Complication after pre-operative India ink tattooing in a colonic lesion

A Case of Laparoscopic Resection of Gastric Cancer Using Novel Laparoscopic Fluorescence Spectrum System and Near-Infrared Fluorescent Clips

INTRODUCTION

In laparoscopic gastrectomy, accurate marking of the lesion site is essential in determining the resection line of the stomach, owing to the lack of haptics and the direct link between negative pathological margins and prognosis. Intraoperative endoscopy may require personnel and prolong the operation time, whereas preoperative endoscopic tattooing using India ink faces problems related to the spread of ink and visibility. ZEOCLIP FS (Zeon Medical, Tokyo, Japan) is a clip made of fluorescent resin, covered by insurance since March 2019. It can be visualized from the serosal side using a near-infrared scope; however, its weak fluorescence intensity often poses viewing difficulties. Lumifinder (ADVANTEST, Tokyo, Japan) is a laparoscopic fluorescence spectrum system available for clinical use since February 2023. It can measure fluorescence intensity using a near-infrared laser and detect weak fluorescent signals. We report a case of gastric cancer in which the location of the lesion was confirmed intraoperatively using ZEOCLIP FS and Lumifinder.

CASE PRESENTATION

A man in his 80s was diagnosed with gastric cancer following an examination for anemia. Two lesions were found: a 0-IIc type (cT1) at the lesser curvature of the gastric angle and a type 1 tumor (cT2) at the anterior wall of the upper gastric body. The preoperative assessment indicated no lymph node or distant metastasis. The tumor was diagnosed as cStage I and laparoscopic distal gastrectomy was planned. Two ZEOCLIP FS clips were placed on the oral side of the tumor on the anterior wall of the upper gastric body on the day before surgery. During surgery, fluorescent signals from the clips were detected using Lumifinder, enabling easy confirmation of the lesion location and determination of the gastric resection line.

CONCLUSIONS

The combined use of ZEOCLIP FS and Lumifinder was a useful new method for identifying the appropriate resection line of the stomach. We plan to evaluate this method further in additional cases to enhance the detection efficacy.

Safety and efficacy of autologous blood tattooing for preoperative colonic localization: a comparative study with conventional India ink tattooing

BACKGROUND

India ink has been a popular choice for a tattooing agent in preoperative endoscopic localization but often results in unfavorable effects. Subsequently, autologous blood tattooing has arisen as an alternative option. Due to the limited availability of comparative studies on the matter, we conducted a study to compare the perioperative outcomes associated with India ink tattooing versus autologous blood tattooing.

METHODS

A total of 96 patients who underwent minimally invasive surgical procedures for left-sided colonic neoplasm following preoperative endoscopic localization were included in the study. These patients were categorized into two groups: 36 patients who received India ink tattooing and 60 patients who underwent autologous blood tattooing. The perioperative outcomes including procedure-related outcomes and postoperative outcomes were compared between the two groups.

RESULTS

There was no significant difference in visibility and spillage of tattooing agent between India ink group and autologous blood group. However, India ink group showed a higher incidence of post-tattooing fever, higher level of postoperative C-reactive protein level, longer time to first flatus, resumption of surgical soft diet, and duration of hospital stay, and a higher occurrence of postoperative complications including ileus and surgical site infection compared with the autologous blood group. In the multivariate analysis, India ink tattooing was significantly associated with the occurrence of postoperative complications. In the subgroup analysis involving patients with intraperitoneal spillage, the autologous blood group demonstrated significantly favorable perioperative outcomes compared with India ink group.

CONCLUSIONS

Autologous blood tattooing demonstrated comparable visibility and enhanced safety, establishing it as a potential alternative to India ink for preoperative endoscopic localization.

