Subtotal Colectomy vs Total Colectomy for Slow-Transit Constipation
Man Guo, Fan Li, Fan Bu, Zhe Cui, Haibo Lan, Ling Ni, Feng Gao, Yongbing Wang, Jianping Zhou, Tao Fu, Weicheng Liu, Dongbo Xu, Xin Liu, Hua Gao, Bin Huang, Li Wang, Lin Zhang, Miao Wu, Congqing Jiang, Jun Jiang, Wenjing Gong, Weidong Tong, , Yafei LiIMPORTANCE
For patients with slow-transit constipation (STC), total colectomy with ileorectal anastomosis (TC-IRA) remains the standard surgical treatment but is frequently complicated by diarrhea, fecal incontinence, and bowel obstruction. Subtotal colectomy with cecorectal anastomosis (SC-CRA) has emerged as a promising alternative; however, recurrence of constipation remains a critical concern. High-quality evidence comparing these 2 procedures is lacking.
OBJECTIVE
To compare the 1-year Wexner Constipation Score of patients with STC who underwent SC-CRA vs TC-IRA.
DESIGN, SETTING, AND PARTICIPANTS
This multicenter, open-label, noninferiority randomized clinical trial was conducted at 12 tertiary hospitals across 8 provinces in China from April 2022 to April 2025, with 12-month follow-up (final follow-up April 2026). Eligible participants were adults aged 18 years or older with Rome IV–defined functional constipation, fewer than 1 spontaneous bowel movement per week, and long-term laxative dependence, defined as the regular use of osmotic or stimulant laxatives, or prokinetic agents, at least 3 times weekly for 6 months or longer before enrollment. Of 272 adults assessed, 252 were randomized. These data were analyzed from March 2025 to March 2026.
INTERVENTIONS
Participants were randomly assigned in a 1:1 ratio to undergo either SC-CRA or TC-IRA.
MAIN OUTCOMES AND MEASURES
The primary outcome was the Wexner Constipation Score (WCS) at 12 months, with a prespecified noninferiority margin of 1.32 points. Secondary outcomes included fecal incontinence, morbidity, quality of life, and patient-reported satisfaction.
RESULTS
A total of 252 participants (mean age, 49.5 years; 221 female [87.7%] and 31 male [12.3%]) were randomized to undergo SC-CRA (n = 126) or TC-IRA (n = 126). At 12 months, adjusted mean (SD) WCS was 7.01 (3.31) in the SC-CRA group and 6.84 (3.68) in the TC-IRA group (adjusted mean difference, 0.17; 95% CI, –0.93 to 1.27), which fell within the prespecified noninferiority margin of 1.32 ( P = .02 for noninferiority). Early postoperative incontinence at 3 months was less frequent in the SC-CRA group than in the TC-IRA group (8.7% vs 21.4%; risk difference, –12.7%; 95% CI, –21.4% to –4.0%; P = .01). Perioperative morbidity did not differ significantly between groups (10.3% vs 12.7%; risk difference, –2.4%; 95% CI, –10.3% to 5.5%; P = .41), and quality-of-life scores at 12 months were comparable. However, patient-reported satisfaction at 12 months favored the TC-IRA group (97.5% vs 95.8%; P = .03).
CONCLUSIONS AND RELEVANCE
In this randomized clinical trial among patients with refractory STC, SC-CRA was noninferior to TC-IRA with respect to the WCS at 12 months, but patient-reported satisfaction at 1 year was higher in the TC-IRA group. Longer-term follow-up is needed.
TRIAL REGISTRATION
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