Tattooing and other methods for localizing colonic lesions
- Douglas G Adler, MD, FACG, AGAF, FASGE
Douglas G Adler, MD, FACG, AGAF, FASGE
- Professor of Medicine
- University of Utah School of Medicine
Precise localization of lesions within the colon is essential in a number of clinical circumstances, particularly when surgical resection is required or a lesion needs to be reinspected at a later date, either by the same endoscopist or a different one. In the vast majority of situations, tattooing provides accurate localization of lesions for later identification. However, in some cases localization is inaccurate .
This topic review will discuss methods to localize colonic lesions, with a focus on endoscopic tattooing. Other issues related to colonoscopy are discussed elsewhere. (See "Overview of colonoscopy in adults".)
INDICATIONS FOR LESION LOCALIZATION
Localization prior to surgery — Lesions in the colon that require surgical excision may sometimes be palpable or easily recognized during surgery. However, small lesions and those that have been previously removed colonoscopically can be difficult to localize even if the same endoscopist performs the subsequent examination. Even large lesions may not be palpable by the surgeon if they are soft and compressible .
This problem is particularly important for patients undergoing laparoscopic-assisted surgical colonic resection as the laparoscopist cannot palpate the colon . Thus, it is important to have a marker that can be readily and reliably seen laparoscopically. It is not sufficient for the endoscopist to state that "a lesion is in the transverse colon" since more specific localization is needed to avoid conversion to an open surgery to find the lesion or resection of an incorrect portion of the colon.
An article comparing lesion localization by colonoscopy and computed tomography (CT) scan noted that preoperative localization was inaccurate for 28.5 percent of lesions, even when the results of CT and colonoscopy were combined . As a result, the authors recommended that tattooing of all suspicious lesions at colonoscopy should be standard practice to prevent inadequate resection and lymphadenectomy, particularly for patients with small lesions or for patients likely to have laparoscopic surgery.
Subscribers log in hereLiterature review current through: Jun 2017. | This topic last updated: Dec 16, 2015.References
- Stanciu C, Trifan A, Khder SA. Accuracy of colonoscopy in localizing colonic cancer. Rev Med Chir Soc Med Nat Iasi 2007; 111:39.
- Richter RM, Littman L, Levowitz BS. Intraoperative fiberoptic colonoscopy. Localization of nonpalpable colonic lesions. Arch Surg 1973; 106:228.
- Hancock JH, Talbot RW. Accuracy of colonoscopy in localisation of colorectal cancer. Int J Colorectal Dis 1995; 10:140.
- Solon JG, Al-Azawi D, Hill A, et al. Colonoscopy and computerized tomography scan are not sufficient to localize right-sided colonic lesions accurately. Colorectal Dis 2010; 12:e267.
- Alva S, Abir F, Tran DD. Laparoscopic gastric wedge resection for Dieulafoy's disease following preoperative endoscopic localization with India ink and endoscopic clips. JSLS 2006; 10:244.
- Park JW, Sohn DK, Hong CW, et al. The usefulness of preoperative colonoscopic tattooing using a saline test injection method with prepackaged sterile India ink for localization in laparoscopic colorectal surgery. Surg Endosc 2008; 22:501.
- Dunaway MT, Webb WR, Rodning CB. Intraluminal measurement of distance in the colorectal region employing rigid and flexible endoscopes. Surg Endosc 1988; 2:81.
- Piscatelli N, Hyman N, Osler T. Localizing colorectal cancer by colonoscopy. Arch Surg 2005; 140:932.
- Frager DH, Frager JD, Wolf EL, Beneventano TC. Problems in the colonoscopic localization of tumors: continued value of the barium enema. Gastrointest Radiol 1987; 12:343.
- Waye JD. Colonoscopy without fluoroscopy. Gastrointest Endosc 1990; 36:72.
- Hilliard G, Ramming K, Thompson J Jr, Passaro E Jr. The elusive colonic malignancy. A need for definitive preoperative localization. Am Surg 1990; 56:742.
- Kim SH, Milsom JW, Church JM, et al. Perioperative tumor localization for laparoscopic colorectal surgery. Surg Endosc 1997; 11:1013.
- Montorsi M, Opocher E, Santambrogio R, et al. Original technique for small colorectal tumor localization during laparoscopic surgery. Dis Colon Rectum 1999; 42:819.
- Tabibian N, Michaletz PA, Schwartz JT, et al. Use of an endoscopically placed clip can avoid diagnostic errors in colonoscopy. Gastrointest Endosc 1988; 34:262.
- Nagata K, Endo S, Tatsukawa K, Kudo SE. Intraoperative fluoroscopy vs. intraoperative laparoscopic ultrasonography for early colorectal cancer localization in laparoscopic surgery. Surg Endosc 2008; 22:379.
- Shatz BA, Thavorides V. Colonic tattoo for follow-up of endoscopic sessile polypectomy. Gastrointest Endosc 1991; 37:59.
- Ambardar S, Arnell TD, Whelan RL, et al. A preliminary prospective study of the usefulness of a magnetic endoscope locating device during colonoscopy. Surg Endosc 2005; 19:897.