A novel polymer platform for endoscopic tattooing with high efficacy and safety

Endoscopic tattooing plays a pivotal role in modern endoscopic localization of gastrointestinal lesions, facilitating further surgical intervention and aiding in the postoperative identification and repositioning of lesions. However, traditional endoscopic tattoo dyes often suffer from drawbacks such as side effects, short tattoo duration, and high overall costs. In this study, we developed polyvinylpyrrolidone (PVP)-modified polypyrrole (PPy) nanoparticles by oxidizing pyrrole in a PVP aqueous solution to create a PPy/PVP nanoparticle solution. This innovation aims to enhance endoscopic tattooing efficiency and mitigate the limitations associated with current tattooing methods. Both in vitro and in vivo evaluations confirmed the biosafety of PPy/PVP nanoparticles. Endoscopic tattooing experiments conducted in a pig model demonstrated the dye's stability within the digestive tract. Similarly, subcutaneous tissue tattooing experiments performed in a mouse model revealed the sustained stability of the PPy/PVP tattoo dye for at least 180 days. With its robust stability, safety, and longevity, PPy/PVP nanoparticles hold promise as novel tattoo dyes for marking intestinal lesion sites. This advancement has the potential to enhance the accuracy of lesion localization and long-term tracking.

Near-infrared fluorescence tattooing: a new approach for endoscopic marking of tumors in minimally invasive colorectal surgery using a persistent near-infrared marker

INTRODUCTION

Intraoperative accurate localization of tumors in the lower gastrointestinal tract is essential to ensure oncologic radicality. In minimally invasive colon surgery, tactile identification of tumors is challenging due to diminished or absent haptics. In clinical practice, preoperative endoscopic application of a blue dye (ink) to the tumor site has become the standard for marking and identification of tumors in the colon. However, this method has the major limitation that accidental intraperitoneal spillage of the dye can significantly complicate the identification of anatomical structures and surgical planes. In this work, we describe a new approach of NIR fluorescent tattooing using a near-infrared (NIR) fluorescent marker instead of a blue dye (ink) for endoscopic tattooing.

METHODS

AFS81x is a newly developed NIR fluorescent marker. In an experimental study with four domestic pigs, the newly developed NIR fluorescent marker (AFS81x) was used for endoscopic tattooing of the colon. 7-12 endoscopic submucosal injections of AFS81x were placed per animal in the colon. On day 0, day 1, and day 10 after endoscopic tattooing with AFS81x, the visualization of the fluorescent markings in the colon was evaluated during laparoscopic surgery by two surgeons and photographically documented.

RESULTS

The detection rate of the NIR fluorescent tattoos at day 0, day 1, and day 10 after endoscopic tattooing was 100%. Recognizability of anatomical structures during laparoscopy was not affected in any of the markings, as the markings were not visible in the white light channel of the laparoscope, but only in the NIR channel or in the overlay of the white light and the NIR channel of the laparoscope. The brightness, the sharpness, and size of the endoscopic tattoos did not change significantly on day 1 and day 10, but remained almost identical compared to day 0.

CONCLUSION

The new approach of endoscopic NIR fluorescence tattooing using the newly developed NIR fluorescence marker AFS81x enables stable marking of colonic sites over a long period of at least 10 days without compromising the recognizability of anatomical structures and surgical planes in any way.

Efficacy and Safety of Gastrointestinal Tumour Site Marking with da Vinci-Compatible Near-Infrared Fluorescent Clips: A Case Series

BACKGROUND

The conventional near-infrared fluorescent clip (NIRFC) ZEOCLIP FS® has been used successfully in marking tumour sites during laparoscopic surgeries. However, this clip is difficult to observe with the Firefly imaging system equipped with the da Vinci® surgical system. We have been involved in the modification of ZEOCLIP FS® and development of da Vinci-compatible NIRFC. This is the first prospective single-centre case series study verifying the usefulness and safety of the da Vinci-compatible NIRFC.

METHODS

Twenty-eight consecutive patients undergoing da Vinci®-assisted surgery for gastrointestinal cancer (16 gastric, 4 oesophageal, and 8 rectal cases) between May 2021 and May 2022 were enrolled.

RESULTS

Tumour location was identified by the da Vinci-compatible NIRFCs in 21 of 28 (75%) patients, which involved 12 gastric (75%), 4 oesophageal (100%), and 5 rectal (62%) cancer cases. No adverse events were observed.

CONCLUSION

Tumour site marking with da Vinci-compatible NIRFC was feasible in 28 patients enrolled in this study. Further studies are warranted to substantiate the safety and improve the recognition rate.

