How to Become an ‘Ink Master’: Endoscopic Colonic Tattooing Tips

This transcript has been edited for readability.

Hi there. I am Dr David Johnson, professor of drugs and chief of gastroenterology at Jap Virginia Medical College in Norfolk, Virginia. Welcome again to GI Common Concerns.

As we speak I would like to speak to you about endoscopic colonic tattooing.

This subject lately got here up in a dialog I had with certainly one of my youthful companions. I used to be complimenting him on his endoscopic tattooing method whereby he lifted up the mucosa after which fastidiously injected the needle to make sure correct distribution of the India ink.

Up to now, we have lacked professional tips or suggestions on the endoscopic tattooing method. Fortunately, a recent publication ensuing from a Delphi consensus convention treatments this. The convention included 29 specialists from throughout the globe, representing views from Europe, the US, and the Asian-Pacific area. Utilizing successive rounds of a Delphi decision-making course of, the group in the end recognized 15 suggestions they thought-about to be greatest observe.

Indications and Contraindications

They started by establishing two contraindications for endoscopic tattooing, the primary of which being that an injection shouldn’t be wanted within the cecum. When you have the ileocecal valve and the appendiceal orifice properly recognized, then there isn’t any motive to threat transmural injection with the India ink.

Second, they stated that tattooing ought to usually not be carried out within the rectum. That is as a result of relative threat of mesorectal spilling of the tattooing, and irritation, fibrosis, and an infection. These components might complicate a transanal or endoscopic resection. Additionally, it ought to already be very straightforward to determine location by documenting the gap from the anal verge, with out the necessity for photograph documentation.

From there, the steering doc strikes on to deal with the indications for tattooing.

First, they advocate tattooing within the case of an endoscopic prognosis of deep invasive most cancers, reminiscent of a Kudo sort V or an NBI Worldwide Colorectal Endoscopic (NICE) sort 3 sample. We’re not going to try endoscopic resection in these instances. As an alternative, we have to doc it so we are able to refer the affected person to a surgeon. On this indication, it is usually really helpful to carry out tattooing earlier than the biopsy. The priority right here is that by not doing so, you possibly can trigger inadvertent contamination of the needle with malignant cells by way of the biopsy channel of the scope after which subsequent most cancers inoculation into one other colonic web site or into the belly cavity.

The second indication is after sufferers endure an endoscopic resection with suspicion of submucosal invasion. In these instances, circumferential tattooing is really helpful.

The third indication is in sufferers who’ve a lesion left in situ thought-about appropriate for endoscopic resection after subsequent referral to a different endoscopist. Though injection of the India ink compounds is mostly secure and really sterile, uncommon issues can happen, notably associated to transmural injection, so pointless tattooing needs to be averted. As an alternative, place an affordable tattoo in a single place, not circumferentially.

The fourth indication is for resected polyps that require additional surveillance. A tattoo needs to be positioned after endoscopic resection to determine the place the scar is or the place the monitoring needs to be targeted. Once more, the tattoo needs to be positioned in that affected person upon the completeness of the resection.

Correct Approach

Relating to correct method, the specialists advocate inserting a saline bleb previous to tattooing. For these not frequently doing endoscopic colonic tattooing, that is carried out by way of a tangential injection into the mucosa with saline. Then, after you have that little mucosal bleb, you inject it with the India ink. It is an easy option to get within the submucosal layer earlier than tattooing and has been related to fewer errors in localization. For these causes, it’s strongly really helpful by the professional panel, relying in your degree of experience.

The tattoo ought to by no means be injected instantly into the lesion or adjoining to the lesion, as a result of the dispersion of the India ink is difficult to foretell. Direct injection additionally represents a possible downside when contemplating future endoscopic therapies, as submucosal fibrosis might develop in consequence.

The authors advocate that the utmost quantity of every tattoo shouldn’t exceed 1 mL per injection web site. There is no such thing as a motive to have a large-volume injection at anyone web site given the danger for undesirable dispersion.

Relating to the localization of the lesion, the professional suggestion was to put the tattoo 3-5 cm distal to the anal aspect.

For the variety of tattoos, they advocate inserting two to a few circumferentially when you are going to be referring sufferers for surgical procedure. Whether it is simply localization for an in-situ lesion or a post-endoscopic resection to watch the place they go, just one tattoo is mostly wanted. Once more, the idea is absolutely to attenuate the tattoo, with the popularity that they are usually secure however not fully so.

The ultimate suggestion associated to documentation of the tattooing. In your endoscopy report, you need to clearly doc the place the tattoo is, together with the gap away from the lesion. This needs to be carried out with photodocumentation, which needs to be a standardized method in establishments.

This new steering doc actually unifies the science round endoscopic tattooing, which is one thing we depend on fairly a bit however can actually do a greater job at performing. I like to recommend you search out this professional Delphi consensus paper for its suggestions so all of us can learn to greatest ship this course of.

I am Dr David Johnson. Thanks for listening. I sit up for seeing you once more quickly.

David A. Johnson, MD, a regular contributor to Medscape, is professor of drugs and chief of gastroenterology at Jap Virginia Medical College in Norfolk, Virginia, and a previous president of the American School of Gastroenterology. His major focus is the scientific observe of gastroenterology. He has revealed extensively within the inside drugs/gastroenterology literature, with principal analysis pursuits in esophageal and colon illness, and extra lately in sleep and microbiome results on gastrointestinal well being and illness.

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