Endoscopic localization of colon cancers

Implementation of Synoptic Reporting for Endoscopic Localization of Complex Colorectal Neoplasms

Introduction  Lack of documented tattooing of colorectal neoplasms at index colonoscopy results in high repeat preoperative colonoscopy rates. We developed national consensus recommendations for endoscopic localization and piloted an electronic synoptic reporting template. We report on the implementation and perceptions of using synoptic reporting to enhance colorectal lesion marking in a central Canadian healthcare system.  Methods We implemented the template within our endoscopy reporting system and ran an infographic education campaign. We then conducted a follow-up email-based interview with all regional endoscopists. Thematic analysis and a mixed-methods triangulation approach were employed to synthesize qualitative and quantitative data.  Results The interview was completed by 28/52 endoscopists (54%). Most (60.7%; n = 17) completed >100 colonoscopies and 71.4% (n = 20) identified six to 20 neoplasms requiring tattooing since introduction. A total of 50% (n = 14) used the template. Those not using it were unaware of it (42.9%; n = 12), or preferred using narrative text (17.9%; n = 5). Users reported modest mean functionality scores (intuitiveness: 3.56/5; efficiency: 3.7/5) and high impact scores (credible: 4.22/5; informative: 4.21/5). However, the perception of the synoptic template's ability to reduce the repeat preoperative colonoscopy rate was more circumspect (3.76/5). Conclusions Endoscopists believed the synoptic template was a functional, impactful tool that would improve communication and help to decrease the repeat preoperative colonoscopy rate. However, synoptic template uptake was limited by provider awareness, therefore more educational efforts are needed to increase uptake.

The Accuracy of Different Modalities Used for Preoperative Primary Tumour Localisation in Operated Colorectal Cancer Patients

Aim Colonoscopy and computed tomography (CT) scans of the abdomen and pelvis are routine pre-operative assessment tools in colorectal cancer (CRC) patients. There have been some discrepancies regarding the location of cancer when seen by colonoscopy versus CT scan. The purpose of this study was to compare the accuracy of a colonoscopy with a computed tomography (CT) scan of the abdomen and pelvis with contrast, which is done routinely before surgery to localise the exact site of the tumour within the large bowel, whilst comparing both to the operative, gross and histopathology findings of the exact location. Methods A retrospective study was carried out on 165 colorectal cancer patients operated on between January 1, 2010, and December 31, 2014, using electronic hospital records that were reviewed anonymously, comparing the location of cancer within the large bowels as was found on colonoscopy and CT scan of the abdomen and pelvis with contrast, comparing both to post-operative histopathology specimen or intra-operative assessment in cases where no resection of the primary tumour was performed. Results CT and colonoscopy were both accurate in diagnosing 70.5% of cases that had done both investigations pre-operatively. The best results were obtained when the cancer was located in the caecum as confirmed post-operatively; the combined accuracy rate was 100%. CT was accurate, whilst colonoscopy was not in eight (6.2%) cases (all are rectal or sigmoid cancers), and colonoscopy was accurate and CT was not in 12 cases, 10 of them were rectal and two were ascending colonic. Colonoscopy was not performed in 36 (21%) cases for a variety of reasons, including large bowel obstruction or perforation on presentation. In 32 of these cases, CT scan managed to accurately predict the location of cancer (mostly rectal and caecal), and CT scan was inaccurate in 20.6% of cases (34 out of 165), whilst colonoscopy was inaccurate in 13.9% of cases (18 out of 129). Conclusion Colonoscopy is more accurate in localising colorectal cancers than CT scan of the abdomen and pelvis with contrast. CT scan diagnoses regional and distant spread of colorectal cancers such as nodal status, invasion of neighbouring organs and/or peritoneum and the presence of liver metastases, whilst colonoscopy is limited to intraluminal diagnosis but can be both a diagnostic and therapeutic tool, with higher accuracy, in general, in localising colorectal cancers. Both CT scan and colonoscopy were equal in appendicular, caecal, splenic flexure and descending colon cancer localisation accuracy.

Carbon black-containing self-healing adhesive hydrogels for endoscopic tattooing

Endoscopic tattooing with India ink is a popular method for identifying colonic lesions during minimally invasive surgery because it is highly challenging to localize lesions during laparoscopy. However, there is a perceived unmet need for the injection of India ink and carbon particle suspension due to various complications and inconstant durability during the perioperative period. In this study, carbon black-containing self-healing adhesive alginate/polyvinyl alcohol composite hydrogels were synthesized as endoscopic tattooing inks. Alginate (Alg) conjugated with phenylboronic acid (PBA) groups in the backbone was crosslinked with polyvinyl alcohol (PVA) because of the dynamic bonds between the phenylboronic acid in alginate and the cis-diol groups of PVA. The carbon black-incorporated Alg-PBA/PVA hydrogels exhibited self-healing and re-shapable properties, indicating that improved intraoperative localization could be achieved. In addition, the adhesive tattooing hydrogels were stably immobilized on the target regions in the intraperitoneal spaces. These carbon black-containing self-healing adhesive hydrogels are expected to be useful in various surgical procedures, including endoscopic tattooing.

A single centre audit: repeat pre-operative colonoscopy

BACKGROUND

Repeat colonoscopy may be required for tumour localisation. The aim of the study is to explore the clinical settings it was used and benchmark the quality of initial colonoscopy against standardized guidelines for tumour localisation, tattooing and colonoscopy reporting amongst clinicians.

METHODS

A retrospective study from 2016 to 2021 has been performed on patients who underwent elective colorectal cancer resections at the Northern Hospital. Patient demographics, colonoscopic and operative details were retrieved from the Bi-National Colorectal Cancer Audit (BCCA) Registry database and hospital medical records.

PRIMARY OUTCOMES

changes in operative approach and delays to operation.

SECONDARY OUTCOMES

reasons for a repeat colonoscopy and complications from repeat colonoscopy.

RESULTS

A total of 339 patients were included in this study. 94 (28.6%) underwent a repeat colonoscopy. Re-scoping rate was 29.6% for surgeons, and 26.2% for non-operating endoscopists. Surgeons had a 5.9% localisation error rate, and non-operating endoscopist 6.95% (p = 0.673). Surgeons did not have a lower rate of repeat colonoscopy (p = 0.462). Repeat endoscopy was associated with a longer time to definitive operation (p < 0.001). No complications were associated with a repeat colonoscopy.

CONCLUSION

There was no difference in localisation error rates or repeat colonoscopy amongst surgeons (29.6%) and non-operating endoscopists (26.2%) (p = 0.462). This could be explained by the standardized endoscopy training in Australia governed by a common training board. Lack of tattooing at index colonoscopy and inadequate documentation often led to a repeat endoscopy, which was associated with a longer time to definitive operation. Standardized guidelines in tattooing of lesions and colonoscopy reporting should be implemented.

Computed Tomography Colonography Angiography (CTC-A) prior to colectomy for cancer: A new tool for surgeons

The pre-operative work-up for non-metastatic colon cancer includes colonoscopy and thoraco-abdomino-pelvic computed tomography (CT) with intravenous (IV) contrast. Colonoscopic determination of the anatomical location of the tumor may be erroneous, particularly with a long redundant colon (dolichocolon), and the search for synchronous colon neoplasms is limited when the endoscope cannot traverse the tumor-bearing segment. While computed tomography colonography angiography (CTC-A) makes it possible to assess distant tumor metastasis, it remains limited for the assessment of loco-regional extension. CTC-A requires specific colonic preparation, controlled colonic insufflation with CO₂, and an injection of IV contrast. CTC-A provides a 3-D view of the overall morphology of the colon and precisely localizes the site of the colonic tumor. Merging the images of the colon with those of mesenteric and colonic vessels provides a representation of anatomical vascular variations. This information could help the surgeon to better plan the colectomy. The use of two-dimensional images of CTC-A with sections perpendicular to the major axis of the tumor-bearing colonic segment can provide precise information on the degree of parietal extension and be useful in evaluating the value of neo-adjuvant chemotherapy.

