Endoscopic Tattooing Research Articles

Bowel obstruction associated with endoscopic tattooing of the colon with India ink

During a laparoscopic resection of small colorectal lesions, preoperative endoscopic marking with India ink is useful for identifying the location of the lesion. India ink has been thought to be a safe agent with few adverse effects. We herein report a case who suffered from postoperative abdominal pain resulting in bowel obstruction, due to massive adhesion around the area with India ink. A 61-year-old man with early transverse colon cancer underwent a laparoscopy-assisted transverse colon resection. Prior to the operation, endoscopic tattooing with India ink was performed. At the operation, spillage of India ink into the peritoneal cavity was observed. Many small black spots were thereafter seen on the peritoneum, mesentery and omentum, but neither severe inflammation nor any adhesion was noticed. The operation was performed without any difficulty. Though his immediate postoperative course was uneventful, a bowel obstruction gradually developed from a week postoperatively. Finally, he had to undergo a re-operation, and was found to have diffuse and massive adhesion around areas with India ink. Especially, severe omental adhesion involved and squeezed the transverse colon. A resection of the omentum with stenotic colon and re-anastomosis was performed. India ink can cause severe inflammation and adhesion when it accidentally leaks into the peritoneal cavity.

Preoperative endoscopic tattooing of pancreatic body and tail lesions decreases operative time for laparoscopic distal pancreatectomy

Precise and expedient localization of small pancreatic tumors during laparoscopic distal pancreatectomy can be difficult owing to the decreased tactile ability of laparoscopy and the homogenous appearance of the surrounding retroperitoneal fat. Precise localization of the lesion is critical to achieving adequate margins of resection while preserving as much healthy pancreas as possible. The objective in this study was to determine the effect of endoscopic tattooing of the distal pancreas on operative time. We reviewed retrospectively 36 consecutive patients who had a laparoscopic distal pancreatectomy at our institution over a 4-year period (2006-2009). Ten patients underwent preoperative tattooing via an endoscopic transgastric technique using ultrasound guidance. The tattoo was performed using 2-4 cc of sterile purified carbon particles injected immediately proximal and anterior to the pancreatic lesion. Operative times were compared according to the presence of a tattoo. The endoscopically placed tattoo was easily visible upon entering the lesser sac in all 10 patients at laparoscopy. Patients with a tattoo had a shorter operative time (median, 128.5 minutes; range, 53-180) compared with patients without a tattoo (median, 180 minutes; range, 120-240; P < .01). None of the tattoo group required repeat surgery, whereas 1 patient who was not tattooed required re-resection for a lesion missed in the initial specimen. There were no complications associated with the endoscopic ultrasound-guided tattoo. Endoscopic ultrasound-guided tattooing of pancreas lesions before a laparoscopic distal pancreatectomy is safe and is associated with decreased operative time compared with nontattooed patients. This technique can allow for quick and precise localization of the lesion, allowing for optimal preservation of pancreas parenchyma and demarcating an appropriate line of resection.

The Lymph Node Yield of Neck Dissections – Is There a Difference Between Consultant Surgeons and Specialist Registrars?

The Lymph Node Yield of Neck Dissections – Is There a Difference Between Consultant Surgeons and Specialist Registrars?

The Frequency and Accuracy of Pre-Operative Endoscopic Tattooing of Colorectal Lesions

The Frequency and Accuracy of Pre-Operative Endoscopic Tattooing of Colorectal Lesions

Black Macular Patches on Parietal Peritoneum and Other Extraintestinal Sites from Intraperitoneal Spillage and Spread of India Ink from Preoperative Endoscopic Tattooing: An Endoscopic, Surgical, Gross Pathologic, and Microscopic Study

