How to perform EUS-guided tattooing?

Abstract

Recently, we introduced a series of papers describing on how to perform certain techniques and controversies in EUS. In the first paper, "What should be known before performing EUS examinations, Part I," the authors discussed clinical information and whether other imaging modalities should be needed before embarking in EUS examination. In Part II, some technical controversies on how EUS is performed are discussed from different points of view by providing the relevant available evidence. Herewith, we describe on how to perform EUS-guided fine needle tattooing (FNT) in daily practice. The aim of this paper is to discuss pros and cons for several issues including historical remarks, injecting material, technical approach, and how to perform EUS-FNT including argues in favor and against.

Keywords: EUS; India ink; neuroendocrine neoplasms; pancreatic; pancreatic solid tumors; tattooing.

Figure 1

Representative diagram on how to perform EUS-guided tattooing of a pancreatic lesion: (a) Marking of an area of normal pancreatic parenchyma located to the right of a pancreatic body/tail lesion as a landmark for limiting the pancreatic resection with tumor-free margins; (b) Tattooing of a pancreatic head lesion, when the marker is usually injected inside the lesion

Figure 2

EUS-guided tattooing of a small pancreatic insulinoma before surgical resection: (a) Priming of the 22-gauge EUS-FNA needle with the marking solution (Spot^®; GI supply, Camp Hill, PA, USA); (b) EUS-guided puncture of the lesion; (c) hyperechoic spot appearing at the tip of the needle by injection of the sterile carbon-based ink initially inside the lesion, injection which is continued while withdrawing the needle; (d) resection specimen harboring the black discoloration determined by tattooing; its appearance at the surface of the lesion helped the surgeon find it intraoperatively and resect it laparoscopically