Preoperative fluorescent clip marking vs. India ink tattooing for tumor identification during colorectal surgery

PURPOSE

Identifying tumor location is important in colorectal tumor resection. Preoperative endoscopic India ink marking is a widespread practice, but local injection of ink is an unstable procedure. Although it is often invisible, the ink may be sprayed into the peritoneal cavity and contaminate the surgical field. At our hospital, we introduced fluorescent clip marking (FCM) using the Zeoclip FS®, an endoscopic clip developed using near-infrared fluorescent resin. We tested the usefulness of FCM by retrospectively comparing cases in which FCM was used with cases in which conventional ink marking was used.

METHODS

We enrolled 305 patients with colorectal tumors who underwent colorectal surgery after preoperative marking from January 2017 to April 2022. We classified the patients into the FCM group (86 patients) and the India ink tattoo group (219 patients). Endoscopic marking was completed in the FCM group by the day before surgery, and fluorescence was evaluated during surgery with a fluorescent laparoscopic system. Patient backgrounds, marking visibility, adverse effects, and early postoperative results were retrospectively compared between groups.

RESULTS

Marking was visually confirmed in 80 patients in the FCM group (93.02%) and in 166 patients in the India ink tattoo group (75.80%) (p = 0.0006). In the group with India ink tattoos, contamination of the surgical field was observed in seven cases (3.20%). No adverse events were observed in the FCM group.

CONCLUSION

In colorectal surgery, FCM provides better visibility than the conventional India ink tattooing method and is a simple and safe marking method.

CLINICAL TRIAL REGISTRATION

Examination of fluorescence navigation for laparoscopic colorectal cancer surgery. Research Ethics Committee of the Kawaguchi Municipal Medical Center (Saitama, Japan) approval number: 2020-3. https://kawaguchi-mmc.org/wp-content/uploads/clinicalresearch-r02.pdf .

Safety and efficacy of preoperative indocyanine green fluorescence marking in laparoscopic gastrectomy for proximal gastric and esophagogastric junction adenocarcinoma (ICG MAP study)

PURPOSE

The incidence of adenocarcinoma of the esophagogastric junction (AEG) and proximal gastric cancer (PGC) is rising worldwide. Recently, the use of indocyanine green (ICG) tracer-guided surgery has been reported; however, its efficacy for total/proximal gastrectomy has not been clarified. We evaluated the feasibility and safety of ICG fluorescent marking for tumor localization in AEG/PGC treatment by laparoscopic surgery.

METHODS

We enrolled patients with AEG/PGC from October 2016 to March 2019 from a prospectively registered database. On the day before surgery, ICG markings were made at four locations just at the edge of the tumor by gastrointestinal fiberscope examination. Surgery was performed while viewing the fluorescence image of ICG, and the proximal portions of the esophagus and the distal portion of the stomach were resected at the edge of the area where ICG had spread.

RESULTS

We enrolled 130 patients with AEG/PGC. Overall, 107 patients were eventually included in the study: AEG n = 64 (60%) and PGC n = 43 (40%). ICG markings were detected intraoperatively in all cases, and cancer invasion into the resection lines of the esophagus and stomach, performed based on ICG fluorescence images, was negative in all cases. The median visible range of ICG fluorescence was 22.5 mm. ICG diffusion expanded 20 mm proximal for AEG. There were no adverse events associated with endoscopic ICG injection.

CONCLUSION

ICG fluorescence imaging is feasible and safe and can potentially be used as a tumor-marking agent for determining the surgical resection line for total/proximal gastrectomy in AEG and PGC treatment.

Preoperative endoscopic marking of the gastrointestinal tract using fluorescence imaging: submucosal indocyanine green tattooing versus a novel fluorescent over-the-scope clip in a survival experimental study

BACKGROUND

Intraoperative localization of endoluminal lesions is can be difficult during laparoscopy. Preoperative endoscopic marking is therefore necessary. Current methods include submucosal tattooing using visible dyes, which in case of transmural injection can impair surgical dissection. Tattooing using indocyanine green (ICG) coupled to intraoperative near-infrared (NIR) laparoscopy has been described. ICG is only visible under NIR-light, therefore, it doesn't impair the surgical workflow under white light even if there is spillage. However, ICG tattoos have rapid diffusion and short longevity. We propose fluorescent over-the-scope clips (FOSC), using a novel biocompatible fluorescent paint, as durable lesion marking.

