Lucía Medina-Prado1, Cesare Hassan2, Evelien Dekker3, Raf Bisschops4, Sergio Alfieri5, Pradeep Bhandari6, Michael J Bourke7, Raquel Bravo8, Marco Bustamante-Balen9, Jason Dominitz10, Monika Ferlitsch11, Paul Fockens3, Monique van Leerdam12, David Lieberman13, Maite Herráiz14, Charles Kahi15, Michal Kaminski16, Takahisa Matsuda17, Alan Moss18, Maria Pellisé19, Heiko Pohl20, Colin Rees21, Douglas K Rex22, Manuel Romero-Simó23, Matthew D Rutter24, Prateek Sharma25, Aasma Shaukat26, Siwan Thomas-Gibson27, Roland Valori28, Rodrigo Jover29. 1. Servicio de Medicina Digestiva, Hospital General Universitario de Alicante, Instituto de Investigación Biomédica Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain. 2. Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome, Italy. 3. Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands. 4. Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Belgium. 5. Surgery Department, Fondazione Policlinico A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico, Università Cattolica del Sacro Cuore, Rome, Italy. 6. Department of Gastroenterology, Queen Alexandra Hospital. Portsmouth Hospital NHS Trust, Portsmouth, United Kingdom. 7. Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia. 8. Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, University of Barcelona, Centro Esther Koplowitz, Cellex Biomedical Research Center, Barcelona, Catalonia, Spain. 9. Gastrointestinal Endoscopy Unit, Gastrointestinal Endoscopy Research Group, Health Research Institute (Instituto de Investigación Sanitaria La Fe. NHS: National Health Service), Hospital Universitari i Politècnic La Fe, Valencia, Spain. 10. Gastroenterology Department, VA Puget Sound Health Care System, University of Washington, Seattle, Washington. 11. Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Wien, Austria. 12. Department of Gastroenterology and Hepatology, Netherlands Cancer Institute, Amsterdam, The Netherlands. 13. Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon. 14. Departamento de Digestivo, Clínica Universitaria de Navarra, Pamplona, Spain. 15. Roudebush VA Medical Center, Indiana University School of Medicine, Indianapolis, Indiana. 16. Department of Gastroenterological Oncology, Maria Sklodowska-Curie Memorial Cancer Center, Institute of Oncology, Warsaw, Poland. 17. Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan. 18. Department of Endoscopic Services, Western Health, Melbourne Medical School Western Precinct, The University of Melbourne, St. Albans, Victoria, Australia. 19. Gastroenterology Department, Institute of Digestive and Metabolic Diseases, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, University of Barcelona, Centro Esther Koplowitz, Cellex Biomedical Research Center, Barcelona, Catalonia Spain. 20. Department of Gastroenterology and Hepatology, VA Medical Center, White River Junction, Vermont; Dartmouth Geisel School of Medicine, Hanover, New Hampshire. 21. Department of Gastroenterology, South Tyneside NHS Foundation Trust, South Shields, United Kingdom. 22. Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana. 23. Unidad de Coloproctología, Servicio de Cirugía General, Hospital General Universitario de Alicante, Instituto de Investigación Biomédica Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain. 24. University Hospital of North Tees, Stockton on Tees, United Kingdom; Northern Institute for Cancer Research, Newcastle University, Newcastle-upon-Tyne, United Kingdom. 25. Department of Gastroenterology and Hepatology, VA Medical Center, University of Kansas School of Medicine, Kansas City, Kansas. 26. Section of Gastroenterology, Department of Medicine, Minneapolis VA Medical Center, University of Minnesota, Minneapolis, Minnesota. 27. Wolfson Unit for Endoscopy, St. Mark's Hospital, Harrow, and Imperial College, London, United Kingdom. 28. Gloucestershire Hospitals National Health Service Foundation Trust, Gloucestershire, United Kingdom. 29. Servicio de Medicina Digestiva, Hospital General Universitario de Alicante, Instituto de Investigación Biomédica Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain. Electronic address: rodrigojover@gmail.com.
Abstract
BACKGROUND & AIMS: There is a lack of clinical studies to establish indications and methodology for tattooing, therefore technique and practice of tattooing is very variable. We aimed to establish a consensus on the indications and appropriate techniques for colonic tattoo through a modified Delphi process. METHODS: The baseline questionnaire was classified into 3 areas: where tattooing should not be used (1 domain, 6 questions), where tattooing should be used (4 domains, 20 questions), and how to perform tattooing (1 domain 20 questions). A total of 29 experts participated in the 3 rounds of the Delphi process. RESULTS: A total of 15 statements were approved. The statements that achieved the highest agreement were as follows: tattooing should always be used after endoscopic resection of a lesion with suspicion of submucosal invasion (agreement score, 4.59; degree of consensus, 97%). For a colorectal lesion that is left in situ but considered suitable for endoscopic resection, tattooing may be used if the lesion is considered difficult to detect at a subsequent endoscopy (agreement score, 4.62; degree of consensus, 100%). A tattoo should never be injected directly into or underneath a lesion that might be removed endoscopically at a later point in time (agreement score, 4.79; degree of consensus, 97%). Details of the tattoo injection should be stated clearly in the endoscopy report (agreement score, 4.76; degree of consensus, 100%). CONCLUSIONS: This expert consensus has developed different statements about where tattooing should not be used, when it should be used, and how that should be done.
BACKGROUND & AIMS: There is a lack of clinical studies to establish indications and methodology for tattooing, therefore technique and practice of tattooing is very variable. We aimed to establish a consensus on the indications and appropriate techniques for colonic tattoo through a modified Delphi process. METHODS: The baseline questionnaire was classified into 3 areas: where tattooing should not be used (1 domain, 6 questions), where tattooing should be used (4 domains, 20 questions), and how to perform tattooing (1 domain 20 questions). A total of 29 experts participated in the 3 rounds of the Delphi process. RESULTS: A total of 15 statements were approved. The statements that achieved the highest agreement were as follows: tattooing should always be used after endoscopic resection of a lesion with suspicion of submucosal invasion (agreement score, 4.59; degree of consensus, 97%). For a colorectal lesion that is left in situ but considered suitable for endoscopic resection, tattooing may be used if the lesion is considered difficult to detect at a subsequent endoscopy (agreement score, 4.62; degree of consensus, 100%). A tattoo should never be injected directly into or underneath a lesion that might be removed endoscopically at a later point in time (agreement score, 4.79; degree of consensus, 97%). Details of the tattoo injection should be stated clearly in the endoscopy report (agreement score, 4.76; degree of consensus, 100%). CONCLUSIONS: This expert consensus has developed different statements about where tattooing should not be used, when it should be used, and how that should be done.