Small Efforts Can Prevent Big Mistakes: Preoperative Colonoscopic Tattooing Using Indocyanine Green

The importance of tumor localization is increasing because the application of laparoscopic surgery in colon cancer surgery is on the rise and the incidence of early cancer is also rising. There are several methods of tumor localization, but the most popular method is preoperative colonoscopic tattooing. Various tattooing agents are used, and among them, India ink is the most widely used agent. However, it is impossible to use India ink in Korea. Therefore, research on other alternative agents is needed.

Ways to perform an endoscopic tattoo. Prospective and randomized study in patients with colorectal neoplasm

BACKGROUND AND AIMS

intraoperative identification of colonic lesions previously detected via colonoscopy may be difficult. Endoscopic tattooing facilitates identification, but there is no evidence regarding which is the best tattoo technique. The goal of the study was to describe the efficacy and safety of endoscopic tattooing and to detect technical and clinical factors associated with its efficacy.

PATIENTS AND METHODS

a prospective and randomized study was performed. All tattoo candidate patients were included prior to surgery and randomized into four groups; tattoo at two or three injection points and with a volume of 1 or 1.5 ml of labeling. Multiple variables were registered.

RESULTS

one hundred and ninety-five patients were included with an endoscopic tattoo and who subsequently underwent a surgical intervention, the mean age was 70.1 years and 67.2 % were male. The laparoscopic approach was applied in 57.9 % of cases. The intraoperative visibility of the endoscopic tattoo was 89.7 % and 30 % of rectal lesions were not visible. Excluding the rectum, the marking was visible intraoperatively in 92 % of patients, without significant differences according to the surgical approach, the type of marking or any of the variables collected. The tattoo was safe in 92.3 % of the cases. The adverse effect rate was 7.7 % and none of the complications were clinically significant. There were no significant differences between any variables collected in relation to adverse effects.

CONCLUSIONS

endoscopic colon tattoo is safe and effective regardless of the technique used. We recommend the technique of two injection points and 1 ml of marking volume for its simplicity, efficiency and safety.

Predictors and rates of prior endoscopic tattoo localization amongst individuals undergoing elective colorectal resections for benign and malignant lesions

BACKGROUND

Appropriate tattooing of suspicious lesions during colonoscopy is critical for surgical planning. However, variability exists in tattoo placement, technique, and reporting. Our aim is to determine the rates and predictors of tattoo placement, tattoo location in relation to the lesion, and localization accuracy during lower endoscopy for individuals undergoing elective colorectal resections.

METHODS

We performed a retrospective chart review on all patients undergoing elective colorectal resections for benign and malignant neoplasms between 2007 and 2017 at a high volume Canadian tertiary centre. Patient demographics, endoscopic, and tumour-related characteristics were collected. Multivariable logistic regression analysis was used to identify predictors of tattoo localization.

RESULTS

Of the 1062 patients identified, laparoscopic resection occurred in 59% of patients. 57% of patients underwent tattooing for tumour localization at index endoscopy. Tattoos were placed distal (27%), both proximal and distal (4%), and just proximal (2%) to the lesion. However, in the majority of cases the tattoo location was not documented (67%). On multivariate analysis, patients who had lesions located in the transverse colon (OR: 1.93, 95% CI 1.04-3.59), had surgery performed after 2010 (2011-2014: OR: 1.88, 95% CI 1.31-2.68; 2015-2017: OR: 2.87, 95% CI 1.93-4.26), underwent laparoscopic resections (OR: 1.69, 95% CI 1.22-2.33), and had their index endoscopy performed in an urban setting (OR: 5.92, 95% CI 3.23-10.87), were at higher odds of having a tattoo placed at index endoscopy.

CONCLUSION

Endoscopic tattoo placement and location in relation to the lesion varies widely, with reports containing suboptimal documentation. Lesion location and laparoscopic procedures were significant predictors of tattoo placement. This study highlights the need for standardized tattooing practices and reporting amongst endoscopists. One of the focus of quality improvement efforts should be educational initiatives for rural endoscopists.

Sterile carbon particle suspension vs India ink for endoscopic tattooing of colonic lesions: a randomized controlled trial

BACKGROUND

Different markers have been used preoperatively to mark colonic lesions, especially India ink. In recent years, another kind of marker has been developed: sterile carbon particle suspension (SCPS). No comparison between these two markers has yet been made. The aim of the present study was to compare the pyrogenic, inflammatory and intraperitoneal effect of these two markers.

METHODS

From September 2015 to December 2018, adult patients who were candidates for elective laparoscopic colon resection were randomized to the SCPS or conventional India ink injection group using computer-based randomization. The primary endpoint of the study was the presence of intraoperative adhesions related to the endoscopic tattoo. Secondary endpoints were differences in white blood cell, C-reactive protein, and fibrinogen levels as well as, abdominal pain and body temperature at baseline (before endoscopic tattooing) and 6 and 24 h after colonoscopy. Finally, the visibility of the tattoo during the minimally invasive intervention was assessed.

RESULTS

Ninety-four patients were included in the study, 47 for each arm. There were 45/94 females (47.9%) and 49/94 males (52.1%), with a median age of 67.85 ± 9.22 years. No differences were found between groups in WBC, fibrinogen levels, body temperature or VAS scores, but we documented significantly higher CRP values at 6 and 24 h after endoscopic tattooing with India ink injection. There were significantly fewer adhesions in the SCPS Endoscopic Marker group. All the endoscopic tattoos were clearly visible.

CONCLUSIONS

SCPS is an effective method for tattooing colonic lesions and has a better safety profile than traditional India ink in terms of post-procedure inflammatory response and intraoperative bowel adhesions.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov (ID: NCT03637933).

Lesion Retrieval, Specimen Handling, and Endoscopic Marking in Colonoscopy

Retrieval of lesions after endoscopic polypectomy enables histopathologic analysis and guides future surgical management and endoscopic surveillance intervals. Various techniques and devices have been described with distinct advantages and disadvantages to accomplish retrieval. Appropriate histopathologic analysis depends on lesion handling and preparation. How lesions are handled further depends on size, endoscopic appearance, and removal technique. Endoscopic marking or tattooing is a well-described process that uses dye mediums to leave longstanding marks in the colon. Techniques, dye mediums, and locations within the colon influence tattoo approach.