Three cases, including one case report and two clinical images, have been reported of extraintestinal or peritoneal black maculae detected at laparoscopy after colonoscopic tattooing, presumably from intraperitoneal spillage of India ink during tattooing. Report three cases of inadvertent extraintestinal tattooing from endoscopic tattooing of intestinal lesions, provide histologic evidence for the presumed pathophysiology, and promulgate recommendations to prevent this complication. Three patients underwent endoscopic tattooing of intestinal lesions using India ink, surgery for lesion removal, and pathologic analysis. Three patients had black macular patches or streaks identified intraoperatively at extraintestinal sites after endoscopic tattooing of intestinal lesions with India ink: (1) black patches on peritoneum 7 days after colonoscopic tattooing of cecal cancer, (2) black streaks on band connecting cecum to peritoneum 13 days after colonoscopic tattooing of cecal cancer, and (3) blackish band on jejunal mesentery 28 days after tattooing presumptive bleeding jejunal lesion. Pigmentation was detected at both injection and extraintestinal sites in all patients by (1) surgery, (2) gross pathology, and (3) microscopic examination demonstrating intracellular black pigmentation within mesothelial cells and macrophages. Special histologic stains were consistent with a carbon-based pigment, and inconsistent with iron or melanin as the pigment. The proposed mechanism is intraperitoneal India ink spillage from deep intestinal injection, as supported by histologic findings of subserosal pigment accumulation. An alternative histologic mechanism is migration of pigment-laden macrophages via lymphovascular channels. Endoscopic injection of India ink using standard sclerotherapy needles can inadvertently tattoo extraintestinal sites in addition to tattooing the primary lesion. Despite its striking appearance, this intraoperative, gross, and microscopic finding is likely not pathologically significant, given its proposed pathophysiology. Surgical recognition of this entity is important, however, to prevent misinterpretation of findings as peritoneal melanoma, endometrial implants, infarcted mesentery, or tattooed cancer. This complication may be prevented by proper tattooing technique.

Colonoscopy and computerized tomography scan are not sufficient to localize right‐sided colonic lesions accurately

Accurate preoperative localization of colonic lesions is critical especially in laparoscopic colectomy where tactile localization is absent particularly in screen-detected tumours. The study aimed to evaluate the accuracy of colonoscopy and double-contrast computerized tomography (CT) scan to localize lesions treated by right hemicolectomy. A retrospective chart review was performed of patients treated by right hemicolectomy under the colorectal service between July 2003 and October 2006. Preoperative tumour location determined by CT scan and colonoscopy was compared with the intra-operative and histopathological findings. Out of 101 patients, 73 (73%) were for adenoma or cancer, with a final diagnosis of adenocarcinoma in 59 (58%). Preoperative localization was inaccurate in 29% of lesions using both CT and colonoscopy. In the transverse colon, colonoscopy alone was only 37.5% accurate, increasing to 62.5% when information from the CT scan was added. Preoperative localization of right-sided colon cancers using colonoscopy and CT scanning is unreliable in at least 29% of cases. Inaccurate localization of transverse colon tumours risks inadequate lymphadenectomy with an adverse cancer outcome. Preoperative abdominal CT scan improves accuracy but endoscopic tattoo localization should be employed routinely especially in patients undergoing laparoscopic resection.

Spontaneous complete regression of a rectal cancer

We report a unique case of a biopsy-proven rectal cancer exhibiting spontaneous complete regression in an extremely short period of 3 months. An 80-year-old man visited our hospital because of a positive fecal occult blood test. Colonoscopy showed a sessile polyp, about 25 mm in diameter, in the middle part of the rectum. Instead of endoscopic resection, two endoscopic biopsies were taken for histological evaluation, as an invasive cancer was endoscopically suspected.Well-differentiated invasive adenocarcinoma was revealed, and thus surgical resection was planned. At the second colonoscopy for endoscopic tattooing before surgery, the polyp was found to have unexpectedly developed into a flat lesion. Furthermore, the surgically removed specimen showed that the flat lesion had transformed to a depressed lesion, and surprisingly, no cancerous tissue was detected histologically.

Endoscopy-assisted gastric resection: a safe and reliable procedure for tumor clearance during laparoscopic high distal or proximal gastrectomy