- Suzuki T, Matsushima M, Tsukune Y, et al. Double-balloon endoscopy versus magnet-imaging enhanced colonoscopy for difficult colonoscopies, a randomized study. Endoscopy 2012; 44:38.
- Cheung HY, Chung CC, Kwok SY, et al. Improvement in colonoscopy performance with adjunctive magnetic endoscope imaging: a randomized controlled trial. Endoscopy 2006; 38:214.
- Cohen JL, Forde KA. Intraoperative colonoscopy. Ann Surg 1988; 207:231.
- Sakanoue Y, Nakao K, Shoji Y, et al. Intraoperative colonoscopy. Surg Endosc 1993; 7:84.
- Hammond DC, Lane FR, Welk RA, et al. Endoscopic tattooing of the colon. An experimental study. Am Surg 1989; 55:457.
- Price N, Gottfried MR, Clary E, et al. Safety and efficacy of India ink and indocyanine green as colonic tattooing agents. Gastrointest Endosc 2000; 51:438.
- Miyoshi N, Ohue M, Noura S, et al. Surgical usefulness of indocyanine green as an alternative to India ink for endoscopic marking. Surg Endosc 2009; 23:347.
- Hammond DC, Lane FR, Mackeigan JM, Passinault WJ. Endoscopic tattooing of the colon: clinical experience. Am Surg 1993; 59:205.
- Ponsky JL, King JF. Endoscopic marking of colonic lesions. Gastrointest Endosc 1975; 22:42.
- Cohen LB, Waye JD. Colonoscopic polypectomy of polyps with adenocarcinoma: When is it curative?. In: Difficult Decisions in Digestive Diseases, Barkin JS (Ed), Year Book Medical Publishers, Chicago 1989. p.528.
- Yeung JM, Maxwell-Armstrong C, Acheson AG. Colonic tattooing in laparoscopic surgery - making the mark? Colorectal Dis 2009; 11:527.
- Voloyiannis T, Snyder MJ, Bailey RR, Pidala M. Management of the difficult colon polyp referred for resection: resect or rescope? Dis Colon Rectum 2008; 51:292.
- Bersentes K, Fennerty MB, Sampliner RE, Garewal HS. Lack of spontaneous regression of tubular adenomas in two years of follow-up. Am J Gastroenterol 1997; 92:1117.
- Ginsberg GG, Barkun AN, Bosco JJ, et al. Endoscopic tattooing: February 2002. Gastrointest Endosc 2002; 55:811.
- Salomon P, Berner JS, Waye JD. Endoscopic India ink injection: a method for preparation, sterilization, and administration. Gastrointest Endosc 1993; 39:803.
- Cho YB, Lee WY, Yun HR, et al. Tumor localization for laparoscopic colorectal surgery. World J Surg 2007; 31:1491.
- Aboosy N, Mulder CJ, Berends FJ, et al. Endoscopic tattoo of the colon might be standardized to locate tumors intraoperatively. Rom J Gastroenterol 2005; 14:245.
- Arteaga-González I, Martín-Malagón A, Fernández EM, et al. The use of preoperative endoscopic tattooing in laparoscopic colorectal cancer surgery for endoscopically advanced tumors: a prospective comparative clinical study. World J Surg 2006; 30:605.
- Nizam R, Siddiqi N, Landas SK, et al. Colonic tattooing with India ink: benefits, risks, and alternatives. Am J Gastroenterol 1996; 91:1804.
- Gopal DV, Morava-Protzner I, Miller HA, Hemphill DJ. Idiopathic inflammatory bowel disease associated with colonic tattooing with india ink preparation--case report and review of literature. Gastrointest Endosc 1999; 49:636.
- Lightdale CJ. India ink colonic tattoo: blots on the record. Gastrointest Endosc 1991; 37:99.
- Shatz BA, Weinstock LB, Swanson PE, Thyssen EP. Long-term safety of India ink tattoos in the colon. Gastrointest Endosc 1997; 45:153.
- McArthur CS, Roayaie S, Waye JD. Safety of preoperation endoscopic tattoo with india ink for identification of colonic lesions. Surg Endosc 1999; 13:397.
- Askin MP, Waye JD, Fiedler L, Harpaz N. Tattoo of colonic neoplasms in 113 patients with a new sterile carbon compound. Gastrointest Endosc 2002; 56:339.
- Poulard JB, Shatz B, Kodner I. Preoperative tattooing of polypectomy site. Endoscopy 1985; 17:84.
- Shatz BA. Small volume India ink injections. Gastrointest Endosc 1991; 37:649.
- Fasoli A, Pugliese V, Gatteschi B, et al. Endocytoscopic imaging and tattooing: a caveat. Endoscopy 2009; 41 Suppl 2:E41.
- INDICATIONS FOR LESION LOCALIZATION
- Localization prior to surgery
- Localization for follow-up colonoscopic procedures
- METHODS TO LOCALIZE LESIONS
- Location of the instrument tip
- Endoscopic clips
- Barium enema
- Magnetic imaging during colonoscopy
- Intraoperative colonoscopy
- - Indocyanine green
- - India ink
- - Technique
- - Efficacy
- - Complications
- SUMMARY AND RECOMMENDATIONS