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Lesion Localization Errors Pose Significant Risks: Why Endoscopic Tattooing Should be Routine
Introduction
The care of colorectal cancer patients is a partnership between the gastroenterologist and the surgeon. In
order to provide the highest medical care possible, precise localization of colorectal lesions must be a top
priority for both physicians. Studies have shown that colonoscopy alone is insufficient for the surgeon to
quickly and accurately identify lesions.1,2,3 There are several risks associated with poor lesion localization,4
the most significant being wrong site surgery. Both the Society of American Gastrointestinal and
Endoscopic Surgeons (SAGES) and the American Society for Gastrointestinal Endoscopy (ASGE) have
recognized the high risk of resecting the wrong section of bowel without accurate preoperative lesion
identification.5,6 Endoscopic tattooing can help mitigate these risks with an easy, fast method for the
gastroenterologist to employ and a clear, precise marker for the surgeon to visualize.
Keywords colon cancer • colonoscopy • localization • endoscopic tattoo • patient safety
Tumor Location Can be Imprecise
Surgeons employ various methods for locating
colorectal lesions, the most prominent being the
referring gastroenterologists notes, either
through pre-surgery communication or the
colonoscopy procedure report, and/or
localization techniques like tattooing, clips or
CT scans/x-rays.7 However, using the referring
gastroenterologist’s notes alone can pose
significant risks to the patient.
The anatomy of the colon along with varying
endoscopic and surgical techniques can make it
difficult to find unmarked lesions during follow-
up surgery and surveillance. The American
Society for Gastrointestinal Endoscopy (ASGE)
Technology Committee says the “estimation of
the tumor site at colonoscopy can be imprecise,
with as many as 14% of tumor locations
incorrectly identified.”8 Another study shows
that “approximately 10%-20% of tumor
locations identified from colonoscopy (alone)
are inconsistent with the intraoperative tumor
site.”9 It becomes even harder to find lesions
during surgical intervention if previous
colorectal procedures have been performed.
The rise in laparoscopic colorectal surgery has
also made it difficult to rely solely on
colonoscopy for lesion location. While
numerous studies have been published about the
benefits of laparoscopic versus open surgery,
colon lesions pose a unique challenge to
surgeons. Tactile sensation is no longer available
and palpation of the colon is blunted, 10,11,12
therefore lesions may be difficult to find
regardless of how precise the referring
gastroenterologist’s notes are. The Society of
American Gastrointestinal and Endoscopic
Surgeons (SAGES) Guidelines for Laparoscopic
Resection of Curable Colon and Rectal Cancer
states, “when approaching the colon resection
laparoscopically, every effort should be made to
localize the tumor preoperatively.”13
Gastroenterologists and endoscopists have
several options for lesion localization, with the
prevailing technique being endoscopic tattooing.
Different studies have discussed barium enema,
CT colonography, and marking the lesion with
metal clips, but due to accuracy, availability,
cost, and time, tattooing is seen as the most
practical option.14,15,16 The tattoo is a permanent
communication tool about the patient for
members of the surgical and surveillance teams.
The Risks: Longer Procedures and
Wrong Site Surgery
Incorrect colorectal lesion localization puts the
patient, surgeon, and gastroenterologist at risk.
In a recent industry research poll, 100% of
colorectal and general surgeons surveyed saw a Copyright © 2014 by GI Supply
Email: [email protected]
www.gi-supply.com Page 2 of 3
risk with not having the colon or rectal lesion
site tattooed prior to surgery.17 Risks noted
include:
Removing the wrong section of bowel
Removing more/less of the colon than needed
Longer surgery times
Patients having to undergo another surgery
Having to move to an open procedure
Having to perform intra-operative
colonoscopy
Major medical organizations such as ASGE and
SAGES have published information that states
inaccurate lesion identification can lead to the
wrong section of colon being removed.18,19
Additionally, numerous papers published in
journals such as Surgical Endoscopy,20
Colorectal Disease,21 The World Journal of
Gastrointestinal Endoscopy,22 and JAMA
Surgery (formerly Archives of Surgery)23 have
echoed the same statements: “without precise
preoperative localization, it is possible to
remove an incorrect segment of intestine.”24
Wrong site surgery is also a crucial factor in the
Joint Commission’s National Patient Safety
Goals. The “mark the procedure site” section of
the JACHO’s Universal Protocol for Preventing
Wrong Site, Wrong Procedure says “marking the
procedure site is one way to protect patients;
patient safety is enhanced when a consistent
marking process is used through the hospital.”25
Inconsistent or absent marking of colorectal
lesions can also cause risks other than wrong site
surgery. Vaziri et al26 noted that inaccurate
localization may result in a change in the
operation performed, while Piscatelli et al27
stated that it can put the patient at risk for
inappropriate trocar placement and prolonged
surgery and anesthesia. Still other studies have
commented on the risks for additional blood
loss28 and the need for intraoperative
colonoscopy.
