Is India ink a more effective method for the follow-up of Barrett's mucosa?
R.T. Shaffer (Houston)
Measurement of esophageal lesions is typically performed by using the centimeter markings on the endoscope, with measurements taken from the incisors. The use of different endoscopes and mouthpieces, as well as variable interpretation by different endoscopists, makes precise location and sizing of lesions in relation to their distance from the incisors, imprecise at best. In addition, the precise location of esophageal lesions using the endoscope as a measuring tool can vary due to elongation of the esophagus during the forward advancement of the endoscope or as the esophagus foreshortens and telescopes over the endoscope [1, 2].
The inaccuracy of using the endoscope markings was recently confirmed in a study of sequential endoscopic measurements of the lower esophageal sphincter (LES) and the most proximal level of Barrett's esophagus (BE) mucosa. Ten of 111 patients had a change in the endoscopic LES location greater than 4 cms at 6 week follow-up endoscopy . In addition, 12 of 88 patients with BE had a greater than 4 cm change in the endoscopic measurement of the most proximal level of Barrett's mucosa. The authors concluded that endoscopically measured differences in LES position and the most proximal level of Barrett's mucosa are significant enough to cause confusion in the diagnosis of BE.
Further evidence of the inadequacy of endoscope measurements was illustrated in an abstract regarding the Barrett's mucosal margin after Nissen fundoplication .
Sampliner et al. found an average of 2.7 cm of migration of the upper border of the squamocolumnar junction up to seven weeks after the Nissen fundoplication was performed. Thus, measurements obtained using the endoscope or barium studies cannot be used as a reliable guide for regression or progression of lesions; especially if the studies include patients with reducible hiatal hernias and in those studies in which regression or change in a lesion site is being reported.
India ink is produced by the grinding of lamp black with glues, gums and other stabilizers. Lamp black is the amorphous carbon product formed when petroleum products such as oil, gas, or fuels are burned incompletely in an oxygen deprived environment. The product, India ink, has been used by multiple cultures for generations for use in writing, as well as with the addition of other pigments, for cutaneous tattooing.
India ink has been successfully used to tattoo colonic and gastric mucosa [4-7]. Colonic tattooing has been used for preoperative tattooing of polypectomy sites, tattooing of postpolypectomy sites for future follow-up, endoscopic marking of specific colonic lesions, and in longitudinal endoscopic studies of specific colonic lesions (i.e. hyperplastic polyps or adenomas) [8-12]. Tattooing has been used in the stomach to mark the site of malignant polyps, to demarcate antrum from body prior to highly selective vagotomy, and to mark areas of acute gastrointestinal hemorrhage preoperatively [5,10,13]. Tattooing has also been used to mark areas of a surgical resection on mucosal and cutaneous surfaces prior to ENT surgery .
A more recent report attested to India ink's safety in colonic tattooing . The authors clearly outline sterilization, preparation and injection guidelines for India ink, with no reported complications in their 20 patients. In their review, Salomon aet al. found that a serial dilution of up to 1:100 with normal saline provided complete opacification to light at the three wave lengths tested. Further, the 1:100 dilution allowed the ink to pass freely through a micropore filter without clogging as seen in the undiluted ink. The India ink diluted 1:10 and 1:100 maintained a pH of 7.39, while the undiluted ink was slightly alkaline at a pH of 7.61. Of the 20 patients that were tattooed, 12 had operative or pathologic follow-up, in which 10 patients had easily discernible India ink staining of the serosal surface. In the six cases that had repeated colonoscopic exams, all six were noted to have obvious ink staining on endoscopic examination up to 47 months after the initial staining.
Figure 1. Endophoto of India ink tattoo in same patient at 3 months (A) and 36 months (B). Tattoo placed at highest level of Barrett's epithelium. (See page IX for colour figure.)
Our institution recently reported the results of a three-year prospective study of the effect of omeprazole 20 mg b.i.d. upon Barrett's mucosa . All 18 patients had their highest level of Barrett's mucosa marked with an India ink tattoo. There was no regression in Barrett's length observed on endophotos (Figure 1). However, when using the endoscope markings, the mean Barrett's length, as well as other gastroesophageal landmarks varied 1-3 cm during repeat endoscopic evaluations at three, nine, fifteen, twenty-four and thirty-six months. Of the 18 patients completing the study, only one patient had a faded tattoo that required repeat tattooing at the three-month interval. During the subsequent endoscopies, all tattoos persisted up to the thirty six-month interval without ulceration, inflammation or break in mucosal integrity noted at any of the tattoo sites .
Although lacking Federal Drug Agency approval in the United States, gastroenterologists have used India ink for some time to mark colonic and gastric lesions with rare overt side-effects. In a technology status evaluation by the American Society for Gastrointestinal Endoscopy  regarding endoscopic tissue staining and tattooing, India ink was noted to be useful for labeling lesions for preoperative localization, as well as for longitudinal study. We have found that India ink can be properly sterilized and filtered, and injected submucosally in minute amounts (0.1 to 0.2 cc) in the esophagus to provide a safe and reliable long-term marker. The routine use of the endoscope markings for repeated measurement of esophageal lesions is grossly imprecise and should be replaced with some type of permanent marker to provide more meaningful longitudinal study of esophageal lesions. Further controlled studies of other ink markers would be welcome as an improvement in the way esophageal lesions are studied and measured.
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