Subtotal colectomy with antiperistaltic caecorectal anastomosis versus total colectomy with ileorectal anastomosis for refractory slow-transit constipation: a comparative analysis.

In selected cases of slow-transit constipation (STC), total colectomy with ileorectal anastomosis (TC-IRA) remains the standard surgical treatment but is associated with heterogeneous outcomes and relevant functional sequelae. Subtotal colectomy with caecorectal anastomosis (SCCRA) has been proposed as an alternative approach aiming to preserve the ileocaecal junction and improve postoperative bowel function. A prospective bicentre cohort of patients undergoing minimally invasive SCCRA for refractory STC was analysed and compared with a retrospective cohort of patients undergoing TC-IRA. Primary outcome was change in PAC-QOL score at 6 months. Secondary outcomes included PAC-SYM, St Mark's incontinence score, bowel movement frequency, and postoperative outcomes. Histopathological findings from colectomy specimens in the SCCRA cohort were also evaluated. Eleven patients underwent SCCRA and 21 underwent TC-IRA. In the SCCRA cohort, PAC-QOL and PAC-SYM scores significantly improved at 6 months (p < 0.001 and p = 0.004, respectively), with bowel movements increasing from a median of 1 to 7 per week (p = 0.003), without deterioration in continence. One anastomotic leak required reoperation. Compared with SCCRA, TC-IRA patients had higher baseline disease burden (PAC-QOL 3.88 vs. 2.00, p < 0.001) and greater absolute improvement in PAC-QOL (Δ3.28 vs. 1.54, p < 0.001). However, TC-IRA was associated with significantly higher postoperative bowel frequency (21 vs. 7/week, p = 0.002). Operative time and baseline characteristics were comparable. Histopathological evaluation of the SCCRA cohort revealed a heterogeneous spectrum of pathological alterations. Minimally invasive SCCRA provides significant functional improvement while maintaining a more physiological bowel frequency. However, direct comparison with TC-IRA is limited by differences in baseline disease burden and study design, and these findings should be confirmed in prospective comparative studies.