Preoperative endoscopic tattooing or clipping is generally used to delineate the tumor-free margin in surgery for early gastric cancer. However, it is sometimes difficult to identify the line of resection during laparoscopic gastrectomy. Between June 2003 and February 2008, we performed a total of 12 endoscopy-assisted gastric resections during laparoscopic gastrectomy for cancer, including four cases of high distal gastrectomy and eight cases of proximal gastrectomy. In the laparoscopic high distal gastrectomy cases, a surgeon performed transduodenal endoscopy to identify the clips before gastric resection. For totally laparoscopic proximal gastrectomy, an endoscopist performed transoral endoscopy to identify the clips placed in the distal margin of the lesion and to facilitate intracorporeal anastomosis. In all cases, we were able to observe clips as well as the primary lesion. Gastric resection was successfully performed with no positive margin. In the high distal gastrectomy group (n = 4), proximal and distal margins were 19.5 +/- 2.1 (range, 10-35) mm and 1,185 +/- 190.9 (range, 850-1,320) mm, respectively. In the proximal gastrectomy group (n = 8), proximal and distal margins were 21.3 +/- 7.1 (range, 5-38) mm and 47.5 +/- 3.5 (range, 15-75) mm, respectively. The intracorporeal side-to-side anastomosis during proximal gastrectomy was successfully performed using an endolinear stapler. Endoscopy-assisted gastric resection is a safe and reliable procedure for tumor clearance during laparoscopic high distal or proximal gastrectomy.

Significance of the localization of small tumors at laparoscopic large bowel resections

Introduction: The premalignant and malignant diseases of the colon could be identified earlier owing to the colonoscopic screening. Although large part of these small lesions could be removed by the new intraluminal techniques (endoscopic submucosal dissection), the other tumors needs minimal invasive surgical (laparoscopic large bowel resection) procedure. To find these small, T1-T2 tumors during the operation is usually very difficult, or impossible owing to the nature of the laparoscopic technique. The correct anatomical localization with the preoperative colonoscopy is false in about 15–20% of the cases, and the intraoperative colonoscopy is not considered to be an ideal solution for various reasons. Patients and method: 158 laparoscopic large bowel resections were performed because of malignant and benignant lesions of the colon between 1 Jan. 2005 and 31 Dec. 2008. The average age of the patients was 68,3 years. The size of the tumors was less than 3cm at 56 cases, and the histology detected lesions which not reached the serosa at 45 patients. Results: At 29/158 (18,4%) cases pre- or intraoperativ techniques had to be used for the localization. Preoperative endoscopic clip placement has been used at 5 cases. Intraoperative colonoscopy was performed at 4 cases owing to the difficulties of intraoperative localization, rectoscopy at 3 cases and rectal digital examination at 15 cases. Re-resection had to be made because of the missed blind resection at 2 cases. The average operation time of these small lesions was not shorter significantly to the large (T3-T4) tumors (168min. vs. 145min.). Conclusions: There is increasing claim for the preoperative (if it is possible at the time of the detection of the lesion) marking with the development of the laparoscopic large bowel surgery. The definition of the exact criteria's (when, where, how) needs consensus between gastroenterologists and surgeons. The present endoscopic tattooing did not live up to expectations, therefore development of such new inks is necessary, which could be detected easily during laparoscopic procedures.

A sessile colonic polyp showing striking morphological changes within a 2-month period

A 67-year-old man underwent total colonoscopy because he had had a positive fecal occult blood test. Colonoscopy showed a sessile polyp, 10 mm in diameter, in the sigmoid colon ([Fig. 1]). Six weeks later, he was scheduled for hospitalization to undergo endoscopic resection of this polyp. At this second colonoscopy the polyp was seen to have developed a morphologically unique “polyp on polyp” appearance ([Fig. 2]). Because invasive cancer was suspected on the basis of the endoscopic appearances, the endoscopic removal was discontinued and surgical resection was recommended. Nine weeks after the initial colonoscopy the patient underwent a third colonoscopy for endoscopic tattooing before surgery. Surprisingly, the polyp had transformed into a nonpolypoid lesion with a type V pit pattern ([Fig. 3]). Laparoscopy-assisted colectomy was performed, and on histological examination the resected specimen revealed a moderately differentiated adenocarcinoma without an adenomatous component, that extended deeply into the submucosal layer with vessel invasion and lymph node metastasis ([Fig. 4]).

