A man of 72years with rectal cancer at 9cms from the anal verge planned for Lap low ant resection.He was sent to the Endoscopy suite for tattooing.Procedure went on well.On exploratory laparoscopy the dye was found splashed all over the pelvis.Exact lower limit of the tumour was not identifiable as the dye spread a large area masking the limits.Of late we are detecting early leisions in this part of the world unlike in the past .
Hi, I would rather go for intraoperative colonoscopy instead tatooing because the ink spread. With the colonoscopy, the certainity of the lesion limits is higher than tatooing.
As stated above, I prefer to check with colonoscope rather than tattoo in this situation
Preoperative Tatooing rectal cancer has no value, a rigid rectoscopy needed in all cases to visualize the lesion and to be sure about margines.
We agree with Dr. Matter in the perception of benefit from tattoos in rectal cancer and the modus operandi for securing distal margin.
In my experience, tattoo is not used below the peritoneal reflection. The reason being that if the needle penetrates too deeply, the spillage of ink into the mesorectal fascial planes makes the TME dissection extremely difficult.
When tattooing in the colon, my practice is to inject at three equidistant points on the circumference of the mucosa in order that at least one of these areas is able to be seen intraoperatively.
Tatooing may have 2 different tasks.
Firstly, spot the location of a small lesion you have destroyed to facilitate a necessary follow up.
Secondly, help the surgeon to determine from peritoneal side the location of a residual lesion which could not be located surgically.
In the first case, it's of paramount importance to evacuate meticulously any air bubble because, otherwise, injection will perdure after relaxing the plunger and excessive dye will be injected. Use an insulin syringe for more precision. 0.1 ml in mucosa is enough, 3 to 4 spots.
In the second case, dye must cross the wall. Therefore press firmly catheter against wall and inject between 0.5 and 1 ml, 1 spot is enough.
I agree with most of what is said, except in infra peritoneal lesions, it all depends on the size and stage of the lesion and the treatment plan. UK classification would not classify a lesion at 9cms from the anal verge as a low lesion. If it is small such that the surgical colonoscopist believes, at first glance, that no new-adjuvant therapy will be necessary, then tattooing is important. I do agree, however, that any such lesion's height must be confirmed by rushing a rigid scope before injecting the dye. Flexible scopes are so unreliable, which is why we always say if you don't put your finger in it....This holds true even in the 21st century. If a lesion is low enough to be easily palpated per rectally, then it is more likely than not that new adjuvant treatment will be indicated. ( Sorry - I have short fingers!) in such a case, as Bernard indicates, as there is at least a 22% chance of pCR after treatment, where the treatment option would be TEMS rather than an anterior resection, marking the lesion is equally important. The teaching I was given from one of the four colonoscopy schools in the UK was this: when in doubt, Mark; always mark below the lesion; in the report, state how distal to the lesion the mark is (usually, between 1-2 CMs, for technical ease); ensure the mark is placed as soon as possible before the intended surgery; ideally not more than 2 weeks before any treatment. This latter step decreases the incidence of external lymphatic or direct permeation. Ensure the needle is inserted slowly; first raising a small submucosal bleb; then, if need be, go just a bit deeper. As everyone has said, as long as the mark is clear intramucosally, it can be seen per operatively; where, at 9 CMs, a rigid scope is better used in place of a flexible one, to reconfirmed the mark. Some spread from submucosal to wall will occur even within 2-4 weeks, without penetrating the muscular is layer. My personal practice is similar to Bernard's: for rectal lesions I was taught to apply 1 distal spot; in colonic lesions, (especially sigmoid and transverse colon lesions with their fatty external me sentries and epiploacae) three small spots suffice, while feeling for the puncture into the muscle layer). Being a colonoscopy trainer, please do let me know if anyone has logical different opinions, as I would like to ensure I train according to current,best available peer experience. Thanks.
Dear Kamal
I agree completely with you.
My remarks were dealing with relatively high lesions.
Transparietal dying is devoid of any utility if below peritoneal flexure.
If task is spotting a mucosal lesion, I prefer dying around.
Location with flexible scope is notoriously unreliable, at any level.
Never forget rigid proctoscope and take into account genu-pectorel position which increases length between lesion and anal verge.
Tattoo is not useful for rectal lesions for all the abovementioned reasons. only rectosigmoid onwards we would tattoo if the lesion is small
Rectal cancer - no tooting ; as it destroys surgical plane and makes TME difficult and challenging. Adds noting. If got concerns -do peroperative flexi
