Endoscopic Tattooing to Mark Distal Margin for Low Anterior Rectal and Select Sigmoid Resections

Abstract

Obtaining a reliable distal margin during anterior colorectal resection can be difficult. In this study, endoscopic transmural tattoos were placed to mark the distal transection point in patients with distal colorectal neoplasms who undergo bowel resection. In the operating room, before surgery, sigmoidoscopy is performed with a 2-channel scope using CO₂ insufflation. Through channel 1, a biopsy forceps, marked 5 cm from its end, is inserted to the tumor's distal edge; in channel 2, a sclerotherapy catheter is placed. The scope is then withdrawn and forceps inserted at the same rate until the mark is seen, next, via the needle catheter, 4 tattoos are placed at that level circumferentially. After rectal mobilization, visible external tattoos guide stapler placement. If no tattoo is seen, sigmoidoscopy is done and the tattoos used to guide stapler placement. In all 27 patients, the tattoos guided stapler placement; tattoos were seen via the abdomen in 26 and the stapler placed as per tattoos in 25. In 2 patients, repeat endoscopy was done and tattoos used to guide or confirm stapler placement. The margin was ≤1 cm from target in 74% while in 22% the margin was 2 to 3.5 cm off target (mean deviation from target margin = 0.33 cm). In conclusion, this method facilitates stapler placement and provides more reliable margins.

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

“…2 Currently, most data strongly support the use of permanent endoscopic tattoos as the most effective means to ensure accurate intraoperative detection of colorectal lesions. [3][4][5]…”

“…21,22 There is currently no evidence-based recommendation on the ideal distance to tattoo; however, anywhere from 2 to 5 cm has been suggested so that the tattoo location can aid surgeons to obtain adequate oncologic resection margins. 5,19 Regardless of the endoscopist’s choice of where to tattoo, we recommend accurate documentation of where tattoo was placed relative to the lesion.…”

A wireless tattooing capsule endoscope using external electromagnetic actuation and chemical reaction pressure

“…Fig 1 shows the recommended position for marking the target in the digestive organs. The tattooing site should be around 2–3 cm distal from the anal or oral margin of the lesion [30,31]. To make it last long, diluted India ink should be injected beneath the mucosal layer (between the mucosal and submucosal layers) to create a visible bleb [25,27,30].…”

Intraoperative colonoscopy in patients with colorectal cancer: Review of recent developments

“…Moreover, endoscopic tattooing is best avoided for anastomosis of cases of lower rectal cancer. The distal margin for rectal cancer, especially in the lower rectum, should be determined more precisely than the distal margin for colon cancer, and preoperative tattooing frequently spreads widely along the rectal wall, resulting in an insufficient resection margin . Therefore, direct visualization of the rectal lumen is frequently necessary to determine an adequate margin (Fig.…”