METHODS

In six pigs, gastric and colonic endoscopic tattoos using 0.05 mg/mL of ICG and markings using the fluorescent OSC were performed (T0). Simultaneously, NIR laparoscopy was executed. Follow-up laparoscopies were conducted at postoperative day (POD) 4-6 (T1) and POD 11-12 (T2). During laparoscopy, fluorescence intensity was assessed. In one human cadaver, FOSC was used to mark a site on the stomach and on the sigmoid colon, respectively. Intraoperative detection during NIR laparoscopy was assessed.

RESULTS

Gastric and colonic ICG tattooing and OSC markings were easily visible using NIR laparoscopy on T0. All FOSC were visible at T1 and T2 in both stomach and colon, whereas the ICG tattooing at T1 was only visible in the stomach of 2 animals and in the colon of 3 animals. At T2, tattoos were not visible in any animal. FOSC were still visible in both stomach and colon of the human cadaver at 10 days.

CONCLUSION

Endoscopic marking using FOSC can be an efficient and durable alternative to standard methods.

Effectiveness and safety of tumor site marking with near-infrared fluorescent clips in colorectal laparoscopic surgery: A case series study

BACKGROUND

In colorectal laparoscopic surgery, accuracy of tumor marking has been an important but not fully resolved issue. The tattoo marking technique or intraoperative endoscopy have been used but they either carry the risk of accidental intestinal puncture or require either longer operation times, a skilled endoscopist and/or intraoperative colon insufflation. We supposed that tumor site marking with the near-infrared fluorescent clips, ZEOCLIP FS clips (Zeon Medical Co., Ltd., Tokyo, Japan) might overcome disadvantages of both tattoo marking and intraoperative endoscopy-based tumor localization methods. This is the first report on the case series using near-infrared fluorescent marking clip. We summarize the early results in 30 patients, who underwent colorectal laparoscopic surgery; we focus particularly on effectiveness and safety of the method.

MATERIALS AND METHODS

Thirty consecutive patients, who underwent laparoscopic surgery for colorectal cancer after previous endoscopic ZEOCLIP FS placement were enrolled from May 2019 till October 2019. The primary endpoint was the rate of intraoperative clip detection and the secondary endpoints were: the rate of adverse effects, percentage of slipped clips and usefulness of plain abdominal radiography to preoperatively confirm the clip retention. Locations of fluorescent clips were identified with a full-color fluorescence laparoscope. All operations and clip placements were performed by the same senior surgeon with sufficient experience in both procedures.

RESULTS

Fluorescent clips could be detected in 94.1% of tumor lesions. Three (2.1%) clips dropped before surgery. Plain abdominal radiography was sufficient to assess clip retention in all cases. No adverse effects related to either clip placement or clip detection were observed.

CONCLUSION

The ZEOCLIP FS could be easily detected from the serosal side of the intestinal tract when placed 1-2 days before surgery. Fluorescent clip-guided laparoscopy may be considered a safe and effective method for localization of colorectal tumor sites. The Research Registry UIN: researchregistry5400.

Preoperative endoscopic tattooing using India ink to determine the resection margins during totally laparoscopic distal gastrectomy for gastric cancer

PURPOSE

This study was conducted to determine whether establishing the proximal resection line using India ink tattooing can ensure safe resection margins during totally laparoscopic distal gastrectomy.

METHODS

This retrospective study included 81 patients who underwent totally laparoscopic distal gastrectomy for gastric cancer on the lower two-thirds of the stomach. The proximal resection margins were analyzed with respect to the macroscopic type and clinical T stage, and the intraoperative appearance of the stain on the serosa was classified by reviewing surgical videos.

RESULTS

R0 resection was performed in all patients. The rates of the intended margins were 89.2% in patients without a frozen section diagnosis and 84.2% in patients with differentiated type lesions who underwent a frozen section diagnosis; however, most patients with undifferentiated advanced lesions failed to achieve the intended resection margins. Intraoperative appearance revealed that 85.2% of patients had localized type stains, whereas 11.1% had widespread-type stains.

