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Developments in anorectal physiologic testing have facilitated better understanding of the process of defecation and factors that might cause chronic constipation.Patients with severe idiopathic chronic constipation were evaluated using colonic transit and pelvic floor function in an attempt to identify those patients suitable for aggressive surgical intervention.Among 1,009 patients studied using either a marker or scintigraphic transit technique and tests of pelvic floor function, 52 with slow-transit constipation (STC) were identified and underwent abdominal colectomy and ileorectostomy (IRA). Twenty-two patients had pelvic floor dysfunction and STC; these patients underwent initial pelvic floor retraining followed by IRA. A total of 249 patients had pelvic floor dysfunction without evidence of slow-transit and were offered pelvic floor retraining alone. The remaining 597 patients had no quantifiable abnormality of colon or pelvic floor dysfunction; these patients had normal transit constipation/irritable bowel syndrome and were treated medically. There were, thus, 74 patients operated on, 68 women, with a mean age of 53 years and a mean follow-up of 56 months. There was no operative mortality, seven patients (9 percent) had small-bowel obstruction, and nine patients (12 percent) had prolonged ileus. All patients were able to pass a stool spontaneously, 97 percent of patients were satisfied with the results of surgery, and 90 percent have a good or improved quality of life. There was no difference in the outcome of surgery in patients with STC alone compared with STC and pelvic floor dysfunction.Physiologic evaluation reliably identified patients with severe chronic constipation who might benefit from surgery. IRA is safe and effective, resulting in prompt and prolonged relief of constipation.