Underwater endoscopic mucosal resection of a laterally spreading tumor overlying a previous endoscopic carbon tattoo

A 53-year-old man with no relevant past medical history was referred to our department for resection of a laterally spreading tumor (LST) on the descending colon, which had been tattooed previously.

The procedure was performed with a transparent cap attached to the tip of the colonoscope (Q185; Olympus Medical Systems, Tokyo, Japan), with the patient under deep propofol sedation. A 40-mm nongranular, homogeneous LST was identified, overlying a previously placed carbon tattoo ([Fig. 1]), with resulting severe fibrosis that precluded elevation for conventional endoscopic mucosal resection (EMR). Therefore, underwater piecemeal EMR was performed, after marking the lesion limits with snare tip coagulation ([Video 1]). Complete resection was achieved without complications. The procedure exposed involvement of almost all of the submucosa by the ink ([Fig. 2]). The patient was discharged on the same day.

Fig. 1 On the descending colon, a 40-mm nongranular, homogeneous, laterally spreading tumor (LST) was identified, overlying a previously placed carbon tattoo. a White-light imaging. b Narrow-band imaging.

Video 1 Underwater piecemeal endoscopic mucosal resection of a laterally spreading tumor overlying a previous endoscopic carbon tattoo with associated severe fibrosis.

Fig. 2 Endoscopic image showing the involvement of almost all of the submucosa beneath the scar by the carbon ink.

Histopathological analysis revealed a tubular adenoma with low grade dysplasia, and with carbon pigment in the margins of most fragments. On surveillance colonoscopy 3 months later, the scar had no endoscopic or histological recurrence ([Fig. 3]).

Fig. 3 Surveillance colonoscopy 3 months later showed the scar with no signs of recurrence. a White-light imaging. b Narrow-band imaging.

Endoscopic tattooing is a widely used technique to facilitate the identification of colorectal lesions for subsequent endoscopic or surgical treatments [1] [2]. However, tattooing has been associated with clinically significant complications, including peritonitis [1] [2]. Additionally, tattooing under a lesion can result in technical difficulties because of associated submucosal fibrosis, which makes endoscopic resection procedures hazardous and has contributed to perforation [1] [2] [3]. In fact, carbon particles can spread across a significant distance within the submucosal plane; it is therefore recommended that tattoos are placed 2 – 3 cm anatomically distal to the lesion [1] [2]. Underwater EMR has been shown to be a useful technique for lesions that are difficult to resect, including those associated with fibrosis [4] [5]. In the present report, we present the first case of a successful underwater EMR of a lesion associated with fibrosis secondary to tattoo.

Endoscopy_UCTN_Code_CPL_1AJ_2AD

• References

• 1 Ferlitsch M, Moss A, Hassan C. et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2017; 49: 270-297
• 2 Moss A, Bourke MJ, Pathmanathan N. Safety of colonic tattoo with sterile carbon particle suspension: a proposed guideline with illustrative cases. Gastrointest Endosc 2011; 74: 214-218
• 3 Ono S, Fujishiro M, Goto O. et al. Endoscopic submucosal dissection for colonic laterally spreading tumors is difficult after target tattooing. Gastrointest Endosc (3 Pt 2) 2009; 69: 763-766
• 4 Ponte A, Pinho R, Proença L. et al. Underwater endoscopic mucosal resection of a large flat adenoma with pseudoinvasion in the rectum. GE Port J Gastroenterol 2017; 24: 255-257
• 5 Kim HG, Thosani N, Banerjee S. et al. Underwater endoscopic mucosal resection for recurrences after previous piecemeal resection of colorectal polyps (with video). Gastrointest Endosc 2014; 80: 1094-1102