Preoperative localization of colonic tumors using transabdominal illumination of the colonoscope

Dear Editor: Colonoscopy is recommended for colorectal polyps in both diagnostic and therapeutic purposes. It was estimated that more than 85% of polyps could be removed by means of colonoscopic polypectomy, although this mainly depends on the size, type, and location of the lesion as well as on the experience and judgment of the performing endoscopist. Those unsuitable for colonoscopic polypectomy are referred to surgeons for surgical resection, which has options of either the laparoscopic or open approach. Laparoscopic resection requires instruments and surgical skill to perform, whereas open surgery results in larger wounds and longer hospitalization for recovery. Precise location of colonic polyps is a critical aspect but is difficult to establish during surgery. Although techniques such as localization by endoscopically placed clips, radiographic and magnetic imaging, and intraoperative colonoscopy have all been suggested, surgical localization is optimized by endoscopically placing a four-quadrant tattoo with India ink before surgery. It has been established that preoperative endoscopic tattooing is efficient and reliable for localizing polypectomy sites at operation with successfully visualized tattoos in 88–97% of cases; however, the injection of an optimal volume of India ink into the submucosa is difficult: Too much ink or an injection too deep dyes the whole peritoneum, obscuring the location of the polypectomy site. Herein, we developed a simple method composed of preoperative colonoscopic localization of the sites of polyps by means of transabdominal illumination to mark the sites of incision on the day before the planned operation. The following transcolonic polypectomy or partial colectomy were executed through a minilaparotomy depending on the results of the frozen section. This method has advantages of a short time of recovery of bowel function and consequent short hospital stay, as well as no additional instruments are required for the tumor site detection. From May 2006 to February 2007, a total of 20 consecutive patients underwent resection of colonic polyps at the Department of Surgery of Kaohsiung Medical University Hospital. The colonic polyps were either hard to approach, potentially malignant polyps, too large for snare resection, or had a high possibility of leading to complications of bleeding or perforation and were conseInt J Colorectal Dis (2008) 32:213–214 DOI 10.1007/s00384-007-0363-2

Clinical outcomes after double-balloon enteroscopy in patients with obscure GI bleeding and a positive capsule endoscopy

Obscure GI bleeding (OGIB) accounts for about 5% of all patients with GI bleeding. There are limited data on double-balloon enteroscopy (DBE) after a positive finding on capsule endoscopy (CE) in this setting. To determine the clinical outcomes after DBE therapy. Prospective single-center cohort study. Tertiary referral university hospital. Recurrent bleeding and blood transfusion requirements. This prospective study of 60 consecutive patients with OGIB was conducted between July 2004 and March 2006. Patients underwent CE before DBE to target the lesion for either further diagnostic evaluation or therapeutic intervention. The mean (standard deviation [SD]) duration of follow-up was 10.0 +/- 5.2 months. The mean (SD) age was 62 +/- 18 years, with 31 men. A total of 74 DBE procedures were performed. An abnormality was seen by DBE in 45 patients (75%). In 12 patients (20%), a diagnosis was clarified or a new diagnosis was made. Therapy at DBE was performed in 34 patients (57%): 30 diathermies and 4 polypectomies. Endoscopic tattooing for targeted surgical removal was made in 3 additional patients. Multiple logistic regression analysis identified previous blood transfusion (odds ratio 10.5, 95% confidence interval 3.1-35; P < .001) to be the only independent predictor that required endoscopic therapy at DBE. Forty-eight patients (80%) had no further bleeding, and 46 patients (77%) had a normal Hb. Blood transfusion requirements fell from 34 patients to 10, P < .001. One patient had a perforation after therapeutic diathermy. Nonrandomized study. In patients with OGIB and a positive finding on CE, DBE provided a safe and ambulatory method to achieve an excellent clinical outcome with significant reductions in recurrent bleeding and blood-transfusion requirements.

