Surgical management of refractory intestinal dysmotility: outcomes of a single-center tailored pathway

Surgical management of severe refractory intestinal dysmotility disorders, including chronic intestinal pseudo-obstruction (CIPO) and colonic dyssynergia, remains challenging. Intestinal transplantation (IT) is a high-risk last resort, while less invasive options like the Trifecta procedure (subtotal colectomy, pyloroplasty, and ileostomy) or colectomy may provide palliative benefits, though direct comparative data are limited. A retrospective cohort study (2017–2024) at Shiraz Transplant Center, Abu Ali Sina Hospital, included 55 patients with severe intestinal dysmotility. A dynamic surgical algorithm was applied: confirmed CIPO cases underwent the Trifecta procedure; colonic dyssynergia cases had total colectomy. Diagnostically uncertain patients initially received the Trifecta, with ileostomy output guiding reassessment. Refractory cases were considered for transplantation. Pre- and postoperative symptoms (pain, bloating, bacterial overgrowth, defecation difficulties) were compared using the Exact McNemar test. The primary endpoint was postoperative symptom status (symptom-free, symptom reduction, or mortality) at last follow-up. Symptom data were retrospectively extracted from clinical records; no validated patient-reported outcomes or standardized complication and nutritional data were collected. Among 55 patients, 12 (21.8%) underwent Trifecta, 16 (29.1%) total colectomy, and 27 (49.1%) IT. Significant postoperative improvements occurred in pain, bacterial overgrowth, and bloating (all p < 0.001), while defecation difficulties showed no significant change ( p = 0.262). Mortality was observed in 12 patients overall (21.8%): 11 of 27 intestinal transplant recipients (40.7%) and 1 of 16 total colectomy patients (6.3%); no deaths were reported in the Trifecta group. Exploratory analyses linked postoperative outcomes (mortality, symptom reduction, symptom-free status) to preoperative BMI ( p = 0.042) and clinical status ( p < 0.001). A tailored surgical algorithm using the Trifecta procedure as both treatment and diagnostic tool suggested symptom improvement in this retrospective series. Higher BMI and better preoperative status were associated with favorable outcomes. However, the lack of standardized outcome measures, complication data, and validated symptom scores limits these findings. Prospective validation is needed.