This week, continuation of tattooing principles on the ASGE SUTAC tip of the week. This week, other issues about tattooing or marking including the medical legal risk associated with it and how to avoid that. But first of all, why tattoo? There are three general indications. The first is you find a lesion that you want to refer for resection and you mark it to make it easier for the consultant endoscopist to find it. This indication is controversial. Some experts think it's unnecessary and that's partly because of the risk associated with it. Tattoo under lesions has been associated with fibrosis that creates a problem for ESD. I think it's less of a problem for EMR, but there are reports of perforation during EMR that have been linked to tattooing. So if you do it, do it correctly. Don't get it under the lesion. Also record the position of the tattoo in relation to the lesion. So three centimeters distal on the same wall or opposite wall, some language that describes it. I actually like it when referring physicians tattoo lesions. First because these patients with large non-peduncular lesions often have a lot of synchronous disease and I think it's helpful to know which lesion the referring physician considered was the one that initiated the referral. And then secondly, we run about a three to 4% rate of not being able to identify any lesion in the colon in patients referred with large lesions. And often what's happened is that there's an area of mucosal prolapse or inflammatory change that has been seen by the referring physician. There was some uncertainty as to whether it was a neoplasm. It undergoes biopsy and the pathologist at the referring center reads it as dysplastic, but it's actually not. And having the tattoo prevents us from spending too long examining the entire colon looking for a dysplastic lesion. Often to resolve these cases, we have to get the slides from the outside center, have them reviewed at our center by GI pathologists. A second reason to tattoo is you've done the resection, you want to make it easier to find the scar at follow-up when you're looking for recurrence. I like to do this if the lesion was not in the cecum or the rectum. Let's just put one spot of tattoo right next to the EMR site. You're not worried about fibrosis caused by the tattoo because fibrosis and scarring from the resection are going to overwhelm any increased fibrosis you get from the tattoo. Do note in your report where you put the tattoo in relation to the site, for example, immediately distal or with the site down just to the right or to the left. Now, a recent report from Australia, large study found basically all of the scars regardless of whether a tattoo was there. So the need for this is controversial. We had a recent tip that emphasized the importance of getting the colon well distended with gas to make it easier to find scars. You can rely on photos taken at the time of the EMR to make it easier, but I think having a tattoo makes it easier and faster to find scars that follow up. Finally, and where tattooing is most important, is marking lesions for surgical resection, which almost entirely should be cancers. Unless the lesion is in the cecum or the proximal right colon where you can still endoscopically see the ileocecal valve, we should mark the lesion. There could be some rectal cancer cases where it's not necessary, but in general, we want to mark cancers. My own preference is to just mark them distal to the tumor and mark them circumferentially. Sometimes endoscopists mark them both proximally and distally. I think that's potentially confusing if only one set of the tattoos is noted. So my preference is mark them distal to the tumor. Do it in a consistent way so that your surgeons know what to expect from you, but always say in your colonoscopy report where you put the tattoo in relation to the cancer. To emphasize this point that if the lesions in the cecum are on the ICV or in the proximal ascending colon and you can photograph it and its relationship to the ICV, those photographs serve as a perfect marker for endoscopic referral, your own subsequent referral, or even marking cancers for surgery is unnecessary in that location because the landmarks of the cecum and the ileocecal valve are so anatomically reliable. Where to place tattoos for referral to another endoscopist, three centimeters distal on the same wall or on the opposite wall. Keep it out from under the lesion and very helpful to record where the tattoo is in relation to the lesion. Here's a previously tattooed 1S lesion in the proximal ascending colon with tattoo completely underneath it. The purported risk of this is muscle injury. You can see the tattoo in the base and the type three muscle injury. So this has to be clipped tightly closed and there's the muscle on the base of the specimen. Whether this was from the on block resection or related to the tattoo, hard to say. I think it's rare. It emphasizes the desire to keep the tattoo out from under the lesion. For marking after your own resection, place the tattoo immediately adjacent to the site utilizing the preexisting submucosal cushion and document the location. This is a tattoo placed just after resection and clip closure of a right colon lesion. Again, for the post resection injection, a single spot of tattoo placed immediately adjacent to the EMR site. You can often utilize the injection mound from the EMR fluid to facilitate the tattoo injection in the report. Note the relation of the tattoo to the EMR site. There's distal only so the lesion is good. Circumferential tattoos document well. Do this before biopsying the cancer. There's circumferential marking for cancer. In this case, three quadrants or if needed for luminal diameter, four quadrant marking. What about the medical legal risk associated with tattooing? This is where you refer a patient to surgery and the surgeon removes the wrong section of the colon. So called wrong site surgery. This is where the medical legal risk is. The danger zone for this is from the distal ascending colon through the proximal half of the sigmoid. This is where the errors occur. When you have cancers and you do tattooing in this area, it's important in the report to not be specific with the language you use to describe the location. Don't say that the cancer and the tattoo are in the descending or in the distal transverse because the truth is you're not sure exactly where it is. And if the surgeon can't find the tattoo in the wall of the colon, you don't want them to rely on language you used in your colonoscopy report that ultimately proves to be wrong. They also can't rely on tattoo that they find in the peritoneal cavity or in another organ. They must understand that they have to find the tattoo in the wall of the colon. If they can't find it, they should either do a colonoscopy themselves or you or your group should be prepared to go to the operating room. Do a colonoscopy and find the tattoo from the luminal site. When you're doing your colonoscopy where you found the lesion, if you see multiple tattoos, it's important to say so in the report because multiple tattoos could potentially confuse the surgeon. You want to be sure that they're going to find the tattoo that you want, the lesion that you want removed. You may, in the case of multiple tattoos, need to put extra markings on. You might want to put clips on the site that can be seen on the subsequent CT scan that you do for staging of the cancer to be absolutely certain with your language, with your testing, with your marking that you make sure the surgeon understands which tattoo is the target for the resection. Place the tattoo correctly. Don't spill it into the peritoneal cavity. Put enough tattoo in. Remember that obese men can have a lot of fat on the cirrhosal surface. You have to have an adequate amount of tattoo. Thanks and see you next week on the ASGE SuTab tip of the week.

tattooing in endoscopy

indications for tattooing

marking lesions

surgical resection

medical legal risks