Determination of Tumor Location in Rectosigmoid Carcinomas: Difficulties in Preoperative Diagnostics

Differentiation between rectal and sigmoid carcinomas is a diagnostic challenge with important implications for further treatment. Depending on the tumor stage, treatment for rectal carcinoma consists of preoperative (chemo)radiotherapy and surgery. Sigmoid carcinomas are treated with surgery alone. We established the diagnostic accuracy of flexible endoscopy, MRI and/or CT scan, and both modalities combined as reflected by the conclusion of our multidisciplinary team (MDT). Furthermore, we assessed the treatment consequences of misdiagnosis. Consecutive patients were included who underwent surgery from January 2012 to January 2017 for colorectal carcinoma located ≤20 cm from the anal verge as determined by flexible colonoscopy. Diagnostic accuracy of MRI/CT, flexible endoscopy and the final MDT conclusion were analyzed as index test. The location of the tumor during surgery and the type of surgery was the reference standard. We included 293 patients. Flexible endoscopy had a diagnostic accuracy of 90% and for MRI/CT scanning this was 86–87%. Combination of both modalities improved diagnostic accuracy to 96%. Due to misdiagnosis during initial staging, three patients (1%) erroneously underwent neoadjuvant treatment and in two patients neoadjuvant treatment was potentially erroneously omitted. In conclusion, the combination of both flexible endoscopy and MRI/CT (the MDT conclusion) improves diagnostic accuracy. Erroneous clinical diagnosis can lead to under- and overtreatment.

Endoscopic tattooing of colorectal neoplasms removed by laparoscopy: a proposal for selective marking

BACKGROUND AND AIM

Preoperative endoscopic tattooing is an effective procedure to identify small intraoperative neoplasms. However, there are no defined criteria with regard to the indications for endoscopic tattooing of these lesions at the time of diagnosis. The aim of this study was to establish endoscopic criteria that allow the selection of patients who will need a tattoo during the diagnostic colonoscopy.

METHODS

An ambispective study of patients undergoing laparoscopy due to a colorectal neoplasia who underwent endoscopic tattooing during the period from 2007-2013 and 2016-2017. According to the endoscopic description of the neoplasms, the classification was polypoid lesions, neoplasms occupying < 50% or ≥ 50% of the intestinal lumen and stenosing neoplasias.

RESULTS

Tattooing of the lesion was performed in 120 patients and the same lesions were identified during surgery in 114 (95%) cases. Most of the neoplasias described as polypoids and neoplasias that occupied < 50% of the intestinal lumen were not visualized during surgery and therefore required a tattoo (33 of 42 and 18 of 26 respectively, p = 0.0001, X2). On the other hand, stenosing lesions or neoplasias occupying ≥ 50% of the intestinal lumen were mostly identified during surgery (15 of 15 and 36 of 37 respectively, p = 0.0001, X2) without the need for a tattoo. Overall, the identification of neoplasms according to established criteria was 98%.

CONCLUSION

These results suggest that it is possible to establish endoscopic criteria that allow a successful selective tattooing during diagnostic endoscopy.

Model-based Iterative Reconstruction in Low-radiation-dose Computed Tomography Colonography: Preoperative Assessment in Patients with Colorectal Cancer

RATIONALE AND OBJECTIVES

To assess the effect of model-based iterative reconstruction (MBIR) on image quality and diagnostic performance of low-radiation-dose computed tomography colonography (CTC) in the preoperative assessment of colorectal cancer.

MATERIALS AND METHODS

This study included 30 patients with colorectal cancer referred for surgical treatment. All patients underwent CTC with a standard dose (SD) protocol in the supine position and a low-dose (LD; radiation dose reduction of approximately 85%) protocol in the prone position. The SD protocol images were post-processed using filtered back projection (FBP), whereas the LD protocol images were post-processed using FBP and MBIR. Objective and subjective image quality parameters were compared among the three different methods. Preoperative evaluations, including site, length, and tumor and node staging were performed, and the findings were compared to the postsurgical findings.

RESULTS

The mean image noise of SD-FBP, LD-FBP, and LD-MBIR images was 17.3 ± 3.2, 40.5 ± 10.9, and 11.2 ± 2.0 Hounsfield units, respectively. There were significant differences for all comparison combinations among the three methods (P < .01). For image noise, the mean visual scores were significantly higher for SD-FBP and LD-MBIR than for LD-FBP, and the scores for SD-FBP and LD-MBIR were equivalent (3.9 ± 0.3 [SD-FBP], 2.0 ± 0.5 [LD-FBP], and 3.7 ± 0.3 [LD-MBIR]). Preoperative information was more accurate under SD-FBP and LD-MBIR than under LD-FBP, and the information was comparable between SD-FBP and LD-MBIR.

CONCLUSION

MBIR can yield significantly improved image quality on low-radiation-dose CTC and provide preoperative information equivalent to that of standard-radiation-dose protocol.

Diagnostic utility of staging abdominal computerized tomography and repeat endoscopy in detecting localization errors at initial endoscopy in colorectal cancer

BACKGROUND

Colonoscopy has a reported localization error rate as high as 21% in detecting colorectal neoplasms. Preoperative repeat endoscopy has been shown to be protective against localization errors. There is a paucity of literature assessing the utility of staging computerized tomography (CT) and repeat endoscopy as diagnostic tools for detecting localization errors following initial endoscopy. The objective of this study is to determine the diagnostic characteristics of staging CT and repeat endoscopy in correcting localization errors at initial endoscopy.

METHODS

A retrospective cohort study was conducted at a large tertiary academic center between January 2006 and August 2014. All patients undergoing surgical resection for CRC were identified. Group comparisons were conducted between (1) patients that underwent only staging CT (staging CT group), and (2) patients that underwent staging CT and repeat endoscopy (repeat endoscopy group). The primary outcome was localization error correction rate for errors at initial endoscopy.

RESULTS

594 patients were identified, 196 (33.0%) in the repeat endoscopy group, and 398 (77.0%) patients in the staging CT group. Error rates for each modality were as follows: initial endoscopy 8.8% (95% CI 6.5-11.0), staging CT 9.3% (95% CI 6.5-11.0), and repeat endoscopy 2.6% (95% CI 0.3-4.7); p < 0.01. Repeat endoscopy was superior to staging CT in correcting localization errors for left-sided / rectal lesions (81.2% vs. 33.3%; p < 0.01), right-sided lesions (80.0% vs. 54.5%; p = 0.21), and overall lesions (80.8% vs. 42.3%; p < 0.01). Repeat endoscopy compared to staging CT demonstrated relative risk reduction of 66.7% (95% CI 22-86%), absolute risk reduction of 38.5% (95% CI 14.2-62.8%), and odds ratio of 0.18 (95% CI 0.05-0.61) for correcting errors at initial endoscopy.

CONCLUSIONS

Repeat endoscopy in colorectal cancer is superior to staging CT as a diagnostic tool for correcting localization-based errors at initial endoscopy.

Tattooing or not? A review of current practice and outcomes for laparoscopic colonic resection following endoscopy at a tertiary care centre

BACKGROUND

Because small colonic tumours may not be visualized or palpated during laparoscopy, location of the lesion must be identified before surgery. The aim of this study was to evaluate the effectiveness of the current recommendation of endoscopic tattooing of lesions prior to laparoscopic colonic resections.

METHODS

All consecutive patients who underwent elective laparoscopic resection for a colonic lesion at a single tertiary institution between 2013 and 2015 were identified for chart review.

RESULTS

In total, 224 patients underwent laparoscopic resection for a benign or malignant colonic lesion during the study period. All patients had a complete colonoscopy preoperatively. In all, 148 patients (66%) had their lesion tattooed at endoscopy. Most lesions were tattooed distally, but 15% were tattooed either proximally, both proximally and distally, or tattooed without specifying location as proximal or distal. Tattoo localization was accurate in 69% of cases. Tattooed lesions were not visible during surgery 21.5% of time; 2 cases were converted to open surgery to identify the lesion. Inaccuracy in endoscopic localization led to change in surgical plan in 16% of surgeries. In the nontattooed group, 1 case was converted to open surgery to localize the lesion, 3 required intraoperative colonoscopy and 1 had positive margins on final pathology.

