Surgical treatment of chronic constipation: who should be referred for surgery?

Chronic constipation is a common gastrointestinal disorder and a frequent indication for referral to gastroenterology and colorectal surgery. Although most cases are functional, a minority of patients are candidates for surgical management. An appropriate surgical indication requires a detailed pathophysiological evaluation, as functional constipation includes distinct subtypes with different therapeutic implications: normal transit constipation, slow transit constipation, and defecatory disorders. Surgery should not be considered a rescue option after failure of medical therapy, but rather a targeted intervention in selected patients with well-defined pathophysiological abnormalities, particularly those with objectively confirmed slow transit constipation. This narrative review summarizes current evidence on preoperative evaluation, patient selection, and surgical management. Key elements include objective confirmation of delayed colonic transit, exclusion of pelvic floor dysfunction, assessment of generalized gastrointestinal dysmotility, and evaluation of psychosocial factors associated with outcomes. Subtotal colectomy with ileorectal anastomosis is the preferred surgical option in appropriately selected patients. Diverting loop ileostomy may be considered as a diagnostic and therapeutic strategy in complex cases. Segmental colectomy has a limited role, the Malone procedure is reserved for selected cases, and sacral neuromodulation is not supported for routine use.