Underwater endoscopic mucosal resection of a laterally spreading tumor overlying a previous endoscopic carbon tattoo
19 June 2018 (eFirst)
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.
Video 1 Underwater piecemeal endoscopic mucosal resection of a laterally spreading tumor overlying a previous endoscopic carbon tattoo with associated severe fibrosis.
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]).
Endoscopic tattooing is a widely used technique to facilitate the identification of colorectal lesions for subsequent endoscopic or surgical treatments  . However, tattooing has been associated with clinically significant complications, including peritonitis  . 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   . 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  . Underwater EMR has been shown to be a useful technique for lesions that are difficult to resect, including those associated with fibrosis  . In the present report, we present the first case of a successful underwater EMR of a lesion associated with fibrosis secondary to tattoo.
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