Tumor Localization for Laparoscopic Colorectal Surgery

Because palpating colonic tumors during laparoscopy is impossible, the precise location of a tumor must be identified before operation. The aim of this study was to evaluate the accuracy of various diagnostic methods that are used to localize colorectal tumors and to propose an adequate localization protocol for laparoscopic colorectal surgery. A total of 310 patients underwent laparoscopy-assisted colectomy between April 2000 and March 2006. We investigated if the locations of the tumors that were estimated preoperatively were consistent with the actual locations according to the operation. All the tumors were correctly localized and resected. Altogether, 203 patients had complete endoscopic reports available. Colonoscopy was inaccurate for tumor localization in 23 cases (11.3%). In total, 104 patients (33.5%) underwent barium enema; five tumors (4.8%) were not visualized, and three tumors were incorrectly localized. Another group of 94 patients (30.3%) underwent computed tomography (CT) colonography, which identified 91 of 94 lesions (96.8%). Finally, 96 patients (31.0%) underwent endoscopic tattooing; 2 patients (2.1%) did not have tattoos visualized laparoscopically and required intraoperative colonoscopy to localize their lesions during resection. Dye spillage was found in six patients intraoperatively, but only one patient experienced clinical symptoms. Intraoperative colonoscopy was performed in four patients; two of the four were followed by endoscopic tattooing, and the other two underwent intraoperative colonoscopy for localization. All lesions were correctly localized by intraoperative colonoscopy. The accuracy of tumor localization was as follows: colonoscopy (180/203, 88.7%), barium enema (97/104, 93.3%), CT colonography (89/94, 94.7%), endoscopic tattooing (94/96, 97.9%), and intraoperative colonoscopy (4/4, 100%). With a combination of methods, localization of tumors for laparoscopic surgery did not seem very different from that during open surgery. Preoperative endoscopic tattooing is a safe, highly effective method for localization. In the case of tattoo failure, intraoperative colonoscopy can be used for accurate localization.

Video capsule endoscopy compared with standard endoscopy for the evaluation of small-bowel polyps in persons with familial adenomatous polyposis (with video)

Video capsule endoscopy (VCE) may be useful for surveillance of small-bowel polyps in patients with familial adenomatous polyposis (FAP). To compare VCE to standard endoscopy for diagnosing small-bowel polyps in a defined segment of small bowel (proximal to a tattoo) and the entire examined small bowel. Prospective. Single tertiary referral center. Participants with FAP (n = 32). The majority were selected for their high number of proximal small-bowel polyps and prior endoscopic tattoo placement in the proximal small bowel. VCE (interpreted by 2 readers), push enteroscopy (PE), and lower endoscopy (LE) to count and measure small-bowel polyps. In the defined segment, VCE detected a median of 10.0 (interquartile range [IQR], 5.0-19.0) and 9.0 (IQR, 6.0-16.0) polyps for each reader compared with a median of 41.0 (IQR, 19.0-64.0) polyps on PE (P = .002). Agreement between the 2 methods was fair (kappa = 0.34, 0.36). Agreement between VCE and PE was poor to fair (kappa = 0.10, 0.22) for estimating the size of the largest polyp and poor (kappa = -0.20, -0.27) for detecting large polyps (> or =1 cm). In the entire examined small bowel, VCE diagnosed a median of 38.0 (IQR, 10.5-71.5) and 54.0 (IQR, 13.0-100.0) polyps for each reader compared with a median of 123.0 (IQR, 38.5-183.0) for combination endoscopy (PE and LE) (P < .001). Agreement between the 2 methods was fair to moderate (kappa = 0.21, 0.56). Participants selected for high polyp burden, and results may not be applicable to all patients with FAP. VCE underestimates the number of small-bowel polyps in persons with FAP and does not reliably detect large polyps.

The Use of Preoperative Endoscopic Tattooing in Laparoscopic Colorectal Cancer Surgery for Endoscopically Advanced Tumors: A Prospective Comparative Clinical Study

Endoscopic India ink marking techniques are often used for the intraoperative location of colonic polyps and early stage neoplasms. The aim of this study was to compare how effective this technique is compared with conventional localization methods, as well as its influence on the results of colorectal laparoscopy (LSCRC) for endoscopically advanced tumors. From January 2003 to January 2005, 47 patients with colorectal carcinomas were included in the study. In one group, lesions were localized preoperatively by endoscopic India ink tattooing (n = 21; tattooed group, TG), while conventional methods were used in the others (n = 26; non-tattooed group, NTG). Patients' perioperative clinical and pathoanatomical data were prospectively collected. Both groups were comparable in age, sex distribution, American Society of Anesthesiologists (ASA) score, body mass index (BMI), technique performed, tumor size and proportion of patients who had previous abdominal surgery. Three patients presented ink spillage without clinical repercussions. Visualization of the correct resection site was higher in the TG (100% vs. 80.8%, P = 0.03). Operative time (147.3 +/- 46.2 vs. 187.0 +/- 52.7 minutes, P = 0.02) and blood loss (99.3 +/- 82.8 vs. 163.6 +/- 96.6 cc, P = 0.03) were lower in the TG. There were no differences between groups regarding peristalsis, introduction of oral intake, hospital stay or intra- and postoperative complication rates. No differences were observed amongst pathoanatomical data studied. Preoperative endoscopic tattooing is a safe and effective technique for intraoperative localization of advanced colorectal neoplasms, improving the operative results of LSCRC.