CONCLUSION

To improve surgical planning, we recommend the practice of endoscopic tattooing of all colon lesions at a location just distal to the lesion using multiple injections to cover the circumference of the bowel wall.

Successful endoscopic submucosal dissection of colon cancer with severe fibrosis after tattooing

Endoscopic tattooing is often used to facilitate the identification of colorectal lesions before endoscopic treatments. However, tattooing under the lesion can result in technical difficulties because of the dark endoscopic field and submucosal fibrosis. A 65-year-old man with a non-granular-type laterally spreading tumor was referred to our hospital after tattooing with India ink for surgery. However, endoscopic submucosal dissection (ESD) was selected for the resection of this lesion because the findings of magnifying endoscopy suggested an intramucosal cancer. Dissection around a dense section was difficult because of the dark endoscopic field and non-lifting as a result of severe fibrosis. We performed ESD using the following strategy: (1) injection with a smaller amount of indigo carmine and (2) cut and dissection from the side of the thinly tattooed area. The lesion was curatively resected en bloc without any complications. This finding suggests that endoscopic tattooing before endoscopic treatment should be performed one or two folds away from the lesion.

Endoscopic Localization of Colon Cancer Is Frequently Inaccurate

BACKGROUND

Colonoscopic location of a tumor can influence both the surgical procedure choice and overall treatment strategy.

AIMS

To determine the accuracy of colonoscopy in determining the location of colon cancer compared to surgical localization and to elucidate factors that predict discordant colon cancer localization.

METHODS

We conducted a retrospective cross-sectional study of colon cancers diagnosed on colonoscopy at two academic tertiary-care hospitals and two affiliated community hospitals from 2012 to 2014. Colon cancer location was obtained from the endoscopic and surgical pathology reports and characterized by colon segment. We collected data on patient demographics, tumor characteristics, endoscopic procedure characteristics, surgery planned, and surgery performed. Univariate analyses using Chi-squared test and multivariate analysis using forward stepwise logistic regression were performed to determine factors that predict discordant colon cancer localization.

RESULTS

There were 110 colon cancer cases identified during the study period. Inaccurate endoscopic colon cancer localization was found in 29% (32/110) of cases. These included 14 cases (12.7%) that were discordant by more than one colonic segment and three cases where the presurgical planned procedure was significantly changed at the time of surgery. On univariate analyses, right-sided colon lesions were associated with increased inaccuracy (43.8 vs 24.4%, p = 0.04). On multivariate analysis, right-sided colon lesions remained independently associated with inaccuracy (OR 1.74, 95% CI 1.03-2.93, p = 0.04).

CONCLUSIONS

Colon cancer location as determined by colonoscopy is often inaccurate, which can result in intraoperative changes to surgical management, particularly in the right colon.

Endoscopic tattoo: the importance and need for standardised guidelines and protocol

Preoperative endoscopic tattoo is becoming more important with the advent of minimally invasive surgery. Current practices are variable and are operator-dependent. There are no evidence-based guidelines to aid endoscopists in clinical practice. Furthermore, there are still a number of issues with endoscopic tattoo including poor intraoperative visualisation, complications from tattooing and inaccurate documentation leading to the need for intraoperative endoscopy, prolonged operative time and reoperation due to lack of oncologic resection. This review aims to collate and summarise evidence for the best practice of endoscopic tattoo for colorectal lesions in order to provide guidance for endoscopists.

Combined assessment using optical colonoscopy and computed tomographic colonography improves the determination of tumor location and invasion depth

INTRODUCTION

An accurate assessment of the depth of tumor invasion in patients with colon cancer is an important part of the preoperative evaluation. Whether computed tomographic colonography (CTC) or optical colonoscopy (OC) is better to accurately determine tumor location and invasion depth has not been definitively determined. The aim of this study was to determine the diagnostic accuracy of tumor localization and tumor invasion depth of colon cancer by preoperative OC alone or combined with CTC.

METHODS

Study participants include 143 patients who underwent both preoperative CTC using automated CO₂ insufflation and OC from July 2012 to August 2013.

RESULTS

The accuracy of tumor localization was significantly better with CTC than with OC (OC, 90%; CTC, 98%; P < 0.05). No tumor in the descending colon was localized accurately via OC alone. The accuracy of tumor invasion depth was better with CTC plus OC than with OC alone (OC, 55%; CTC, 73%; P < 0.05).

CONCLUSIONS

OC combined with CTC provides a more accurate preoperative determination of tumor localization and invasion depth than OC alone.

Analysis of lesion localisation at colonoscopy: outcomes from a multi-centre U.K. study

Background

Colonoscopy is currently the gold standard for detection of colorectal lesions, but may be limited in anatomically localising lesions. This audit aimed to determine the accuracy of colonoscopy lesion localisation, any subsequent changes in surgical management and any potentially influencing factors.

Methods

Patients undergoing colonoscopy prior to elective curative surgery for colorectal lesion/s were included from 8 registered U.K. sites (2012–2014). Three sets of data were recorded: patient factors (age, sex, BMI, screener vs. symptomatic, previous abdominal surgery); colonoscopy factors (caecal intubation, scope guide used, colonoscopist accreditation) and imaging modality. Lesion localisation was standardised with intra-operative location taken as the gold standard. Changes to surgical management were recorded.

Results

364 cases were included; majority of lesions were colonic, solitary, malignant and in symptomatic referrals. 82% patients had their lesion/s correctly located at colonoscopy. Pre-operative CT visualised lesion/s in only 73% of cases with a reduction in screening patients (64 vs. 77%; p = 0.008). 5.2% incorrectly located cases at colonoscopy underwent altered surgical management, including conversion to open. Univariate analysis found colonoscopy accreditation, scope guide use, incomplete colonoscopy and previous abdominal surgery significantly influenced lesion localisation. On multi-variate analysis, caecal intubation and scope guide use remained significant (HR 0.35, 0.20–0.60 95% CI and 0.47; 0.25–0.88, respectively).

Conclusion

Lesion localisation at colonoscopy is incorrect in 18% of cases leading to potentially significant surgical management alterations. As part of accreditation, colonoscopists need lesion localisation training and awareness of when inaccuracies can occur.

Preoperative localization of colorectal cancer: a systematic review and meta-analysis

BACKGROUND

Preoperative colorectal tumor localization is crucial for appropriate resection and treatment planning. As the localization accuracy of conventional colonoscopy is considered to be low, several localization techniques have been developed. We systematically reviewed the tumor localization error rates of several preoperative endoscopic techniques and synthesized information on risk factors for localization errors and procedure-related adverse events.

METHODS

MEDLINE, EMBASE, the Cochrane Library, and the grey literature were searched. Studies were included if they reported tumor localization errors in patients with colorectal cancer undergoing resection with curative intent. Using random-effects models, pooled incidence of tumor localization errors were derived for conventional colonoscopy and colonoscopic tattooing. Due to the lack of comparative studies, a direct comparison of the pooled estimates was performed. Procedure-related adverse events, risk factors for localization errors, and the localization outcomes of other techniques such as colonoscopic clip placement, radioguided occult colonic lesion identification, and the use of magnetic endoscope imaging were also synthesized.

RESULTS

A total of 38 non-randomized controlled and observational studies were included in this review (2578 patients underwent conventional colonoscopy and 643 colonoscopic tattooing). The pooled incidence of localization errors with conventional colonoscopy was 15.4 % (95 % CI 12.0-18.7), whereas that of colonoscopic tattooing was 9.5 % (95 % CI 5.7-13.3), mean difference 5.9 % (95 % CI 0.65-11.14, p = 0.03). Adverse events secondary to tattooing were infrequent, and most were cases of ink spillage. Limited information was available for other localization techniques.

