Localization of Colonic Lesions with
Endoscopic Tattoo
V. Alin Botoman, M.D., Michael Pietro, M.D., Richard C. Thirlby, M.D.
From the Divisions of Gastroenterology and General Surgery, Virginia Mason Clinic,
Seattle, Washington
PURPOSE: Intraoperative localization of small tumors or
polypectomy sites is frequently a difficult problem. In
addition, the distance measured from the anus to the
lesion by the endoscopist can be inaccurate. The purpose
of our study was to evaluate the utility of India ink tattoo
injection as a preoperative marking technique before
colon surgery. METHODS: Colonic lesions were marked
at preoperative colonoscopy, by multiple, small-volume
injections of sterile India ink using a sclerotherapy
needle, adjacent to the lesion. RESULTS: This technique
was used in 14 patients with colonic carcinoma or villous
adenoma not amenable to polypectomy. There was excellent intraoperative localization of the lesion in 11
patients. The complication rate was 7 percent. CONCLUSION: Colon tattoo allows precise localization of lesions
with minimal risk at the time of resection. [Key words:
Colon cancer; Tattoo; India ink]
troit, MI) was diluted 1:1 and injected s u b m u c o s ally into five freshly r e s e c t e d c o l o n s p e c i m e n s
using an e n d o s c o p i c s c l e r o t h e r a p y n e e d l e (Microvasive Inc. | Watertown, MA). Injection v o l u m e was
varied f r o m 0.5 ml to 1.0 ml and the length of the
n e e d l e e x t r u d e d from the sheath also was varied
from 5 m m to 8 m m . W h e n the n e e d l e was fully
e x t e n d e d to 8 m m and p u s h e d at a 90 ~ angle, it
p e n e t r a t e d through the serosa, too d e e p l y to be
safe, in two of the five s p e c i m e n s . W h e n the n e e d l e
was e x t e n d e d to 5 m m and inserted tangentially at
a p p r o x i m a t e l y a 45 ~ angle, it p e n e t r a t e d the mucosa but not the serosa in all of the s p e c i m e n s and
p r o d u c e d an easily visible serosal tattoo in all of
the s p e c i m e n s with both 0.5-ml and 1-ml India ink
injections.
We s e l e c t e d 14 patients with c o l o n carcinomas,
or large villous a d e n o m a s , n e e d i n g surgical resection. The previously tested neutral p H India ink
was sterilized in an autoclave and diluted 1:1 with
normal saline. I n f o r m e d c o n s e n t was o b t a i n e d
from all patients. At the time of colonscopy, the
Mlcrovaslve s c l e r o t h e r a p y n e e d l e was e x t e n d e d
for 5 m m outside the sheath and u s e d to inject
tangentially 0.5 ml to 1.0 ml of diluted India ink in
four quadrants at the level of the lesion.
Botoman VA, Pietro M, Thirlby RC. Localization of colonic
lesions with endoscopic tattoo. Dis Colon Rectum
1994;37:775-776.
mall fiat colonic m a l i g n a n c i e s or previously
snared malignant polyps can b e quite difficult
to palpate or locate at the time of s u b s e q u e n t
operation 9 Precise localization of the site of colonic
m a l i g n a n c y is necessary in o r d e r to secure adequate margins and l y m p h a d e n e c t o m y . Several
authors I ~ have d e s c r i b e d m e t h o d s of e n d o s c o p i c
injection of dye or ink to m a r k colonic lesions.
Some agents, such as m e t h y l e n e blue, 4 are not
p e r m a n e n t , and diffuse quickly from the polypect o m y site. Our p u r p o s e was to evaluate a t e c h n i q u e
that can be u s e d at the time of c o l o n o s c o p y , potentially w e e k s b e f o r e surgery, to p e r m a n e n t l y m a r k
c o l o n o s c o p i c lesions and thus aid the s u r g e o n in
localization. We describe our e x p e r i e n c e with a
p e r m a n e n t India ink tattoo at the t i m e of colonscopy. We s e l e c t e d this a g e n t b e c a u s e of its longstanding safe use in skin tattoos and d e m o n s t r a t e d
safety1, 2 w h e n injected into the colon.
