What is the best management approach for a patient with severe pelvic adhesions, probable deep endometriosis, chronic constipation, and Ehlers-Danlos syndrome (EDS) once their probability of requiring bowel resection is high?

Management of Severe Pelvic Adhesions with Probable Deep Endometriosis, Chronic Constipation, and EDS When Bowel Resection is Highly Probable

In a patient with severe pelvic adhesions, probable deep endometriosis, chronic constipation, and Ehlers-Danlos syndrome where bowel resection probability is high, proceed with multidisciplinary surgical planning involving experienced gynecologic and colorectal surgeons, but exercise extreme caution given the EDS diagnosis—this population requires special consideration as the same cautions that apply to functional gastrointestinal disorders should apply when escalating to invasive procedures in EDS patients. 1

Critical EDS-Specific Considerations

Understanding EDS and Gastrointestinal Symptoms

• Hypermobile EDS (hEDS) patients frequently present with gastrointestinal symptoms that mimic dysmotility, but most do not have true small bowel dysmotility—rather, they have visceral hypersensitivity. 1
• Patients with hEDS/HSD represent approximately one-third of referrals to tertiary neurogastroenterology clinics and tend to be young females with poorer quality of life. 1
• It remains unclear whether hEDS is associated with greater chronic intestinal dysmotility or whether treatment approaches differ from functional gastrointestinal disorders. 1
• The association with chronic constipation in EDS may be related to visceral hypersensitivity, autonomic dysregulation (particularly postural tachycardia syndrome), or opiate use rather than true mechanical obstruction. 1

Surgical Risk Assessment in EDS

• The same cautions that apply to functional gastrointestinal disorders should apply when considering escalating invasiveness of procedures in hEDS patients, especially with pain-predominant presentations. 1
• EDS patients have increased risk of complications from pelvic floor disorders and require multidisciplinary management involving multiple specialties. 2
• Tissue fragility and abnormal collagen synthesis in EDS may increase surgical complications and healing difficulties. 2

Endometriosis-Specific Surgical Considerations

When Bowel Resection is Indicated

• For severe endometriosis with bowel involvement, medical treatment alone is insufficient—surgical intervention is necessary. 1, 3
• Deep infiltrating endometriosis affecting the rectosigmoid (which occurs in approximately 90% of bowel endometriosis cases) requires complete excision of all visible disease for optimal outcomes. 4, 5, 6
• Laparoscopic segmental colorectal resection by an experienced interdisciplinary team (gynecologic and colorectal surgeons) achieves radical resection in 97% of cases with low major complication rates (anastomotic leakage 2.8%). 4

Expected Surgical Outcomes

• Long-term outcomes following bowel resection for severe endometriosis show significant improvement: pelvic pain (96%), dyschezia (88%), and dyspareunia (87%). 6
• However, post-operative severe constipation occurs in approximately 20% of patients after colorectal resection for rectal endometriosis. 7
• Up to 44% of women experience symptom recurrence within one year after endometriosis surgery. 1, 3
• Pregnancy rates of 50% are achievable in those desiring fertility after bowel resection for endometriosis. 5, 6

Adhesion-Related Considerations

Risk of Post-Operative Adhesions

• A major risk of pelvic surgery is development of postoperative adhesions at incision sites and de novo adhesions from peritoneal trauma, which can result in reduced fertility or bowel obstruction. 1
• Adhesion prevention barriers (oxidized regenerated cellulose, hyaluronic acid/carboxymethylcellulose combinations) should be utilized to minimize postoperative adhesion formation. 1
• Minimizing surgical trauma and confining incisions strategically can reduce adhesion rates. 1

Managing Existing Adhesions

• Severe pelvic adhesions may already be present and contribute to chronic pain and bowel dysfunction. 1
• Adhesiolysis during surgery for endometriosis is often necessary but carries risk of inadvertent bowel injury. 1

Pre-Operative Workup Requirements

Comprehensive Imaging

• Preoperative imaging before surgery reduces morbidity, mortality, and need for repeat surgeries. 3
• Expanded protocol transvaginal ultrasound (TVUS) or MRI should be performed to identify and "map" deep endometriosis extent. 3
• CT imaging can help define obstruction location, grade (partial vs. complete), and identify transition zones, though accuracy for exact cause in virgin abdomen may be limited. 1

Functional Assessment

• A step-by-step workup is mandatory to understand the pathophysiologic mechanisms of constipation: colonic transit time measurement, anorectal manometry, electromyography, and defecographic evaluation. 7
• Distinguish between mechanical obstruction from endometriosis/adhesions versus functional constipation related to EDS. 1, 7
• Rule out other causes: anastomotic stricture potential, neurological sequelae risk, and transit disorders. 7

Surgical Planning Algorithm

Multidisciplinary Team Assembly

• Assemble an experienced interdisciplinary surgical team including gynecologic surgeon, colorectal surgeon, anesthesiologist familiar with EDS, and potentially gastroenterology and physiatry specialists. 4, 5, 2, 6
• Ensure surgeons have specific expertise in laparoscopic management of deep infiltrating endometriosis with bowel involvement. 4, 5

Surgical Approach Selection

• Laparoscopic approach is preferred and achievable in 85.7% of cases, with conversion to laparotomy in select cases. 4
• Plan for complete excision of all visible endometriotic lesions—radical resection correlates with symptom improvement. 6
• Depending on lesion size and location, perform either full-thickness disc excision or segmental bowel resection. 5

Intraoperative Considerations

• Complete r-ASRM classification for all patients, Enzian classification for deep endometriosis, and EFI score if fertility concerns exist. 3
• Minimize surgical trauma to reduce de novo adhesion formation. 1
• Apply adhesion prevention barriers at conclusion of surgery. 1

Post-Operative Management and Monitoring

Immediate Post-Operative Period

• Monitor closely for anastomotic leakage (occurs in approximately 2.8% of cases) and rectovaginal fistula formation. 4
• Implement enhanced recovery protocols appropriate for EDS patients with attention to tissue fragility. 2

Long-Term Follow-Up

• Perform systematic evaluation for post-operative bowel dysfunction, as constipation mechanisms may vary: anastomotic stenosis, neurological sequelae, intussusception, or transit disorders. 7
• Monitor for symptom recurrence, which occurs in up to 44% within one year. 1, 3
• Coordinate ongoing care with gastroenterology for management of EDS-related gastrointestinal symptoms. 1

Critical Pitfalls to Avoid

• Do not proceed with surgery without confirming that symptoms are truly from mechanical obstruction/deep endometriosis rather than EDS-related visceral hypersensitivity or functional disorders. 1
• Avoid operating without experienced colorectal surgical expertise—this significantly impacts complication rates. 4, 5
• Do not fail to counsel patient about 20% risk of severe post-operative constipation requiring additional interventions. 7
• Avoid inadequate preoperative imaging—this leads to incomplete resection and need for repeat surgery. 3
• Do not underestimate tissue fragility and healing complications specific to EDS patients. 2