CONCLUSION

Conventional colonoscopy has a higher incidence of localization error compared to colonoscopic tattooing for localization of colorectal cancer. Colonoscopic tattooing is safe and leads to fewer tumor localization errors. Given the widespread adoption of laparoscopic resections for colorectal cancer, routine colonoscopic tattooing should be adopted. However, studies directly comparing different localization techniques are needed.

Endoscopic tattooing to aid tumour localisation in colon cancer: the need for standardisation

BACKGROUND/AIMS

An increasing number of colon and rectal tumours are being resected using laparoscopic techniques. Identifying these tumours intraoperatively can be difficult. The use of tattooing can facilitate an easier resection; however, the lack of standardised guidelines can potentially lead to errors intraoperatively and potentially result in worse outcomes for patients. The aim of this study was to identify the most reliable method of preoperative tumour localisation from the available literature to date.

METHODS

A literature review was undertaken to identify any articles related to endoscopic tattooing and tumour localisation during colorectal surgery.

RESULTS

To date there is still mixed evidence regarding tattooing techniques and the choice of ink that should be used. There are numerous studies demonstrating safe tattooing techniques and highlighting the risks and benefits of different types of ink available.

CONCLUSION

Based on the available studies we have recommended a standardised approach to endoscopic tattooing of colorectal tumours prior to laparoscopic resection.

Accuracy of preoperative tumor localization in large bowel using 3D magnetic endoscopic imaging: randomized clinical trial

Background

Laparoscopic surgery has become the standard treatment for colorectal cancer. A tumor that does not involve serosa is invisible intraoperatively, and manual palpation of the tumor during laparoscopy is not possible. Therefore, accurate localization of the neoplastic infiltrate remains one of the most important tasks prior to elective laparoscopic surgery. The aim of this study was to evaluate the utility of a magnetic endoscopic imaging (MEI) for precise preoperative endoscopic localization of neoplastic infiltrate within the large bowel.

Materials and methods

The study enrolled 246 patients who underwent elective surgery for colorectal cancer in 2012–2015 with accurate preoperative colonoscopic localization of the tumor. The analysis concerned patients with neoplastic infiltrate localized more than 30 cm from the anal verge. For evaluative purposes and accuracy of localization, the intestine was divided anatomically into 13 parts. Colonoscopic examinations were conducted with two types of endoscopes: group I—with MEI and group II—without MEI. Patients were assigned to the groups by random allocation. Ultimate confirmation of the tumor localization was accomplished by intraoperative evaluation.

Results

Group I involved 127 patients and group II 129. The two groups were compared in terms of age, sex, BMI and frequency of previous abdominal procedures. Proper localization of the lesion was confirmed in 95.23 % of group I patients and in 83.19 % of group II patients (p < 0.05). The greatest discrepancy in localization occurred in 8.9 % of patients from group I and 20 % of patients from group II in which the lesion was assessed primarily in the distal sigmoid.

Conclusions

A magnetic endoscopic imaging allows more accurate localization of neoplastic infiltrate within the large intestine compared to standard colonoscopy alone, especially within the sigmoid colon. This method can be particularly useful in planning and performing laparoscopic procedures to diminish the likelihood of improper bowel segment resection.

ClinicalTrials.gov number

NCT01688557

Electronic supplementary material

The online version of this article (doi:10.1007/s00464-016-5203-4) contains supplementary material, which is available to authorized users.

Discrepancy between gastroenterologists' and general surgeons' perspectives on repeat endoscopy in colorectal cancer

BACKGROUND

A myriad of localization options are available to endoscopists for colorectal cancer (CRC); however, little is known about the use of such techniques and their relation to repeat endoscopy before CRC surgery. We examined the localization practices of gastroenterologists and compared their perceptions toward repeat endoscopy to those of general surgeons.

METHODS

We distributed a survey to practising gastroenterologists through a provincial repository. Univariate analysis was performed using the χ² test.

RESULTS

Gastroenterologists (n = 69) reported using anatomical landmarks (91.3%), tattooing (82.6%) and image capture (73.9%) for tumour localization. The majority said they would tattoo lesions that could not be removed by colonoscopy (91.3%), high-risk polyps (95.7%) and large lesions (84.1%). They were equally likely to tattoo lesions planned for laparoscopic (91.3%) or open (88.4%) resection. Rectal lesions were less likely to be tattooed (20.3%) than left-sided (89.9%) or right-sided (85.5%) lesions. Only 1.4% agreed that repeat endoscopy is the standard of care, whereas 38.9% (n = 68) of general surgeons agreed (p < 0.001). General surgeons were more likely to agree that an incomplete initial colonoscopy was an indication for repeat endoscopy (p = 0.040). Further, 56% of general surgeons indicated that the findings of repeat endoscopy often lead to changes in the operative plan.

CONCLUSION

Discrepancies exist between gastroenterologists and general surgeons with regards to perceptions toward repeat endoscopy and its indications. This is especially significant given that repeat endoscopy often leads to change in surgical management. Further research is needed to formulate practice recommendations that guide the use of repeat endoscopy, tattoo localization and quality reporting.

Accuracy of polyp localization at colonoscopy

BACKGROUND AND STUDY AIMS

Accurate documentation of lesion localization at the time of colonoscopic polypectomy is important for future surveillance, management of complications such as delayed bleeding, and for guiding surgical resection. We aimed to assess the accuracy of endoscopic localization of polyps during colonoscopy and examine variables that may influence this accuracy.

PATIENTS AND METHODS

We conducted a prospective observational study in consecutive patients presenting for elective, outpatient colonoscopy. All procedures were performed by Australian certified colonoscopists. The endoscopic location of each polyp was reported by the colonoscopist at the time of resection and prospectively recorded. Magnetic endoscope imaging was used to determine polyp location, and colonoscopists were blinded to this image. Three experienced colonoscopists, blinded to the endoscopist's assessment of polyp location, independently scored the magnetic endoscope images to obtain a reference standard for polyp location (Cronbach alpha 0.98). The accuracy of colonoscopist polyp localization using this reference standard was assessed, and colonoscopist, procedural and patient variables affecting accuracy were evaluated.

RESULTS

A total of 155 patients were enrolled and 282 polyps were resected in 95 patients by 14 colonoscopists. The overall accuracy of polyp localization was 85 % (95 % confidence interval, CI; 60 - 96 %). Accuracy varied significantly (P < 0.001) by colonic segment: caecum 100 %, ascending 77 % (CI;65 - 90), transverse 84 % (CI;75 - 92), descending 56 % (CI;32 - 81), sigmoid 88 % (CI;79 - 97), rectum 96 % (CI;90 - 101). There were significant differences in accuracy between colonoscopists (P < 0.001), and colonoscopist experience was a significant independent predictor of accuracy (OR 3.5, P = 0.028) after adjustment for patient and procedural variables.

CONCLUSIONS

Accuracy of localization of polyps is imprecise and affected by position within the colon and colonoscopist, including their level of experience. Magnetic endoscope imaging may improve the localization of lesions during colonoscopy.

[Colonoscopic Tattooing of Colonic Lesions]

With the development of minimal invasive surgery including laparoscopic and robot surgery, colonoscopic tattooing of colonic lesions is becoming more important to ensure easy localization of the lesion during surgery. Lack of accurate lesion identification during minimal invasive surgery may lead to resection of wrong segment of the bowel. In this article, some topics including proper materials, injection technique, and safety of colonoscopic tattooing are reviewed.

