In this tip we are going to extend the discussion of tattooing. We talked about it briefly in tip 16 in tattooing lesions prior to referral for endoscopic resection and said that it's important to keep the tattoo out from under the lesion because it can induce some submucosal fibrosis that can be a real problem during ESD and is at least a potential problem during endoscopic mucosal resection with even some suggestion that it can increase the risk of perforation. But also once the tattoo is in, and usually a single tattoo works in that instance, take a photograph of the tattoo in relation to the lesion and then describe in the report carefully where it is. In the next tip we are going to primarily focus on when you choose to do tattooing, making sure that it's done correctly so the tattoo can be identified by either the surgeon or the subsequent endoscopist and that it's not in the wrong place, it doesn't create a misleading situation. I think overall there's still some controversy about tattooing or marking, mostly as to whether or not too much of it or too little of it is done with regard to tattooing for surgery. Perhaps that too little of it is done with regard to endoscopic follow-up either for initial resection or follow-up of resection that perhaps some experts would say that too much of it is done. But I think while we will discuss in the next tip some of those areas of controversy and also focus on avoiding medical legal risk that can be associated with tattooing or wrong site surgery, that in this tip we're going to focus on getting the tattoo in correctly so that it's in the right place and so that it's easy to identify. Our technical goals in placing a tattoo are first of all to put it in the submucosa. It goes in the submucosa and nowhere else. If you put it in the submucosa, it will be visible to a surgeon from the serosal surface and of course would be visible for endoscopic follow-up. You don't want to get it in the peritoneal cavity or shoot it in another organ. Most experienced surgeons will recognize that that's just inadvertent spillage. But occasionally if the tattoo in the wall of the colon is not identified, some surgeons have relied on the general location of where that spillage is and that can lead to errors. You also don't want it in the muscle layer. The muscle of course can't really be expanded by injection, but having the needle go into the muscle and trying to inject there probably can induce some fibrosis that could increase the risk of perforation. And then you want to put enough in so the next operator can see it. For surgery, particularly laparoscopic surgery, this involves placing it in three to four quadrants especially very heavy men can have a lot of fat on the serosal surface so you need to have enough in there. For endoscopic follow-up, generally a single location that is accurately described in relation to the lesion is adequate. So the first technique I'll describe and I think it's a very good one, a very reasonable one to use is the BLEB method or the BLEB technique. It's very widely advocated as a way to avoid spillage into the peritoneal cavity or deep injection. And the idea is basically take something that is cheap and innocuous, saline, and make a submucosal cushion and then inject the tattoo into that cushion of saline so that basically you can't miss. You're going to hit that submucosal space very easily because you've already got a submucosal cushion, a target of saline in place. Here's a tattoo placed with the BLEB technique on an EMR site. The site is just proximal to the haustral fold on the right, there's a clip on it, and now we're placing the saline BLEB. So we have the catheter flushed with saline and we are putting in a half an ml to an ml of saline in this site and then take the needle out, flush it with the tattoo, two cc's however much the injection catheter holds, and then put an ml or so of tattoo into that BLEB of submucosal saline and this means we can't miss, we've got to get it in that submucosal space. Finally, in the report, we say where it is in relationship to the site. In this case, if the site is down, the tattoo would be to the left. So that's the BLEB method of tattooing. It's an excellent way to avoid spillage into the peritoneal cavity. If you were injecting for the surgeon, you would first make three or four quadrants of submucosal saline cushions and then pull the needle back, fill the catheter with tattoo and inject each of those submucosal saline mounds with the tattoo. Fantastic way to avoid spillage, but some inefficiency associated with having to first create those submucosal saline cushions. So I will admit that I don't use it. I do train my fellows in it. I think it's important for people to be familiar with it. But I think if you're more skilled and you use excellent technique, you can do it direct or freehand, a so-called non-BLEB method. It's a PPD technique, but it has to be done correctly to avoid spillage. If it's done correctly, you can satisfy two goals. One, number one goal, get it into the submucosal space. Two, be more efficient. This is the lesion that we're tattooing for a transanal resection. You can see the ulcer there where I've performed endoscopically a resection of a malignant polyp. And after a review of the past, staging discussion with experts, we've decided to perform a transanal resection in order to avoid a more extensive resection and then use some adjuvant therapy with that. I'm tattooing this for the surgeon to make absolutely clear where the resection was performed. So this is the freehand technique for tattooing, and we're going to tattoo either side of it. And the key thing is that once we get through the mucosa, what we're going to do is pull back on the needle and then deflect the needle toward the center of the lumen with the goal of being able to see the bevel, the shape of the bevel, right there it is, through the mucosa. Then we know we're in the submucosa, we can shoot in just a little bit of tattoo and then push in the full amount of the tattoo. That's the freehand or direct non-blood method. Just to verify that we're all on the same page, when I say that we're seeing the shape of the needle through the mucosa, I'm referring to the impression that the needle makes as we deflect toward the center of the lumen. It's outlined by these two yellow lines. Once we see that shape, we're verifying that we're in the submucosa. This is why I think it's very similar to a PPD technique. When you place a PPD, you make a stick and then to verify that you're intradermal, you lift up a little bit so that you see the impression of the needle and the bevel of the needle through the superficial skin. In this case, when we do it, when we lift up and we see the impression, the shape of the needle through the mucosa, we're verifying that we're in the submucosa and we're ready to inject. Here's the direct non-blood method being used again. We have the needle in place, we're deflecting toward the lumen. Once we can see the bevel, we shoot in just a little bit and then we're ready to go put the rest of the tattoo in. Now in this case, we are tattooing the hepatic flexure. We're marking the place. We've cleared distal to this. You can see the blue there, indigo carmine. These are EMR sites, distal to this place that we're marking for the surgeon. Proximal to this, we haven't cleared and we also haven't biopsied the cancer. We have to go back and do that. We are placing the tattoo. There you can see a serrated lesion. There were a couple of others in the ascending colon. This patient was actually diagnosed with serrated polyposis in this colonoscopy and there's the cancer. We're going to biopsy the cancer after we place the tattoo and clear the colon. Here's the direct method, the non-bled method being used to tattoo where we've just resected a pedunculated polyp. So we get through the mucosa and then pull back on the needle, deflect toward the lumen. There we can see the shape of the bevel of the needle. Now we're ready to inject. Clearly this is easier when we're more tangential to the wall than if we're directly on FOS. We're marking this in case this polyp is malignant and we don't need to worry about fibrosis because we've already resected the lesion. One more example of this non-bled direct freehand method. We're going to approach as tangentially as possible, get through the mucosa and then pull back on the catheter and the needle. Deflect toward the lumen until we see the shape of the needle through the mucosa. That verifies that we're in the submucosal space and then we can initiate the injection. Those are the keys to success with this more efficient freehand method of tattoo creation. Next week, more on tattooing on the ASGE SuTab tip of the week.

tattooing

endoscopic procedures

lesion identification

submucosa placement

complications