Small-dose India Ink Tattooing for Preoperative Localization of Colorectal Tumor: A Pilot Study

INTRODUCTION: India ink tattooing is widely used for tumor localization. However, the procedure of india ink tattooing was not standardized yet. Our group reported previously that preoperative colonoscopic tattooing using a saline test injection method with prepackaged, sterile India ink was a safe and effective method for tumor localization in laparoscopic colorectal surgery. And then we tried to identify the appropriate amount of injected ink because large-dose ink injection could increase the spillage of ink and obscure the tumor site. This pilot study aims to evaluate the efficacy of small-dose tattooing with a sterile india ink using a saline test injection methods.
METHODS AND PROCEDURES: Between April 2009 and August 2009, 20 patients underwent colonoscopic tattooing with prepackaged sterile India ink before resection of colorectal tumors. Using a 23 gauge sclerotherapy needle (Olympus Medical Systems Co, Ltd., Tokyo, Japan), 0.5 ml of saline was injected into the submucosal layer to form a proper submucosal elevation, and then 0.5 ml of India ink (SPOT®; GI Supply, Camp Hill, PA) was injected into the submucosal bleb. The syringe was replaced by the first syringe containing saline and 0.7 ml of saline was injected to flush out the India ink within the needle device. The India ink was injected at three circumferential sites 120° apart and 1cm distal to the tumor or prior polypectomy site. Visualization and leakage of india ink were assessed during surgery, and the diameter of tattoos in the specimen was measured.
RESULTS: The median time interval between tattooing and surgery was 3 days (range, 0-45 days). Tattooing sites were 3 in transverse colon, 2 in descending colon, 14 in sigmoid colon and 1 in rectum. The median time of tattooing was 3 minutes (range, 2-15 minutes). No patient had fever or pain after tattooing. Tattoos were seen on the colonic serosal surface in 18 patients (90%) during surgery. In two patients, tattoos were not seen on the serosal surface but it could be identified on mucosal surface by intraoperative colonoscopy. Localized leakage of ink was identified in one patient (5%) during surgery. The mean diameter of the tattoos was 2.1 cm in serosal surface and 2.0 cm in mucosal surface. The mean distal margin from tumors was 5.0 cm.
CONCLUSIONS: Small-dose tattooing with a sterile india ink using a saline test injection methods is effective for tumor localization.

Session: Poster

Program Number: P369

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