Perioperative Colonic Evaluation in Patients with Rectal Cancer; MR Colonography Versus Standard Care

RATIONALE AND OBJECTIVES

Preoperative colonic evaluation is often inadequate because of cancer stenosis making a full conventional colonoscopy (CC) impossible. In several studies, cancer stenosis has been shown in up to 16%-34% of patients with colorectal cancer. The purpose of this study was to prospectively evaluate the completion rate of preoperative colonic evaluation and the quality of perioperative colonic evaluation using magnetic resonance colonography (MRC) in patients with rectal cancer.

MATERIALS AND METHODS

Patients diagnosed with rectal cancer were randomized to either group A: standard preoperative diagnostic work-up or group B: preoperative MR diagnostic work-up (standard preoperative diagnostic work-up + MRC). A complete and adequate perioperative clean-colon evaluation (PCE) was defined as either a complete preoperative colonic evaluation or a complete colonic evaluation within 3 months postoperatively.

RESULTS

Twenty-eight patients were randomized to group A and 28 to group B. Complete preoperative colonic evaluation with CC was achieved in 39% patients in group A and 93% for group B (Fisher's exact test, P < .001). PCE with CC was achieved in 64% and 93% in groups A and B, respectively (Fisher's exact test, P = .02). In group A, one synchronous cancer was found by CC. However, the location was misjudged as a sigmoid cancer. In group B, two synchronous cancers were found in the same patient who had an insufficient preoperative CC due to an obstructing rectal cancer.

CONCLUSIONS

MRC is a valuable tool and is recommended as part of the standard preoperative evaluation for patients with rectal cancer.

Preoperative endoscopy localization error rate in patients with colorectal cancer

BACKGROUND

Preoperative repeat endoscopy in colorectal cancer (CRC) patients is considered by many to be an integral component of surgical planning. Little is known, however, about the utility of re-endoscopy.

METHODS

A retrospective review of 342 consecutive patients undergoing elective surgical resection for CRC from January 2008 to December 2011 was performed. Patients were included if the initial endoscopist was different than the operating surgeon. A localization error was recorded if the final tumor location identified during surgery was in a different anatomical segment than that identified by endoscopy. The Chi-squared test was used to compare categorical variables. An error rate with a 95% confidence interval was obtained using the exact binomial distribution.

RESULTS

298 patients were identified, 118 (39.6%) of whom also underwent a preoperative re-endoscopy by the operating surgeon or partner. Nineteen patients had incorrect tumor localization at initial endoscopy, equivalent to a 6.4% error rate (95% CI 3.88-9.78). In comparison, there were two localization errors on re-endoscopy, 1.69% (95% CI 0.21-6.00). Re-endoscopy was found to be protective against localization errors (P < 0.05), correcting 10 of the 12 errors made at the initial endoscopy. The sensitivity of re-endoscopy as a diagnostic tool to detect errors was 83% with a corresponding specificity of 100%. The overall accuracy of re-endoscopy in preventing endoscopic localization errors was 92% (95% CI 81-100).

CONCLUSIONS

There is a small but important localization error rate in preoperative endoscopic evaluation of colorectal tumors. Re-endoscopy appears to be safe and may potentially identify and correct these errors and help with preoperative planning at the expense of delaying surgery. Further research is necessary to find ways to improve localization and identify which patients would benefit from re-endoscopy.

Preoperative re-endoscopy in colorectal cancer patients: an institutional experience and analysis of influencing factors

BACKGROUND

This study serves to establish the re-endoscopy rate in patients undergoing surgery for colorectal cancer (CRC) at a tertiary academic center and to identify significant factors that may influence the decision for preoperative re-endoscopy.

METHODS

A retrospective review of 341 consecutive patients undergoing elective surgical resection for CRC was performed from January 2008 to December 2011. Descriptive statistics were used to define the patient population and to establish the institutional re-endoscopy rate. In order to identify factors associated with re-endoscopy, univariate and multivariate analysis was performed using the chi square test and logistic regression modeling.

RESULTS

Patients within the two comparison groups had similar demographic profiles. Excluding patients where the primary endoscopist was the operating surgeon, 121 of 299 patients (40.5%) underwent re-endoscopy. The most common reasons for re-endoscopy included tattooing of the lesion in 55 patients (45.5%), surgical planning in 43 (35.5%), and repeated therapeutic attempts in 11 (9%). Significant factors associated with re-endoscopy included left-sided colon cancers (compared to right-sided lesions, P < 0.001), planned laparoscopic procedures (P = 0.011), and the absence of a tattoo on the first colonoscopy (P = 0.010). There was also a trend toward a reduction in re-endoscopy if the operating surgeon was consulted at the time of the initial endoscopy (P = 0.085). There was a clear trend toward increased laparoscopic procedures over the duration of the study (P < 0.001). Although this did not correlate with an increase in re-endoscopy, it did coincide with a significant increase in preoperative tattooing at the first colonoscopy (P < 0.001).

CONCLUSIONS

The repeat preoperative endoscopy rate in CRC patients was 40.5%. Re-endoscopy was associated with an initial failure to tattoo the lesion, left-sided colonic neoplasms, and a planned laparoscopic resection. Further research is needed to help identify which patients would benefit from re-endoscopy and where this may be safely omitted.

The accuracy of colonoscopic localisation of colorectal tumours: a prospective, multi-centred observational study

Background and aims

Colonoscopy is essential for accurate pre-operative colorectal tumour localisation, but its accuracy for localisation remains undetermined due to limitations of previous work. This study aimed to establish the accuracy of colonoscopic localisation and to determine how frequently inaccuracy results in altered surgical management.

Method

A prospective, multi-centred, powered observational study recruited 79 patients with colorectal tumours that underwent curative surgical resection. Patient and colonoscopic factors were recorded. Pre-operative colonoscopic and radiological lesion localisations were compared to intra-operative localisation using pre-defined anatomical bowel segments to determine accuracy, with changes in planned surgical management documented.

Results

Colonoscopy accurately located the colorectal tumour in 64/79 patients (81%). Five out of 15 inaccurately located patients required on-table alteration in planned surgical management. Pre-operative imaging was unable to visualise the primary tumour in 23.1% of cases, a finding that was more prevalent amongst bowel screener patients compared to symptomatic patients (45.8% vs. 13%; p = 0.003).

Conclusion

Colonoscopic lesion localisation is inaccurate in 19.0% of cases and occurred throughout the colon with a change in on-table surgical management in 6.3%. With CT unable to visualise lesions in just under a quarter of cases, particularly in the screening population, preoperative localisation is heavily reliant on colonoscopy.

Novel technique for intraoperative tumor localization during totally laparoscopic distal gastrectomy: endoscopic autologous blood tattooing

BACKGROUND

Knowledge of the intraoperative location of lesions is a prerequisite for deciding the proper extent of gastric resection or the choice of anastomosis technique during totally laparoscopic distal gastrectomy (TLDG) for early gastric cancer (EGC). In this study we introduce a novel tumor localization method for TLDG: endoscopic blood tattooing.

METHODS

Twenty-three consecutive patients scheduled for TLDG for EGC were enrolled in this prospective study. The day before surgery, 2-3 ml of autologous blood was injected into the gastric muscle layer at 3-4 cm proximal to the lesion during endoscopy.

