Preoperative Colonoscopic Tattooing Using a Direct Injection Method with Indocyanine Green for Localization of Colorectal Tumors: An Efficacy and Safety Comparison Study

Abstract

Purpose Endoscopic tattooing is used to mark colorectal lesions for subsequent surgery. As a tattooing agent, India ink has been widely used but is not currently available in Korea. Indocyanine green (ICG) can be applied as an alternative agent. However, studies on colonoscopic tattooing by the direct injection of indocyanine green are lacking. This study aimed to compare the efficacy and safety between an ICG direct injection method and an India ink saline test injection method. Methods A total of 227 patients who underwent preoperative endoscopic tattooing for colorectal neoplasm (149 patients in the ICG direct injection group and 78 patients in the India ink saline test injection group) were included in the study. The efficacy of the two methods was compared by visualization and safety was compared by evaluating the perioperative tattooing complications. Results The visualization of lesions in the ICG group was not different from that of the India ink group (p=0.42, 96.0% vs 98.7%, respectively). Only one patient in the ICG group had abdominal pain related to tattooing, but no complications developed in the India ink group. Conclusion Considering the good visualization and low complication rate, the direct injection of ICG can be used as an alternative tattooing method.

Preoperative tumor marking with indocyanine green prior of robotic colorectal resections

“…Watanabe et al used 0.5 ml of 0.25% ICG which was sufficiently visible when the procedure was performed up to 7 days prior (11). Alternatively, Kim et al injected 0.5-1 ml of 1.25% ICG a day prior of surgery and compared the measured outcomes to a group of non-tattooed patients, reporting a shorter operation time, hospital stay and postoperative oral ingestion period in favour of the tattooed group (18). The purpose of this study was to evaluate the use of ICG as a preoperative tumor marking dye and describe the technique that we have been using in order to maximise the potential benefits of this procedure.…”

“…Narihiro et al observed the safety and effectiveness of near-infrared fluorescent clips and reported a detection rate 94.1% without adverse effects related to clip marking ( 17 ). Intraoperative colonoscopy can be used to identify GI lesions, however this extends the overall duration of the operation and can generate intestinal distention, which might limit the surgeon's surgical field ( 14 , 18 ). Preoperative colonoscopy with simultaneous tumor marking using a dye may be necessary to precisely determine the level of the tumor and perform the appropriate excision.…”

“…Watanabe et al used 0.5 ml of 0.25% ICG which was sufficiently visible when the procedure was performed up to 7 days prior ( 11 ). Alternatively, Kim et al injected 0.5–1 ml of 1.25% ICG a day prior of surgery and compared the measured outcomes to a group of non-tattooed patients, reporting a shorter operation time, hospital stay and postoperative oral ingestion period in favour of the tattooed group ( 18 ).…”

“…As opposed to the currently standard method of tumor marking which is India Ink injection following submucosal elevation with saline test injection, we injected ICG directly to the submucosa without saline test injection. ICG may be managed more effectively than India Ink and injected straight into the submucosa without the need for a saline test injection due to the fact that it does not contain particles ( 18 ). The benefit of the direct injection technique is that there is no need of changing syringes.…”

Indocyanine Green Fluorescence Guided Surgery in Colorectal Surgery

“…The first report of intraoperative fluorescent tumor localization was published in 2016 by Handgraaf et al [ 47 ], although the main focus was sentinel lymph node identification using ICG. There are several reports in the literature [ 48 , 49 , 50 , 51 , 52 ] regarding the feasibility of ICG imaging in primary tumor visualization and real-time navigation. Atallah et al [ 53 ] reported a case wherein fluorescence-guided surgery along with a robotic-assisted stereotactic navigational system were successfully utilized for complex locally advanced rectal cancer surgery.…”