We share the opinion expressed by Dr. Runde that abdominal colectomy and ileorectostomy must be done with caution. No responsible surgeon or gastroenterologist would lightly suggest that a patient have an ileorectostomy for slow-transit constipation unless the disease had left the patient with a severely limited lifestyle. Before any surgery is considered, each patient must overcome several hurdles. Patients must have quantifiably significant slow transit (proven by clinical markers or scintigraphy) and must show normal pelvic floor function. In older patients, a history of fecal incontinence must also be ruled out. We agree that ileorectostomy in the setting of fecal incontinence is an invitation to disaster.

After slow transit is documented, all nonsurgical treatment options must be explored fully. Only then, if no change is evident in the patient's symptoms or lifestyle, should an ileorectostomy be considered. Finally, a patient who has the irritable bowel syndrome must never have an ileorectostomy because the procedure will result in poor control of the multiple loose stools that characterize the syndrome. In the case cited by Dr. Runde, we would be concerned that the patient with 16 bowel movements per day may have the irritable bowel syndrome, which may have preceded the colectomy, or a simple stricture, which can also cause increased stool frequency and loss of control.

In the study mentioned by Dr. Runde [1], patients were followed for a maximum of 3 years. At the end of that time, no patient had recurrent constipation or fecal incontinence. The mean number of stools per day was 2. This experience mirrors that of nearly all surgeons who do ileorectostomies for motility disorders, inflammatory bowel disease, or multiple cancers. A less than optimal result in the patient described by Dr. Runde should not prejudice the approach to future patients who might benefit from surgical intervention for slow-transit constipation.

In summary, if an otherwise healthy patient has quantifiable slow transit, absence of features suggestive of the irritable bowel syndrome and normal pelvic floor function; has exhausted all options of medical management; and does not have fecal incontinence, that patient will gain prompt relief of constipation and will have few complications after ileorectostomy.