Should All Excised Rectal Polyps Be Tattooed? A Plea for Localization

Deborah Keller, MD, Jane Jaffee, DO, Amit Khanna, MD MPH. Temple University Hospital


Five to eight percent of colonoscopically removed benign rectal lesions contain invasive carcinoma. Rectal tattooing has been advocated for follow-up localization of the resection site. Despite proven benefits, tattooing is not routinely performed on benign appearing rectal polyps. Our hypothesis was that benign appearing rectal polyps with invasive cancer are rarely tattooed, confounding management. Our objective is to show malignant character is not commonly recognized and all lesions should be tattooed to aid identification. Secondary goals are to determine the frequency of localization, tattoo placement, polyp characteristics, and accuracy of prediction of malignant potential

Patients with polyps containing rectal cancer that underwent resection were identified from our institution’s IRB approved Tumor Registry. A retrospective chart review was performed on the colonoscopic records. Data extracted included polyp size, gross appearance, pathology, resection margins, location on preoperative colonoscopy, removal technique, tattoo performance, and surgical procedure performed.

Forty-eight patients had polypectomies with rectal cancer in the specimen from 1/1/2003 to 8/1/2010. Forty-six reports were available for analysis. Distance from the anal verge was only noted in 7 patients (15.2%). The predominant procedure was hot snare polypectomy (n=30; 62.5%). Three polyps were “suspicious for malignancy”. Two of the 3 suspicious lesions were carcinoid, 1 was benign. Polyp histology varied, including adenocarcinoma (n = 5), carcinoma-in-situ (n = 20), and carcinoid (n = 22). Thirteen patients had incomplete polypectomy resections. None of the incomplete resections were “suspicious for malignancy” or tattooed. Additional strategies were used to manage incomplete resections, including surveillance (38%), repeat colonoscopic polypectomy (30.7%), and surgery (30.7%). Narrow band imaging was used to identify the polypectomy site in 2 patients that underwent segmental resection of the polypectomy site without tattoo localization.

In our cohort, the majority of rectal polyps were not readily identified as malignant or tattooed at initial colonoscopy. This suggests that clinical endoscopic visual features underestimate malignant potential. Repeat colonoscopy has been advocated as the procedure of choice for the management of incomplete polypectomy, but necessitates precise localization. Narrow band imaging and re-endoscopy may assist in localization. The distance from the anal verge should be measured and a tattoo should be performed in all patients.

Session Number: SS20 – Colorectal
Program Number: S114

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