Endoscopic Tattoo of the Colon might be Standardized to
Transcription
Endoscopic Tattoo of the Colon might be Standardized to
Endoscopic tattoo of the colon 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 intraoperatively. 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 words Colorectal lesions - endoscopic tattoo - laparoscopy Rotring® ink - budget - standardization - histology - lymphnodes Rezumat Premize. Leziunile mici ale colonului, identificate în timpul endoscopiei, sunt de obicei dificil de localizat Romanian Journal of Gastroenterology September 2005 Vol.14 No.3, 245-248 Address for correspondence: Prof. Dr. C.J.J. Mulder VU University Medical Center Dept. Gastroenterology P.O. Box 7057 1005 MB Amsterdam, The Netherlands E-mail: [email protected] 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. 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- 246 Aboosy et al 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. (Rotring ®) is available from any stationary store for drawingmaterials. 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. 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 Table I Visibility of the colonic lesions intra- and post-operatively Patient Location Pathology 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 DC DC RS DC RS RS RS RS TC DC RE RE TC RS RS RS RS RS RS ACA TVA ACA ACA ADE ACA ADE ACA ADE ACA ACA ACA ADE ACA ACA ADE ACA ACA ACA Operation LHC STC LAR LHC SIR LAR LAR LAR LPE LHC LAR TEM TCR RSR LAR LAR LAR SIR SIR Intraoperative histopathological examination Postoperative visible visible visible not visible visible not visible not visible visible visible not visible not visible not visible visible visible visible visible visible visible visible visible, LNV visible visible visible visible not visible not visible visible not visible visible not visible not visible visible,LNV visible visible visible visible, LNV visible, LNV visible, LNV Comments colon adhesion to spleen * Intraoperative endoscopy polypectomy palpable tumour palpable tumour tumour obvious during TEM 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 Fig.1 Submucosal deposition of tattoo-particles. 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). 247 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 investigation 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 248 and needs the cooperation of the surgeon and the gastroenterologist. 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. Aboosy et al 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 endoscopic 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. References 1. Kim SH, Milsom JW, Church JM, Ludwig KA, Garcia-Ruiz A, Okuda J, Fazio VW. Preoperative tumor localization for laparoscopic colorectal surgery. Surg Endosc 1997; 11:1013106. 2. Ponsky JL, King JF. Endoscopic marking of colonic lesions. Gastrointest Endosc 1975;22: 42-43. 3. McArthur CS, Roayaie S, Waye JD. Safety of preoperation endoscopic tattoo with India ink for identification of colonic lesions. Surg Endosc 1999; 13:397-400 4. Askin MP, Waye JD, Fiedler L, Harpaz N. Tattoo of colonic neoplasms in 113 patients with a new sterile carbon compound. Gastrointest Endosc 2002;56:339-342. 5. Frager DH, Frager JD, Wolf EL, Beneventano TC Problems in the colonoscopic localization of tumors: continued value of barium enema. Gasterointest Radiol 1987; 12: 343-346. 6. Botoman VA, Pietro M, Thirlby RC. Localization of colonic lesions with endoscopic tattoo. Dis Colon Rectum 1994; 37:775-776. 7. Coman E, Brandt LJ, Brenner S, Frank M, Sablay B, Bennett B. Fat necrosis and inflammatory pseudotumour due to endoscopic tattooing with India ink. Gastrointest Endosc 1991; 37: 6568. 8. Park SI, Genta RS, Romeo DP, Weesner RE. Colonic abscess and focal peritonitis secondary to India ink tattooing of the colon. Gastrointest Endosc 1991; 37: 68-71 9. Snider TE, Goodell WM, Pulitzer DR. Gastrointestinal tattoos. Arch Pathol Lab Med 1994; 118: 640-641 10. Lipof T, Bartus C, Sardella W, Johnson K, Vignati P, Cohen J. Preoperative colonoscopy decreases the need for laparoscopic management of colonic polyps. Dis Colon Rectum. 2005;48:1076-1080. 11. Nizam R, Siddiqi N, Landas SK, Kaplan DS, Holtzapple PG. Colonic tattooing with India ink: benefits, risks, and alternatives. Am J Gastroenterol 1996; 91:1804-1808