RESULTS

The study subjects consisted of 15 males and 8 females with a mean age of 61 ± 10.4 years. During surgery, the endoscopic blood tattooed sites were successfully identified in all 23 patients. No complications associated with the procedure occurred, and no patient had microscopic residual tumor cells at the proximal resection margin, with a mean proximal margin length of 3.3 ± 2.7 cm. Eighteen patients underwent TLDG with Billroth II anastomosis, four patients with Roux-en-Y gastrojejunostomy, and one patient with laparoscopic total gastrectomy. At final pathologic examinations, 20 patients were of stage IA and 3 were of stage IB according to the UICC TNM classification (6th ed.).

CONCLUSIONS

Endoscopic blood tattooing provides a simple and useful means of localizing lesions during TLDG for EGC. Although the superiority of this technique over other localization methods needs to be evaluated further, the authors recommend endoscopic blood tattooing as an alternative to other intraoperative localization methods for laparoscopic surgery for EGC.

Endoscopic tattooing of colorectal lesions: Is it a risk-free procedure?

Endoscopic tattooing is one of the most useful tools for the localization of small colorectal lesions especially in the laparoscopic setting. This is a minimally invasive endoscopic procedure without risk of major complications. However, many studies have revealed complications resulting from this procedure. In this article, several topics are reviewed including the accuracy, substance preparation, injected techniques and complications related to this procedure.

Leaving a mark: the frequency and accuracy of tattooing prior to laparoscopic colorectal surgery

AIM

Intra-operative localization of small cancers and polyps during laparoscopic colorectal surgery is difficult due to reduced tactile feedback. The consequences of failing to identify the lesion for resection can result in open conversion or removal of the wrong segment of bowel.

METHOD

Data were collected from a prospectively-kept database over a 12-month period from April 2008 to March 2009 and analysed retrospectively. Details concerning the documentation, visibility and accuracy of tattoos were recorded.

RESULTS

Eighty-five patients (88 lesions) underwent laparoscopic resection for a benign or malignant colorectal tumour during 1 year from April 2008. Eighty-one patients underwent endoscopic visualization of the tumour as a first or second procedure. Of these 81 patients, 83 lesions were visualized endoscopically and 54 (65.1%) were tattooed in 52 patients. In the 52 patients, 36 (69%) of the tattoos were carried out on the first endoscopy. At operation the tattoo was judged to be visible and accurate in 70%, visible but inaccurate in 7% and not visible in 15%. It was significantly easier to see the tattoo in women (19/21 women vs 21/29 men; P=0.03) but there was no relationship between tattoo visibility and BMI. An accurate tattoo did not reduce the conversion rate (P=0.71). No tattoo-related complications were encountered.

CONCLUSION

The practice of tattooing colorectal cancers is variable in frequency, technique and accuracy. We advocate that all colonic lesions suspicious for cancer should be tattooed during endoscopy at a defined distance below the tumour, adhering to a departmental protocol in case surgery is required.

Endoscopic tattooing

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through January 2010 for articles related to endoscopic tattooing by using the Keywords tattooing, colonic, endoscopic, India ink, indocyanine green in different search term combinations. Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

Colonoscopy and computerized tomography scan are not sufficient to localize right-sided colonic lesions accurately

AIM

Accurate preoperative localization of colonic lesions is critical especially in laparoscopic colectomy where tactile localization is absent particularly in screen-detected tumours. The study aimed to evaluate the accuracy of colonoscopy and double-contrast computerized tomography (CT) scan to localize lesions treated by right hemicolectomy.

METHOD

A retrospective chart review was performed of patients treated by right hemicolectomy under the colorectal service between July 2003 and October 2006. Preoperative tumour location determined by CT scan and colonoscopy was compared with the intra-operative and histopathological findings.

RESULTS

Out of 101 patients, 73 (73%) were for adenoma or cancer, with a final diagnosis of adenocarcinoma in 59 (58%). Preoperative localization was inaccurate in 29% of lesions using both CT and colonoscopy. In the transverse colon, colonoscopy alone was only 37.5% accurate, increasing to 62.5% when information from the CT scan was added.

CONCLUSION

Preoperative localization of right-sided colon cancers using colonoscopy and CT scanning is unreliable in at least 29% of cases. Inaccurate localization of transverse colon tumours risks inadequate lymphadenectomy with an adverse cancer outcome. Preoperative abdominal CT scan improves accuracy but endoscopic tattoo localization should be employed routinely especially in patients undergoing laparoscopic resection.

Small-dose India ink tattooing for preoperative localization of colorectal tumor

INTRODUCTION

India ink tattooing is widely used for tumor localization; however, the tattooing procedure is not yet standardized. This study aims to evaluate the efficacy of small-dose tattooing with sterile India ink using a saline test-injection method.

PATIENTS AND METHODS

Between April 2009 and August 2009, 20 patients underwent colonoscopic tattooing with prepackaged sterile India ink before resection of colorectal tumor. We injected 0.5 cc of India ink at three circumferential sites at the distal tumor using a saline test-injection method. Observation and leakage of India ink were evaluated during laparoscopic surgery, and the diameter of tattooing in the specimen was assessed.

RESULTS

Tattoos were observed intraoperatively in 18 patients (90%). In 2 patients, tattoos were not observed on the serosal surface but were detected on the mucosal surface. Localized leakage of ink was identified during surgery in 1 patient (5%), without fever or abdominal pain. Mean tattoo diameter was 2.1 cm on the serosal surface and 2.0 cm on the mucosal surface.

CONCLUSIONS

Small-dose tattooing with sterile India ink using a saline test-injection method is effective for tumor localization.

Timing and necessity of a flexible sigmoidoscopy in patients with symptoms suggestive of haemorrhoids

OBJECTIVE

This study was performed to determine the probability of finding additional pathology, requiring treatment or follow-up, in patients referred with symptoms suggestive of haemorrhoids. Secondly, to determine, at what age a flexible sigmoidoscopy should be performed in these patients.

METHOD

All patients referred for the treatment of haemorrhoids over a period of 5 years were prospectively included in a database. Data included patient characteristics, clinical information, histopathological analysis and the sigmoidoscopy results.

RESULTS

Haemorrhoids were present in 961 (95.6%) of 1005 patients. Of these patients, 692 (72.0%) patients were free from any additional pathology, 161 (16%) patients had diverticulosis, in 15 (1.5%) patients the sigmoidoscopy showed signs of colitis, 116 (11.5%) patients had polyps and a malignancy was present in eight (0.8%) patients. In the age group between 30-40 and 40-50, the presence of additional pathology increased significantly (P < 0.05). No malignancies were found under the age of 40.

CONCLUSIONS

The vast majority of patients referred for the treatment and analysis of haemorrhoids were free from any additional pathology. But, over the age of 40, the incidence of additional pathology increased significantly. Therefore, we suggest that a flexible sigmoidoscopy should be performed in all patients over the age of 40, with clinical signs of haemorrhoids.