S
MATERIALS AND
9
.
|
RESULTS
The tattoos w e r e easily s e e n at l a p a r o t o m y in 11
of 14 patients. Most of the cases in which no ink
was s e e n o c c u r r e d early in the series w h e n smaller
v o l u m e s of ink and m o r e superficial injections
w e r e used. The longest interval b e t w e e n injection
and o p e r a t i o n was three m o n t h s in a patient with
rectal cancer w h o r e c e i v e d p r e o p e r a t i v e radiotherapy. The tattoo was clearly visible in this patient,
facilitating a d e q u a t e low anterior resection of a
n o n p a l p a b l e tumor. In a n o t h e r patient, the India
ink was taken up b y the lymphatics, greatly facilitating l y m p h n o d e localization and resection.
T h e r e was o n e complication. It was in a patient
w h o d e v e l o p e d left lower quadrant pain and tenderness, fever, and leukocytosis following endoscopic tattoo of a s i g m o i d cancer.
METHODS
In an initial in vitro pilot study, standard commercial grade India ink (Difco Laboratories, DeRead at meeting of the Washington State Chapter of the American College of Surgeons, June 15 to 17, 1989.
Address reprint requests to Dr. Botoman: Division of Gastroenterology-Allegheny General Hospital, 320 East North Avenue,
Pittsburgh, Pennsylvania 15237.
775
BOTOMAN E T AL
776
Computed tomography showed evidence of inflammation without abscess in the region of the
sigmoid. The symptoms resolved after seven days
of intravenous antibiotics. Colectomy was performed without incident when the symptoms
cleared, no evidence of perforation was seen.
There was an extensive ulcer at the site of the
previous cautery snare biopsy of the lesion.
DISCUSSION
Colonoscopic tattoo injections can be carried out
either at the time of the initial colonoscopy for an
obviously malignant lesion, or later for a completely excised lesion with malignant histology.
Ulceration at the polypectomy site is typically visible for five to seven days after electrocautery excision, facilitating localization for later injection.
When tattoo injection is carried out, it is best to
make separate injections in all 90 ~ quadrants, since
the endoscopist cannot reliably identify the anterior wall of the colon. Although it is also important
to note the distance from the anus where the lesion
is located, we have found this latter parameter
much less helpful in lesion localization, presumably because of plication of the bowel on the
endoscope. The tattoo technique allows for shortened operative time by rapidly allowing localization of the lesion and avoiding the need for "blind"
resection of nonpalpable lesions. Another important value of this technique is in localization of low
rectal cancers. Intraoperative palpation of small
rectal cancers can be difficult, making the determination of distal margins problematic. The tattoo
technique greatly facilitates the surgeon's ability to
resect low rectal cancers with adequate margins.
One of our patients experienced pain, fever, and
leukocytosis after the injection. Localized perforation, abscess, and pseudotumor inflammatory
masses have been reported with this technique. 5' 6
In our patient, we believe that India ink injection
in a deep cautery-induced ulcer may have been
contributory, although no frank perforation occurred. We agree with Fennerty e t al. 7 who caution
Dis Colon Rectum, August 1994
against indiscriminate use of this technique, and
suggest limiting the injections to less than 1 ml at
a time. Our i n v i t r o studies also suggest that limiting the length of needle extruding from the
sheath to 5 mm and a tangential angle minimize
the risk of serosal perforation. Thus, endoscopic
India ink injection should be performed by endoscopists experienced at colonoscopy as well as in
the use of endoscopic sclerotherapy needles; those
who can precisely position the instrument and
needle for optimal tattoo injection with minimal
risk.
CONCLUSIONS
Our study confirms that endoscopic India ink
tattoo is a safe and effective method for localizing
malignant lesions of the colon. It is permanent,
allowing for preoperative radiation and other delays, without loss of the marked site. Nonpalpable
lesions are easily localized, allowing more precise
resection and shortened operative time.
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