CONCLUSIONS

Our procedure to determine the proximal resection line in totally laparoscopic distal gastrectomy is oncologically safe. However, careful observation of the resected specimen and a frozen section analysis should be performed for undifferentiated advanced lesions.

Endoscopic Preoperative Tattooing and Marking in the Gastrointestinal Tract: A Systematic Review of Alternative Methods

Background: An accurate and reliable localization of endoluminal gastrointestinal (GI) lesions is crucial, particularly during minimally invasive surgery. As an extreme consequence, a misdetected GI lesion can lead to the resection of the wrong segment, especially in colorectal surgery. A preoperative endoscopic marking is recommended in case of GI lesions, which are expected to be difficult to detect from the serosal side. In clinical practice, three preoperative endoscopic marking methods are currently used: India ink, SPOT™, and endoclips with intraoperative fluoroscopy. All of them have substantial limitations. This has encouraged research on alternative solutions. Methods: In the current systematic review, animal and clinical studies about alternative preoperative endoscopic marking methods of GI lesions were analyzed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Thirty studies were found using PubMed/MEDLINE, EMBASE/Ovid, and the Cochrane Library for the qualitative analysis. Conclusion: Although several smart solutions have been proposed and tested successfully, all of them seem to have a substantial drawback related either to scarce stability on the marking site or potential spreading on the bowel wall or diffusion into the surgical planes.

A novel fluorescent marking clip for laparoscopic surgery of colorectal cancer: A case report

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This is the first report on fluorescent marking clip for laparoscopic surgery.

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In laparoscopic surgery, marking of tumor location has been gaining importance.

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Tattoo marking technique carries the risk of accidental intestinal wall perforation leading to peritoneal scattering or other organ perforation.

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The fluorescent marking clips were easily placed and recognized with a fluorescent laparoscope.

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The fluorescent clip is expected to reduce risks related to other marking methods.

Introduction

In laparoscopic surgery, marking of tumor location has been gaining importance. Tattoo marking has been often used but the technique carries the risk of accidental peritoneal scattering or other organ injury. We have been involved in the development of a novel fluorescent clip for marking tumor sites and supposed that its usage would reduce risks related to other marking methods.

Case presentation

A 52-year-old man was diagnosed with sigmoid colon cancer and polyp, and was scheduled for laparoscopic sigmoidectomy. On the day before operation, fluorescent clips (ZEOCLIP FS: Zeon Medical co, Ltd, Tokyo) were endoscopically placed around the tumor and polyp sites, 4 clips for each lesion attached every 90 degrees within the colonic lumen, respectively. During the operation, locations of the fluorescent clips were easily confirmed using a full-color fluorescent laparoscope, VISION SENSE (Medtronic Co., U.S.). Curative operation was performed accordingly with the preoperative pathological and radiological findings. The postoperative course was uneventful.

Discussion

Locations of intraluminally placed fluorescent clips were clearly and easily recognized through the serosal layer of the intestinal wall using a fluorescent laparoscope. Complications related to dye scattering or intestinal wall/other organ perforation were not observed suggesting that future incorporation of this tumor site marking technique into laparoscopic surgery might be beneficial.

Conclusion

The fluorescent marking clips were easily placed and recognized with a fluorescent laparoscope. This method is expected to be safe and risks of accidental puncture related to tattoo marking method can be reduced or almost eliminated.

The Feasibility and Safety of Preoperative Fluorescence Marking with Indocyanine Green (ICG) in Laparoscopic Gastrectomy for Gastric Cancer

BACKGROUND

Securing the surgical margin is the most essential and important task in curative surgery. However, it is difficult to accurately identify the tumor location during laparoscopic surgery for gastric cancer, and existing methods, such as preoperative endoscopic marking with tattooing and clipping, have multiple disadvantages.

AIMS

We investigated the feasibility and safety of indocyanine green (ICG) fluorescence marking for determining the tumor location during laparoscopic gastrectomy.

METHODS

We retrospectively analyzed preoperative and perioperative data from consecutive patients with gastric cancer undergoing planned laparoscopic distal gastrectomy. Data was maintained in a prospectively compiled surgical database, and patients were categorized into ICG (n = 84) or non-ICG (n = 174) groups based on whether they underwent preoperative endoscopic mucosal ICG injection. One-to-one propensity score matching (PSM) was performed to compare outcomes between the two groups.