Colonoscopy in the operating room poses its
own challenges by being “time-consuming,
technically difficult, and cumbersome because
of positioning of the patient on the table. In
addition, colonic insufflation, even with
proximal bowel occlusion, can sacrifice
intraperitoneal domain, limit operative exposure,
and severely handicap the laparoscopic
surgeon.”29,30 This procedure also prolongs
surgical and anesthesia time for the patient.
Discussion
Colonoscopy has become the most commonly
used screening test for colon cancer in the
United States.31 However, colonoscopy alone is
not enough to prevent wrong site colorectal
surgery and longer surgical times for colon
resections. Recent industry research shows that
92% of colorectal and general surgeons
surveyed think endoscopic tattooing should be a
Practice Guideline or Standard of Care.32 In
order to increase patient safety, many studies
suggest endoscopic tattooing should be used
routinely by gastroenterologists and
endoscopists to assist the surgeon in locating
colorectal lesions in an accurate, timely manner.
In addition to the numerous medical risks the
patient faces for inaccurate lesion localization,
both the gastroenterologist and surgeon may
face legal ramifications for wrong site surgery
and complications that can result from longer
surgical times.
To read more about the legal risks associated
with wrong site colon surgery, please visit
www.gi-supply.com/casereview.
1 Solon JG at al. Colonoscopy and computerized tomography scan are not sufficient to localize right-sided colonic lesions
accurately. Colorectal Dis. 2010 Oct;12(10 Online):e267-72. 2 Trakarnsanga A et al. Endoscopic tattooing of colorectal lesions: Is it a risk-free procedure? World J Gastrointest Endosc. Dec
16, 2011; 3(12): 256–260. 3 Piscatelli N et al. Localizing colorectal cancer by colonoscopy. Arch Surg. 2005 Oct;140(10):932-5. 4 Salloway & Associates, Inc. Cancer Lesion Tattooing Research Results. 2014 Sep. 5 SAGES. Guidelines for Laparoscopic Resection of Curable Colon and Rectal Cancer. 2012 Feb. 6 ASGE Technology Committee. Endoscopic tattooing. Gastrointest Endosc. 2010 Oct;72(4):681-5. 7 Salloway & Associates, Inc.
www.gi-supply.com Page 3 of 3
8 ASGE Technology Committee. 9 Trakarnsanga A et al. 10 Zmora O et al. Laparoscopic colectomy for colonic polyps. Surg Endosc. 2009 Mar;23(3):629-32. 11 Vaziri K et al. Accuracy of colonoscopic localization. Surg Endosc. 2010 Oct;24(10):2502-5 12 Solon JG at al. 13 SAGES. 14 Vaziri K et al. 15 Feingold DL et al. Safety and reliability of tattooing colorectal neoplasms prior to laparoscopic resection. J Gastrointest Surg.
2004 Jul-Aug;8(5):543-6. 16 Solon JG at al. 17 Salloway & Associates, Inc. 18 ASGE Technology Committee. 19 SAGES. 20 Vaziri K et al. 21 Solon JG at al. 22 Trakarnsanga A et al. 23 Piscatelli N et al. 24 Trakarnsanga A et al. 25 The Joint Commission. National Patient Safety Goals Effective January 1, 2014. 26 Vaziri K et al. 27 Piscatelli N et al. 28 Arteaga-González I et al. The use of preoperative endoscopic tattooing in laparoscopic colorectal cancer surgery for
endoscopically advanced tumors: a prospective comparative clinical study. World J Surg. 2006 Apr;30(4):605-11. 29 Feingold DL et al. 30 Zmora O et al. 31 Lieberman DA, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US
Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2012 Sep;143(3):844-57. 32 Salloway & Associates, Inc.