constipation and to identify which patients may benefit from surgical intervention.1,2

Constipation is a common disorder affecting approximately 1 out of every 6-7 people worldwide, and annually leading to > 1.5 million healthcare provider visits in the United States alone. While clinicians today have a wide therapeutic armamentarium, including osmotic and stimulant laxatives, secretagogues, and prokinetic agents, as well as emerging device-based therapeutic approach designed to enhance colonic motility without pharmacologic action like the vibrating capsule, some patients still do not respond to treatment.3,4

“Though most patients with chronic constipation respond to standard treatments, a subset remains refractory to available therapies and merit the designation of ‘refractory.’ Such patients consume significant healthcare resources and frequently present to tertiary care centers,” Kyle Staller, MD, MPH, director of the Gastrointestinal Motility Laboratory at Mass General., and colleagues wrote.1

Commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board, the review is designed to provide best practice advice on 14 key clinical issues related to the diagnosis, treatment, and medical and surgical management of patients with refractory constipation.1

Acknowledging that refractory constipation is relatively rare, the document recommends clinicians systematically exclude correctable secondary causes such as medications, neurologic disorders, and defecatory disorders, confirm the presence of slow colonic transit, and ensure that patients have undergone adequate trials of over-the-counter and Food and Drug Administration–approved medications and nonpharmacologic therapies, including combinations thereof.1,2

While the update says surgical treatments like colectomy can be considered in patients who fail available treatments, the authors note surgical treatment of chronic constipation is associated with increased risk of complications and a not insignificant number of unsatisfactory outcomes. Prior to advising surgery, it is recommended that clinicians confirm slow colonic transit, exclude concurrent defecatory disorders, and evaluate for severe, symptomatic delays in gastric emptying or small bowel dysmotility.1,2

Because psychological comorbidities may exacerbate symptoms and adversely affect surgical outcomes, preoperative psychological evaluation is advised to assess suitability for surgery.1,2

Relative contraindications to surgical treatment of refractory constipation include clinically significant upper-gut dysmotility, severe, untreated psychiatric disease, and predominant complaints of bloating and/or abdominal pain.1,2

In uncertain cases, the authors note a temporary diverting loop ileostomy may help predict the potential response to colectomy, but that a colectomy with ileorectal anastomosis should only be offered to patients without ongoing defecatory disorders.1,2

Of note, the authors caution that even with careful assessment as outlined in the practice update, the decision to pursue surgery for refractory constipation should be made by an experienced clinician based on the preponderance of available evidence for a given patient without adhering to a strict algorithm.1

References

1. Staller K, Neshatian L, Lembo A, Bharucha AE. AGA Clinical Practice Update on Evaluation and Management of Refractory Constipation: Expert Review. Clinical Gastroenterology and Hepatology. doi:10.1016/j.cgh.2025.09.031

2. American Gastroenterological Association. New expert guidance urges caution before surgery for patients with treatment-resistant constipation. January 7, 2026. Accessed January 8, 2026. https://www.eurekalert.org/news-releases/1111165

3. International Foundation for Gastrointestinal Disorders. Chronic Constipation. Accessed January 8, 2026. https://iffgd.org/gi-disorders/lower-gi-disorders/constipation/

4. Brenner D. Real-World Data Highlight a New Approach to Chronic Constipation, With Darren Brenner, MD. December 15, 2025. Accessed January 8, 2026. https://www.hcplive.com/view/real-world-data-highlight-a-new-approach-to-chronic-constipation-with-darren-brenner-md