Endoscopic tattooing provides a substantial impact on colon cancer treatment. Endoscopic tattoos improve the effectiveness of surgical localization for cancer resection as well as enabling long-term clinical surveillance for residual cancerous tissue. Endoscopic tattoos have proven to both decrease time spent in the operating room1 and greatly improve tumor localization.2 Endoscopic tattoos are a vital piece of the fight against colon cancer.
They’re also recommended in the ESGE’s Guidelines for EMR and Polypectomy3 and society-recommended by the American College of Gastroenterology,4 European Society of Gastrointestinal Endoscopy,5 British Society of Gastroenterology,6 and Society of American Gastrointestinal Endoscopic Surgeons.7
However, this vital step is oftentimes overlooked. In “A Gastroenterologist’s Guide to Endoscopic Tattooing Methods” (and a recent blog post) we outlined the two primary methods used in endoscopic tattooing — direct and bleb — but there are other best practices to keep in mind when tattooing.
No matter the technique, remember that an effective endoscopic tattoo always requires the following steps:8,9
Insert the Needle at a 30-45° Angle
Carefully insert the needle tangentially, not en face, into the submucosal plane at a 30-45° angle.
Keep the Injection Controlled
Closely monitor and control the injection to avoid accidental injection into the peritoneal cavity and diffuse intra-abdominal staining, which can be potentially misleading during surgery.
Do Not Tattoo Directly Into or Underneath the Lesion
If the lesion is being marked for surgical resection or for therapeutic colonoscopy, mark the lesion on the downstream side and place the tattoos 2-3 cm from the lesion in 3-4 quadrants. If the lesion is being marked after endoscopic resection for colonoscopy follow up, place the tattoo after completion of the resection. Place the tattoo 2 cm distal to the resection defect.
In “A Gastroenterologist’s Guide to Endoscopic Tattooing Methods” we’ve outlined even more tips to help medical professionals leverage this integral tool in their fight against colon cancer.
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1 - Arteaga-Gonzalez I, et. al., The use of preoperative endoscopic tattooing in laparoscopic colorectal cancer surgery for endoscopically advanced tumors: a prospective comparative clinical study. World J Surgery. 2006. 30(4):605–611.
2 - Askin MP, Waye JD, Fiedler L, Harpaz N. Tattoo of colonic neoplasms in 113 patients with a new sterile carbon compound. Gastrointestinal Endoscopy. 2002;56(3):339-342. doi:10.1067/mge.2002.126905.
3 - Ferlitsch M, Moss A, Hassan C, etal. Colorectal polypectomy and endoscopic mucosal resection (EMR): ESGE Clinical Guideline. 2017.
4 - Rex D, Schoenfeld P, Cohen J, et al. Quality Indicators for Colonoscopy. Am J Gastroenterol. 2014: 1-19.
5 - Ferlitsch M, Moss A, Hassan C, et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): ESGE Clinical Guideline. 2017.
6 - Rees C, Bevan R, Zimmerman-Fraedrich K, et al. Expert opinions and scientific evidence for colonoscopy key performance indicators. Gut BMJ. 2016.
7 - SAGES. Guidelines for laparoscopic resection of curable colon and rectal cancer. 2012.
8 - Spot Ex Instructions For Use. Rev 03. May 2018.
9 - Rex DK. Driving patient safety with endoscopic tattooing. Gastroenterology and Endoscopy News. May 2015.