Endoscopic tattoo of the colon

Romanian Journal of GastroenterologySeptember 2005 Vol.14 No.3, 245-248Address for correspondence:

Endoscopic Tattoo of the Colon might be Standardized

to Locate Tumors Intraoperatively

Nail Aboosy1, Chris J.J. Mulder1, Frits J. Berends2, Jos W.R. Meijer3, Adriaan A. V. Sorge4

1) Gastroenterology, VU Medical Centre, Amsterdam. 2) General Surgery, Rijnstate Hospital.

3) Histopathology, Rijnstate Hospital. 4) Pharmacy, Rijnstate Hospital, Arnhem, The Netherlands

Abstract

Background. Small colonic lesions which are identified

during endoscopy are usually difficult to locate intra-

operatively. Endoscopic tattoo of the colon seems the most

efficient method, however it does fail in some cases to

identify the lesion peroperatively. We studied this method

to evaluate its efficacy. Methods. Nineteen patients were

tattooed during colonoscopy with “India ink” (drawing ink

Rotring ®). These patients had lesions in which difficulties

were anticipated when retracing them again during colorectal

surgery. Seventeen patients underwent colonic surgery. One

patient underwent laparoscopic polypectomy and the other

TEM (Transanal Endoscopic Microsurgery). Results. The

visibility of the “India ink” peroperatively and afterwards

during histological examination were evaluated. The tattoos

were visible in 68.4 % patients intraoperatively.

Histopathological macroscopic examination of the specimens

showed ink in 73.6 % patients. In 31.5 % patients the tattoo

could not be recognised peroperatively. Conclusions.

Endoscopy assisted tattooing of the colon has been reported

to be a safe method to landmark lesions in the colon. In the

majority of our patients the tattoo was obvious during

surgery. Endoscopic tattoo seems an efficient technique in

identifying small colonic lesions intraoperatively.

Key wordsColorectal lesions - endoscopic tattoo - laparoscopy -

Rotring® ink - budget - standardization - histology - lymph-

nodes

intraoperator. Tatuarea endoscopicã a colonului pare cea

mai eficientã metodã, deºi s-au descris cazuri de eºec al

identificãrii leziunilor peroperator. Scopul studiului a fost

stabilirea eficacitãþii acestei metode. Material ºi metodã. 19

pacienþi au fost tatuaþi în timpul colonoscopiei cu „cernealã

India” (cernealã de desenat Rotring®). Aceºti pacienþi aveau

leziuni dificil de localizat în timpul chirurgiei colo-rectale. 17

pacienþi au fost supuºi chirurgiei colorectale. Un pacient a

suferit polipectomie endoscopicã ºi un altul MET

(Microchirurgie Endoscopicã Transanalã). Rezultate. A fost

evaluatã vizibilitatea „cernelei India” peroperator ºi în timpul

examinãrii histologice. Tatuajele au fost vizibile la 68,4%

pacienþi intraoperator. La 73,6% pacienþi examinarea

macroscopicã histopatologicã a mostrelor a arãtat existenþa

cernelei. Tatuajele nu au fost recunoscute peroperator la

31,5% pacienþi. Concluzii. Tatuarea endoscopicã a colonului

este o metodã sigurã de topografiere a leziunilor colonice.

Tatuajul a fost vizibil în timpul intervenþiei la majoritatea

pacienþilor. Tatuarea endoscopicã pare o tehnicã eficientã

de identificare a leziunilor colonice mici intraoperator.

Prof. Dr. C.J.J. MulderVU University Medical CenterDept. GastroenterologyP.O. Box 70571005 MB Amsterdam, The NetherlandsE-mail: cjmulder@vumc.nl

Introduction

Precise localization of lesions within the colon is

essential in a number of clinical circumstances, particularly

when surgical resection is required or the lesion after

polypectomy needs to be reinspected at a later date.

Landmarking soft colorectal lesions during colonoscopy

for surgical recognition during (laparoscopic) operation is a

topic for surgeons. The laparoscopist does not have the

ability of palpating the colon between the fingers during

exploration. Even in conventional surgery, intra-operative

localization of small nonpalpable soft tumours or

polypectomy sites has been reported to be a difficult

problem. There are many different methods to help the

surgeon to find these lesions intraoperatively. Most of the

methods which have been reported seem insufficient in

recognizing the lesions (1).

Distance estimation for instance is a method which

roughly gives the location of a lesion, due to the distensi-

Rezumat

Premize. Leziunile mici ale colonului, identificate în

timpul endoscopiei, sunt de obicei dificil de localizat

Aboosy et al246

bility characteristics of the colon and the fact that during

colonoscopy air is inflated which also will lead to distension

of the colon. Another well-known method is peroperative

endoscopy which is time consuming and needs the

attendance of an additional endoscopist. In laparoscopic

surgery, palpation of colonic tumour is impossible and the

location of these tumours must be defined preoperatively.

