What are the next steps for a 30-year-old female patient with suspected Deep Infiltrating Endometriosis (DIE), Ehlers-Danlos Syndrome (EDS), and a history of bowel adhesions, who is scheduled for a pelvic Magnetic Resonance Imaging (MRI) and endometriosis excision surgery?

Management of Confirmed Deep Infiltrating Endometriosis (DIE)

Immediate Next Steps

Proceed with the scheduled pelvic MRI next week to complete surgical mapping, followed by excision surgery with a multidisciplinary team experienced in DIE, as this represents the definitive treatment for symptomatic DIE. 1

The planned sequence of MRI followed by surgery is the correct approach, as preoperative imaging reduces morbidity and mortality by decreasing incomplete surgeries that require reoperation 1, 2. Given the patient's history of bowel adhesions and suspected DIE, comprehensive surgical planning is essential.

Critical Pre-Surgical Imaging Requirements

MRI Protocol Specifications

• Request MRI pelvis WITH and WITHOUT IV contrast rather than without contrast alone, as IV contrast helps differentiate endometriomas from ovarian malignancies and identifies other causes of symptoms 1
• Ensure the protocol includes moderate bladder distention and vaginal contrast to improve lesion conspicuity 2, 3
• Request documentation of specific surgical planning measurements: lesion length, circumferential extent, distance to anal verge, and muscular involvement for any bowel lesions 1

Key Anatomic Areas to Map

The MRI must evaluate:

• Uterosacral ligaments (common DIE location) 2, 3
• Anterior rectosigmoid wall and bowel involvement proximal to rectosigmoid junction 1
• Bladder wall involvement 2
• Pouch of Douglas obliteration and adhesions 2, 3
• Ovarian endometriomas 2, 3

Special Considerations for EDS and Bowel Adhesions

Pre-Surgical Planning Imperatives

• Ensure the surgical team includes colorectal surgery expertise given the history of bowel adhesions and high likelihood of bowel involvement in DIE 4, 5
• Urologic consultation should be available, as urinary tract involvement occurs in approximately 1% of endometriosis patients but may be higher with extensive DIE 5
• The patient's EDS diagnosis increases risk for tissue fragility and wound healing complications—this must be communicated to the surgical team

Surgical Approach Decision Points

For bowel involvement, three techniques exist with different risk profiles 5:

• Rectal shaving (lowest morbidity, but higher recurrence risk)
• Anterior discoid resection (intermediate approach for focal lesions)
• Segmental resection (most definitive but highest complication risk including anastomotic fistula, rectovaginal fistula, intestinal obstruction) 5, 6

The choice depends on depth of bowel wall infiltration and circumferential involvement, which the MRI will clarify 1.

Pre-Operative Medical Optimization

Consider GnRH Agonist Pre-Treatment

• Three cycles of GnRH agonist before surgery may facilitate complete disease removal by reducing lesion vascularity and size 6
• However, this delays definitive treatment by 3 months—weigh against symptom severity
• This is particularly relevant if the MRI shows extensive disease requiring complex bowel surgery 6

Contraindications to Delay

Do NOT delay surgery if:

• Bowel obstruction symptoms are present 6
• Severe pain is uncontrolled with current management 7
• Urinary tract obstruction is suspected 5

Post-MRI Decision Algorithm

If MRI Shows Limited DIE (No Bowel/Bladder Involvement)

• Proceed with scheduled excision surgery by gynecologic surgeon experienced in endometriosis 4, 7
• Complete excision of all visible disease in one-step procedure is the goal 4

If MRI Shows Bowel Involvement

• Confirm multidisciplinary team availability (gynecologic surgeon + colorectal surgeon) before proceeding 4, 7
• Consider pre-surgical GnRH agonist if surgery cannot be performed by experienced team within 2-4 weeks 6
• Bowel preparation protocol will be required 1

If MRI Shows Urinary Tract Involvement

• Mandatory urology consultation before surgery 5
• May require ureteral stent placement 5

Critical Surgical Principles

• Complete excision of all lesions in a single operation is essential to minimize recurrence and optimize long-term pain relief 4, 8
• Laparoscopic approach is preferred over laparotomy, as it reduces postoperative complications, hospitalization length, and convalescence time 5
• Incomplete excision leads to symptom recurrence in 25-44% of patients within 12 months 9

Common Pitfalls to Avoid

• Do not proceed with surgery if the surgical team lacks experience with DIE and bowel/urologic involvement—this is the most common cause of incomplete excision requiring reoperation 1, 2
• Do not assume standard gynecologic surgery expertise is sufficient for complex DIE—multidisciplinary team is mandatory 4, 7
• Do not accept MRI without IV contrast for this complex case—contrast is needed to rule out malignancy and identify vascular structures 1
• Given EDS, ensure anesthesia is aware of potential joint hypermobility and positioning complications

Post-Operative Monitoring

• Recurrence risk remains significant even after complete excision 9, 7
• Long-term hormonal suppression post-operatively reduces recurrence risk 7, 8
• Monitor for specific complications: anastomotic fistula, rectovaginal fistula, urinary fistula, deep pelvic abscess if bowel surgery performed 5