RESULTS

We included 84 patient pairs after PSM, and there were no significant differences in preoperative patient characteristics. The ICG group had shorter procedure time (p < 0.001), lower estimated blood loss (p = 0.005), and significantly shorter postoperative hospital stay (p < 0.001). Positive resection margins were confirmed in five cases (6.0%) in the non-ICG group, whereas there were none in the ICG group (p = 0.008). Real-time confirmation was possible during laparoscopy, and the injected ICG did not affect the surgical procedure or result in adverse events.

CONCLUSION

ICG fluorescence imaging is feasible and safe and can potentially be used as a tumor-marking agent for determining the surgical resection line.

Overstaged Rectal Cancer by MRI due to Fibrosis Induced by Tattoo Marker

Endoscopic colorectal tattooing with carbon-based dyes is commonly employed in order to assist with later localization of the lesion. Although carbon is thought to be nontoxic, there usually is some inflammatory reaction with fibrosis and granuloma formation after tissue injection. The aim of this report is to alert to a possible underestimated, late consequence of colorectal carbon-based marker tattooing, namely pronounced fibrosis at the site of the injection that could lead to a blurring and misinterpretation of changes evaluated by radiological techniques. We describe a case of cT stage overestimation due to fibrosis of the rectal wall and perirectal fat, induced by carbon-based dye injection in a 66-year-old patient. In our case it was an overestimation of MR evaluation in the case of early invasive carcinoma. Although there have been some studies on tissue effect of carbon-based dyes, the possible scenario consequence of cancer stage overestimation due to fibrosis has not yet been described. Such a mistake could lead to inappropriate overtreatment. Clinicians must be aware of the possible consequences of dye injection and resultant overestimation of T stage of colorectal cancer. More histological studies concerning histological changes after carbon-based marker tattooing are needed to establish the extent of its significance.

Hematemesis With Gastric Laceration After Tattooing a Polyp With Purified Carbon: A Review of the Literature

Endoscopic tattooing is a simple and effective technique for marking small lesions, so they can be localized during surgery or in later endoscopies. Various agents can be used such as India ink or a solution of purified carbon particles. The number of complications from tattooing is relatively small, but not rare. The majority of the literature on the subject refers to complications in the colon. We present a case of gastric bleeding secondary to a laceration following tattooing with purified carbon, and a literature review.

Effect of preoperative colonoscopic tattooing on lymph node harvest in T1 colorectal cancer

OBJECTIVE

This study aimed to identify the impact of preoperative colonoscopic tattooing (PCT) on lymph node harvest in T1 colorectal cancer patients.

MATERIAL AND METHODS

One hundred and forty-three patients were included who underwent curative resection and were diagnosed with T1 colorectal cancer. These patients were categorized into the tattooing group and the non-tattooing group depending on whether preoperative India ink tattooing was done. Clinicopathological findings and lymph node harvest were compared between the two groups.

RESULTS

The median number of lymph nodes examined was 18 in the tattooing group and 13 in the non-tattooing group (p < 0.001). The rate of adequate lymph node harvest (retrieval of more than 12 lymph nodes) was higher in the tattooing group than that in the non-tattooing group (83.7 vs. 58.5 %, p = 0.002). The PCT was significantly associated with adequate lymph node harvest in multivariate analysis (hazard ratio, 3.8; 95 % confidence interval, 1.5-9.2; p = 0.003). Among the 40 patients who showed at least one carbon particle-containing lymph nodes, the positive lymph node rate was not different between carbon-containing LNs (0.9 %) and non-carbon-containing LNs (1.7 %).

CONCLUSIONS

PCT was associated with higher lymph node yield in T1 colorectal cancer. It is questionable if tattooing has additional detection power as a sentinel lymph node mapping tool in T1 colorectal cancer.

A novel endoscopic fluorescent clip visible with near-infrared imaging during laparoscopic surgery in a porcine model

BACKGROUND

In gastrointestinal cancer surgery, particularly in early cancer, accurate tumor localization is important in order to determine the extent of resection. In laparoscopic surgery, because of the inability to palpate the lesion, the most prevalent method of localization is endoscopic tattooing. However, complicated maneuvering makes it difficult to control local dye spreading and dye leakage into the intraperitoneal cavity. A simpler, safe method is needed. In this study, we developed a novel method for applying fluorescence-coated endoscopic clips to visualize locations inside the colon during laparoscopic surgery. We tested the procedure in an in vivo porcine model and with ex vivo human colon tissues.