Indocyanine Green is an Ideal Dye for Endoscopic Ultrasound-Guided Fine-Needle Tattooing of Pancreatic Tumors

Endoscopic ultrasound-guided fine-needle tattooing (EUS-FNT) is an ideal technique for preoperative marking of lesions detected on preoperative examination. Although India ink has been used for endoscopic tattooing, there have been numerous reports of complications associated with its use. This is the first report of EUS-FNT using indocyanine green (ICG) and describes its use for preoperative marking of a tumor in a 78-year-old man with multiple pancreatic tumors. There were no complications associated with the EUS-FNT procedure and it is suggested that ICG is a more suitable dye for tattooing of pancreatic lesions than India ink, being far less frequently associated with side effects.

Laparoscopic Removal of an Intrauterine Device Perforating the Sigmoid Colon: A Case Report and Review of the Literature

We report a case of a translocated intrauterine device (IUD) embedded within the colon wall. Endoscopic tattooing and laparoscopy was used to identify the colonic site and facilitate extraction by colonic resection. A review of the literature and discussion of laparoscopic management of this complication is presented.

Minimally invasive surgery for early lower GI cancer

Two technical developments in colorectal surgery-i.e. transanal endoscopic microsurgery (TEM) and laparoscopic surgery for colorectal disease-are now available for the treatment of early lower GI cancer. Benign lesions and early-stage tumours of the rectosigmoid are amenable for a transanal approach. Transanal endoscopic microsurgery is performed using a rectoscope 4 cm in diameter with a four-port insert. After installation of a pneumorectum, lesions up to 25 cm from the anal verge, including circumferential lesions, can be removed with a recurrence rate of 0-5% for adenomas, 3% for low-risk T1 carcinomas, and 8% for all carcinomas. Laparoscopic-assisted colonoscopic polypectomy, laparoscopic wedge resection or laparoscopic-assisted colostomy have a 67-100% success rate for avoiding a formal bowel resection for benign tumours that cannot be treated by colonoscopy alone. Early colonic cancer requires laparoscopic colectomy guided by preoperative colonoscopy or preoperative endoscopic tattooing for localisation of the affected segment.

Localizing Colorectal Cancer by Colonoscopy

Colonoscopic localization of colorectal carcinoma is frequently inaccurate and unreliable. Consecutive case series. Tertiary care teaching hospital. Three hundred fourteen consecutive patients undergoing surgical resection for colorectal cancer from January 1, 2000, to December 31, 2003. Surgical resection for colorectal cancer. Incidence of erroneous site localization. Two hundred thirty-six patients had complete endoscopic, pathologic, and operative records. Colonoscopy was inaccurate for tumor localization in 49 cases (21%). In 27 (11%) of these cases, a different procedure was required than initially planned; in an additional 10 cases (4%), the surgical approach required modification. Inaccurate localization was associated with previous colorectal procedures on both univariate analysis (odds ratio, 3.94; 95% confidence interval, 1.50-10.32; P<.005) and multivariate analysis (odds ratio, 4.47; 95% confidence interval, 1.64-12.08; P = .003). Having the colonoscopy performed by a surgeon trended toward protection from error on multivariate analysis (odds ratio, 0.47; 95% confidence interval, 0.20-1.08; P = .07). Age, sex, diverticular disease, endoscopist volume and years of training, and bowel preparation had no significant effect. Colonoscopy has a considerable error rate for localization of colorectal cancer, especially when previous colorectal procedures have been performed. Adjunctive localizing techniques, such as endoscopic tattooing, should be strongly considered.

Endoscopic Tattooing of Colonic Lesions with a Carbon Particle Highly-Purified Suspension

Endoscopic Tattooing of Colonic Lesions with a Carbon Particle Highly-Purified Suspension