Large soft lesions are not well palpable.

Colonic tattoo with “India ink” is a method reported in

1975 by Ponsky and King (2). The safety and the efficacy of

this method was reported in other studies (3,4). We evaluated

the efficacy of this method with a low-budget tattoo ink

(Rotring®) in identifying soft colorectal lesions.

Methods

It is our practice to inject a permanent surgical marker

during the initial colonoscopy if a lesion cannot be removed

or if an endoscopically removed polyp has clinical features

that may require surgical resection or surveillance

colonoscopy.

Between September 2001 and March 2003, 19 patients

underwent surgery for small lesions, such as colonic polyps.

During colonoscopy these patients were prospectively

marked with a low budget, easily available “India ink”

(Rotring ®). The “India ink” suspension was first filtered by

a 5 micron filter, then produced in ampulla, sterilised (15

min. 121 °C) and used. The “ink” was not diluted prior to its

submucosal injection of 1 cc proximal or distal of the lesion,

with a sclerosing needle (Cobra Medical®). India ink is a

black drawing ink made with carbon particles. India ink

Results

None of the patients developed fever, abdominal pain or

tenderness after tattooing the colon. The tattoo was visible

in 13 patients (68.4 %) intra-operatively (Table I). During

post-operative examination of the specimens, the tattoo was

visible in 14 (73.6 %) patients macroscopically. The mean

time-interval between injection of the ink and subsequent

operation was 3 weeks (range 1-8 weeks).

In one patient who underwent laparoscopic polypectomy

no “India ink” could be identified at histopathology,

although the tattooing was clearly visible during the

operation near the resected area. This finding could be due

to the fact that the tattooing had been injected distal of the

lesion. In 6 patients (31.5 %) the “India ink” was not

recognised during surgery. The lesion was easily found by

(Rotring ®) is available from any stationary store for drawing-

materials.

Patients were operated for both premalignant and

malignant diseases of the colon and rectum (13

adenocarcinomas, 6 adenomas).

Seventeen patients underwent surgical intervention: 8

low anterior resection, 3 left hemicolectomy, 3 sigmoid

resection, 1 rectosigmoid resection, 1 transverse colon

resection, 1 subtotal colostomy. One patient underwent

laparoscopic polypectomy and another patient a TEM. We

evaluated these patients regarding the visibility and safety

of the tattooing during operation and in histopathological

investigation.

The local ethical committee approved the study.

Table I Visibility of the colonic lesions intra- and post-operatively

Patient Location Pathology Operation Intraoperative Postoperative Comments

histopathological

examination

1 DC ACA LHC visible visible, LNV

2 DC TVA STC visible visible

3 RS ACA LAR visible visible

4 DC ACA LHC not visible visible colon adhesion to spleen

5 RS ADE SIR visible visible

6 RS ACA LAR not visible not visible *

7 RS ADE LAR not visible not visible Intraoperative endoscopy

8 RS ACA LAR visible visible

9 TC ADE LPE visible not visible polypectomy

10 DC ACA LHC not visible visible palpable tumour

11 RE ACA LAR not visible not visible palpable tumour

12 RE ACA TEM not visible not visible tumour obvious during TEM

13 TC ADE TCR visible visible,LNV

14 RS ACA RSR visible visible

15 RS ACA LAR visible visible

16 RS ADE LAR visible visible

17 RS ACA LAR visible visible, LNV

18 RS ACA SIR visible visible, LNV

19 RS ACA SIR visible visible, LNV

DC: descending colon, TC: transverse colon, AC: ascending colon, RE: rectum, RS: rectosigmoid; ACA: adenocarcinoma,

ADE: adenoma; LAR: low anterior resection, LHC: left hemicolectomy, SCD segment resection descending colon, SIR:

sigmoid resection; LPE: laparoscopic polypectomy. TCR: transverse colon resection, RSR: rectosigmoid resection, STC:

subtotal colectomy; Visible: macroscopically visible, LNV: tattoo visible in the lymph nodes

* tumour in the small pelvis, difficult to inspect, bimanually per rectum palpable

Endoscopic tattoo of the colon 247

palpation in two patients. In another patient, the lesion was

difficult to detect, due to the location in the small pelvis.

The fourth patient had a colonic lesion with adhesions to

the spleen, after previous surgery. TEM was performed in a

patient with a rectal lesion and the lesion was obvious. The

tattoo was not reported by the surgeon. In the sixth patient

it was necessary to perform an intraoperative endoscopy in

order to locate the lesion.