METHODS

Bovine serum albumin was conjugated to indocyanine green or the succinimidyl ester CF™ 790 to form a pasty mixture, which was used to coat the front ends of endoscopic clips. The fluorescence-coated clips were endoscopically placed on the mucosal surface of a porcine colon. Using an Olympus near-infrared laparoscopy system, we attempted to identify the fluorescent clips from the outer, serosal side of the porcine colon during laparoscopic surgery in vivo. The clips were also evaluated using ex vivo human colon tissues.

RESULTS

After placing two clips on the inner, mucosal surface of the porcine colon, we used near-infrared laparoscopy to view them from the outer, serosal surface of the colon in real time during in vivo laparoscopic surgery. We also identified the fluorescence-coated clips through human colon tissues in an ex vivo study.

CONCLUSIONS

We developed a novel, fluorescence-coated clip that can be placed endoscopically for rapid, exact localization of colonic lesions. The clips were successfully visualized with near-infrared fluorescence imaging during laparoscopic surgery in an in vivo porcine model and in ex vivo human colon tissues.

Endoscopic tattooing of gastrointestinal and pancreatic lesions

The intraoperative identification of the lesions found at endoscopic examination is often difficult, especially during laparoscopic surgery. At present, the most used technique for the intraoperative detection of pathological lesions is endoscopic tattooing. The large majority of studies carried out concern colorectal lesions; however, endoscopic tattooing has also been described for esophageal, gastric, small bowel and, more recently, pancreatic lesions. In this review, the authors evaluated indications, substances used, injection techniques, accuracy, safety and, finally, the risk of complications related to this procedure.

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.

Black macular patches on parietal peritoneum and other extraintestinal sites from intraperitoneal spillage and spread of India ink from preoperative endoscopic tattooing: an endoscopic, surgical, gross pathologic, and microscopic study

BACKGROUND

Three cases, including one case report and two clinical images, have been reported of extraintestinal or peritoneal black maculae detected at laparoscopy after colonoscopic tattooing, presumably from intraperitoneal spillage of India ink during tattooing.

AIMS

Report three cases of inadvertent extraintestinal tattooing from endoscopic tattooing of intestinal lesions, provide histologic evidence for the presumed pathophysiology, and promulgate recommendations to prevent this complication.

METHODS

Three patients underwent endoscopic tattooing of intestinal lesions using India ink, surgery for lesion removal, and pathologic analysis.

RESULTS

Three patients had black macular patches or streaks identified intraoperatively at extraintestinal sites after endoscopic tattooing of intestinal lesions with India ink: (1) black patches on peritoneum 7 days after colonoscopic tattooing of cecal cancer, (2) black streaks on band connecting cecum to peritoneum 13 days after colonoscopic tattooing of cecal cancer, and (3) blackish band on jejunal mesentery 28 days after tattooing presumptive bleeding jejunal lesion. Pigmentation was detected at both injection and extraintestinal sites in all patients by (1) surgery, (2) gross pathology, and (3) microscopic examination demonstrating intracellular black pigmentation within mesothelial cells and macrophages. Special histologic stains were consistent with a carbon-based pigment, and inconsistent with iron or melanin as the pigment. The proposed mechanism is intraperitoneal India ink spillage from deep intestinal injection, as supported by histologic findings of subserosal pigment accumulation. An alternative histologic mechanism is migration of pigment-laden macrophages via lymphovascular channels.

CONCLUSIONS

Endoscopic injection of India ink using standard sclerotherapy needles can inadvertently tattoo extraintestinal sites in addition to tattooing the primary lesion. Despite its striking appearance, this intraoperative, gross, and microscopic finding is likely not pathologically significant, given its proposed pathophysiology. Surgical recognition of this entity is important, however, to prevent misinterpretation of findings as peritoneal melanoma, endometrial implants, infarcted mesentery, or tattooed cancer. This complication may be prevented by proper tattooing technique.

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.