Variability in Endoscopic Tattoo Practices Among Colorectal Surgeons and Gastroenterologists: A Nationwide Survey

Background: Endoscopic tattooing is a crucial surgical landmark for colorectal neoplasms prior to operative resection. Despite widespread use, no established endoscopic tattooing guidelines exist for optimal location or technique. We aimed to study the practices among gastroenterologists (GI) and colorectal surgeons (CRS). Methods: A national, electronic, anonymous survey was sent to program directors of adult GI and CRS residencies in the US. 108 were completed and analyzed. Descriptive statistics was used to summarize demographic and response variables. The difference in response rates between groups was assessed using the Fisher exact test and summarized as odds ratio with 95% confidence intervals (CI) and 2-tailed statistical significance. Results: Of 108 physicians who responded to the survey, 86% reported tattooing suspected colorectal cancer lesions: GI (68 of 78, 87.2%) and CRS (25 of 30, 83.3%). GI tattoo proximal and distal to the lesion (57.7%) compared to CRS who tattoo 2- 3cm distal to the lesion (76.7%), which was statistically significant (p <0.001, OR =9.52, CI=3.6-25.5). This remained unchanged when corrected for practice setting, age, gender and training. A minority tattoo cecal lesions—18.0% of GI and 23.3% of CRS. Rectal lesions were tattooed by GI 39.7% and 73.3% for CRS. For tattoo injection technique, most reported injecting while withdrawing the needle (80.8% of GI and 73.3% of CRS, p=0.227), rather than while advancing the needle. Most reported placing 2-3 marks at tattoo site (72.2%). Conclusion: There is wide variability of endoscopic tattooing practices between GI and CRS. Improvements in training and societal guidelines are needed to standardize practices