In 5 patients there were minimal or no lymph nodes in

the specimens during postoperative examination. In the

remaining 14 patients, the lymph nodes were examined and

the “India ink” particles were microscopically visible in 5 of

the patients (35.7 %). In one patient the tattoo was also

macroscopically visible in the lymph nodes. No signs of

inflammatory reaction, granulomas or other complications

were recognised during surgery.

Pathological examination showed adenocarcinoma in 13

patients. In 6 of them, this was recognised preoperatively

either as premalignant lesion or highly suspected lesion.

The diameter of the ink particles was approximately 0.1

micron and they were present in the stromal interstitium and

in macrophages especially in the adjacent lymph nodes.

However, no inflammatory reaction was present in the vicinity

of the ink particles (Figs.1,2).

Fig.1 Submucosal deposition of tattoo-particles. Fig.2 Deposition of tattoo-particles in adjacent lymphnodes.

Discussion

Small colorectal lesions are difficult to locate during

colorectal surgery. Endoscopic measurement during

preoperative colonoscopy usually gives a rough estimation.

The colon is a distensible organ and the inflated air together

with the endoscope can lead to misinterpretation easily.

Frager et al (5) reported six patients in whom reliance on

preoperative colonoscopic tumour localisation had led to

errors of the diagnosis and therapy. Three patients required

a relaparotomy because the tumour had been left in place

during the first colorectal surgery.

Intraoperative colonoscopy is a difficult investi-

gation for endoscopists. Poor operative exposure due

to bowel distension is another disadvantage for the

surgeon (1). Endoscopically placed mucosal clips were tried

in the past. However, clips fall off in an average of 10 days,

and laparoscopic recognition therefore seems inadequate

(1).

Laparoscopic clips applied to the serosal surface of the

bowel under the guidance of intraoperative colonoscopy is

less attractive to the surgeon because the clips tend to

dislodge from the serosa (1). Moreover, the clips are too

small to be recognised easily. This method is time consuming

Aboosy et al248

and needs the cooperation of the surgeon and the gastro-

enterologist.

The safety of “India ink” has previously been reported

in several studies. Botoman et al. (6) described the only

case of a clinical complication. A patient underwent snare

biopsy of a sigmoid cancer with cauterisation followed by

“India ink” tattooing of the lesion. However, these findings

could well be attributed to the cauterisation procedure and

not to a possible complication of “India ink” .

Histopathological complications have been reported in

the literature, such as local reactions like fat necrosis with

inflammatory pseudotumour formation, colonic abscess with

localised peritonitis, and chronic inflammation (7-9). In

another study in which “India ink” was used in 195 patients

no complications were recognized (3).

“India ink” is a permanent dye. Ponsky and King who

first described the use of this method, reported a patient in

whom the ink was visible after 22 years.

In our pilot - study with Rotring® India Ink we did not

encounter any clinical or histopathological complications.

Rotring® India Ink is easily available at very low prices (100

cc: • 12,00).

The presence of “India ink” during surgery helped in

targeting lesions in the majority of our patients. Quick

identification during surgery saves time.

In six patients the tattoo in the colon was not visible,

but in five patients the lesion could be detected with other

means, further intraoperative colonoscopy being not

necessary. In one patient it was necessary to perform an

intraoperative colonoscopy in order to retrace the lesion.

Unfortunately, we marked the lesion with a single injection

of 1 cc. A second injection of 1 cc given contralaterally

would have probably allowed to recognize the tattooing.

Since the colonoscopist cannot know which portion of

the bowel is the superior aspect, multiple injections should

be made circumferentially in the wall around a lesion to

prevent a single injection site from being located in a

“sanctuary” site, which is hidden from the eyes of the

surgeon when the abdomen is opened.

Obviously endoscopic tattooing of the colon mucosa

outperforms the other alternatives in identifying a colorectal

lesion (10).

Safety in performance has been reported in many

studies. It is important to sterilise the ink before its use in

order to avoid infection. India ink itself is not conducive for

culture on media (11). The absence of inflammatory reactions

even after 10 years as reported by King et al. is reassuring

(3). We looked very carefully for secondary inflammation

due to ink in the mucosa and lymph nodes but we did not

find any adverse reaction at the histopathological

examination.

Conclusion

Endoscopic tattooing of the colon seems a safe and

effective low-budget method to landmark small lesions in

the colon. In our patients we did not encounter any adverse

reactions to the “India ink” clinically or histopathologically.

In the presented series the tattoo was clearly visible

during surgery in the majority of patients. The use of endo-

scopic tattoo is an essential and efficient technique to help

identifying small lesions intraoperatively, still underused

and undervalued in many hospitals. We recommend the use

of this method as a standard method of marking small lesions

during colonoscopy when a planned colorectal surgical

intervention is anticipated.

Injecting a second shot contralaterally may help in

decreasing the percentage of undetected tattoos during

surgery. The surgeon should be informed whether the

injections are proximal or distal to the lesions.

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