AGA Warns: Surgery Not First Choice for Refractory Constipation
- Back to Healio"Because 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...
- "The AGA commissioned this update to provide practical, expert-driven guidance for clinicians facing these challenging scenarios - especially where the stakes are highest, such as decisions around surgery."
- Healio spoke with Staller about the updated guidance, including why refractory constipation is especially challenging to define and treat, how the 14 best practice advice statements were decided...
January 22, 2026
4 min read
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“Because 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 – especially where the stakes are highest, such as decisions around surgery.”
Healio spoke with Staller about the updated guidance, including why refractory constipation is especially challenging 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 – manny 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 New Research Highlights Potential of Tenapanor for Chronic Kidney Disease-Associated Itch
Table of Contents A recent interview with Kenneth Staller, MD, suggests tenapanor may offer a novel approach to managing chronic kidney disease-associated pruritus (CKD-AP), a debilitating symptom affecting many patients with kidney disease. The findings, discussed in a Healio interview, point to tenapanor’s potential to reduce itch intensity by modulating gut microbiota and reducing uremic toxin absorption. CKD-AP is a common and distressing symptom experienced by individuals with chronic kidney disease. It considerably impacts quality of life, frequently enough leading to sleep disturbances, anxiety, and depression. Current treatments offer limited relief, creating a need for new therapeutic options. Tenapanor, initially approved for hyperphosphatemia in chronic kidney disease, works by inhibiting the sodium-hydrogen exchanger 3 (NHE3) in the gut.This mechanism reduces phosphate absorption, but also alters gut microbiota composition and decreases the absorption of uremic toxins, which are believed to contribute to CKD-AP. Dr. Staller, speaking with Healio, highlighted the promising results observed in clinical trials. he noted that tenapanor demonstrated a statistically notable reduction in itch intensity compared to placebo in patients with CKD-AP. “The mechanism is really captivating because it’s not just about lowering phosphate,” Dr. Staller said in the Healio interview. “It’s about changing the gut microbiome and reducing the amount of uremic toxins that are absorbed.” Dr. Staller disclosed research support from Ardelyx and consulting fees from AbbVie, Ardelyx, Atmo, Laborie, Mindset Health, Salix and Takeda. Source: Healio Interviews Worth a lookUnderstanding Chronic Kidney Disease-Associated Itch
How tenapanor Works
Research Findings and Expert Commentary
Disclosures
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