Comparison of CT colonography vs. conventional colonoscopy in mapping the segmental location of colon cancer before surgery

Once presence of a colorectal cancer has been diagnosed, a key factor for patient's prognosis in view of surgical intervention is the correct segmental localization and resection of the tumor. The aim of this work was to compare the accuracy of the current gold standard technique, conventional colonoscopy (CC), to computed tomography colonography (CTC) in the segmental localization of tumor. Sixty-five patients (mean age 64; 45 female and 19 male) with colorectal cancer diagnosed at colonoscopy underwent CTC before surgery. In 45 out of 65 cases (69%), patients were referred to CTC after incomplete CC. Reasons were patient intolerance to CC or presence of stenosing cancer, with consistent difficulties in crossing the tract of the colon involved by the lesion. CTC allowed the complete colonic examination in 63/65 cases, since in 2 patients with an obstructing lesion of the sigmoid colon, pneumocolon could not be obtained. However, per patient and per lesion sensitivity of CTC was 100%. Difference from colonoscopy was statistically significant (P < 0.05). In terms of segmental localization of masses, CTC located precisely all lesions, while colonoscopy failed in 16/67 (24%) lesions, though six were missed for incomplete colonoscopy (9%). In the remaining 10/67 (15%) lesions, detected by colonoscopy but incorrectly located, the mismatch occurred in the rectum (n = 3), sigmoid (n = 2), descending (n = 1), transverse (n = 2), ascending colon, and cecum. Agreement between CTC and CC was fair (k value 0.62). Sensitivity, specificity, positive predictive value and negative predictive value of CTC in determining the precise location of colonic masses were respectively 100%, 96%, 85%, and 100%. CT detected hepatic (6/65 patients) and lung metastases (3/65 patients). CT colonography has better performance in the identification of colonic masses (diameter > 3 cm), in the completion of colonic evaluation and in the segmental localization of tumor. CTC should replace colonoscopy for preoperative staging of colorectal cancer.

Colonic tattooing in laparoscopic surgery - making the mark?

OBJECTIVE

Laparoscopic surgery for colorectal cancer is now widespread. Small lesions in the colon can be difficult to palpate and with lack of tactile sensation, it is essential to accurately localize them preoperatively. This is a review article on current methods of tattooing including the use of different agents and associated complications. Aim To review current techniques in preoperative tumour localization and methods used for colonic tattooing including agents used, dosage and potential complications.

METHOD

A literature search (Medline and Pubmed) was performed with manual cross referencing of all articles related to colonic tattooing.

RESULTS

Methods for localizing colonic tumours for laparoscopic resection include preoperative barium enema examination, CT colonography and intraoperative colonoscopy. The most effective method is, however, by tattooing with India ink performed endoscopically before surgery.

CONCLUSION

India ink is a reliable method of marking tumour location within the colon as prelude to laparoscopic resection. Surgeons must, however, be aware of potential complications associated with this technique.

Intraoperative colonoscopy for anastomosis assessment in laparoscopically assisted left-sided colon resection: is it worthwhile?

BACKGROUND

The aim of our study was to evaluate the use of intraoperative colonoscopy in laparoscopically assisted left-sided colon resection for the assessment of anastomosis.

MATERIALS AND METHODS

All consecutive laparoscopically assisted left-sided colon resections performed at our department between May 2001 and February 2006 were included in this study. After colon resection and reanastomosis, an intraoperative colonoscopy was performed to detect anastomosis risk.

RESULTS

A total of 122 patients were enrolled in this study. In 73 patients (59.84%), the anastomosis was checked via colonoscopy (the study group, (SG), whereas the control group (CG) consisted of 49 (40.16%) patients without colonoscopy. Of the 122 patients, 65 (53.28%) underwent a laparoscopically assisted sigmoid resection, 45 (36.89%) a laparoscopically assisted sigmoid rectum resection, 4 (3.28%) a laparoscopically assisted anterior rectum resection, and 8 (6.56%) a laparoscopically assisted left hemicolectomy. In the study group, 5 (6.85%) anastomotic leakages were intraoperatively detected and oversewn. A total of 6 (4.92%) anastomotic leakages occurred in the early postoperative period (SG: 4 [5.47%] vs. CG: 2 [4.08%]; P = 0.541).

CONCLUSIONS

Intraoperative evaluation of anastomosis prevents early anastomotic insufficiency because intraoperative identification of leaks allows for repair during surgery. Nevertheless, a certain rate of anastomotic dehiscence occurs in every kind of colon resection. The sometimes increased rate of dehiscence in laparoscopic-assisted colon resection can be reduced by intraoperative colonoscopy.

Incomplete colonoscopy in patients with occlusive colorectal cancer: usefulness of CT colonography according to tumor location

PURPOSE

We sought to evaluate the clinical usefulness of CT colonography (CTC) after incomplete conventional colonoscopy (CC) for occlusive colorectal cancer (CRC) according to the tumor location.

MATERIALS AND METHODS

Seventy-five patients with occlusive CRC underwent subsequent CTC immediately after incomplete CC. Fifty-nine patients had distal CRC and 16 had proximal colon cancer. Experienced radiologists prospectively analyzed the location, length, and TNM staging of the main tumor. The colorectal polyps in the remaining colorectum and additional extraluminal findings were also recorded. Sixty-seven patients underwent colorectal resection. We retrospectively analyzed the surgical outcome and correlated CTC and CC findings.

RESULTS

The overall accuracies of tumor staging were: T staging, 86%; N staging (nodal positivity), 70% (80%); and intra-abdominal M staging, 94%. Additional colonic polyps were found in 23 patients. Six synchronous carcinomas were detected (9%); three in the proximal colon and three in the distal colon of occlusion. Clinically significant localization errors at CC were noted in 8 patients (12%, 5 proximal colon cancers and 3 distal CRCs) and were corrected by CTC. After CTC, the surgeons modified the initial surgical plan in 11 cases (16%).

CONCLUSION

In occlusive CRC, CTC is not only useful in the evaluation of the proximal bowel, but can also provide surgeons with accurate information about staging and tumor localization. CTC is recommended when endoscopists encounter occlusive CRC, regardless of tumor location.

Tumor localization for laparoscopic colorectal surgery

BACKGROUND

Because palpating colonic tumors during laparoscopy is impossible, the precise location of a tumor must be identified before operation. The aim of this study was to evaluate the accuracy of various diagnostic methods that are used to localize colorectal tumors and to propose an adequate localization protocol for laparoscopic colorectal surgery.

METHODS

A total of 310 patients underwent laparoscopy-assisted colectomy between April 2000 and March 2006. We investigated if the locations of the tumors that were estimated preoperatively were consistent with the actual locations according to the operation.

RESULTS

All the tumors were correctly localized and resected. Altogether, 203 patients had complete endoscopic reports available. Colonoscopy was inaccurate for tumor localization in 23 cases (11.3%). In total, 104 patients (33.5%) underwent barium enema; five tumors (4.8%) were not visualized, and three tumors were incorrectly localized. Another group of 94 patients (30.3%) underwent computed tomography (CT) colonography, which identified 91 of 94 lesions (96.8%). Finally, 96 patients (31.0%) underwent endoscopic tattooing; 2 patients (2.1%) did not have tattoos visualized laparoscopically and required intraoperative colonoscopy to localize their lesions during resection. Dye spillage was found in six patients intraoperatively, but only one patient experienced clinical symptoms. Intraoperative colonoscopy was performed in four patients; two of the four were followed by endoscopic tattooing, and the other two underwent intraoperative colonoscopy for localization. All lesions were correctly localized by intraoperative colonoscopy. The accuracy of tumor localization was as follows: colonoscopy (180/203, 88.7%), barium enema (97/104, 93.3%), CT colonography (89/94, 94.7%), endoscopic tattooing (94/96, 97.9%), and intraoperative colonoscopy (4/4, 100%).

CONCLUSIONS

With a combination of methods, localization of tumors for laparoscopic surgery did not seem very different from that during open surgery. Preoperative endoscopic tattooing is a safe, highly effective method for localization. In the case of tattoo failure, intraoperative colonoscopy can be used for accurate localization.