Table 40.2.

Review of 11 studies with >16 subjects, using carbon black based inks for medical marking

Author (ref #) Year country	Ink brand or homemade in pharmacy	Medical use	# of study participants and areas injected	Adverse events/reactions	Other problems/comments?
Sun [24] 2009 China	Pelikan	Long-term localization of atrophic gastritis	53 patients	None	None
Fennerty [17] 1992 USA	Pelikan,	localization of colonic lesions	26 patients with 32 india ink tattoos in colonic mucosa	Biopsies showed carbon particles in the mucosa, but no inflammatory reactions.	The mean follow-up time was 14 months. All follow-up visits showed the mucosa still darkly tattooed
Shaffer [22] 1999 USA	Difco India Ink (now BD)	localization of Barrett’s mucosa in esophagus	19 patients	None	None
Shatz [23] 1991 USA	Higgins	Localization of colonic lesions	64 patients	None	One patient had ink injected through the wall of the sigmoid into the peritoneal cavity, but was asymptomatic. Leakage may occur and obscure the polypectomy site.
Choy [38] 2015 USA	Spot	Localization of axillary lymph nodes (breast cancer)	28 patients	Inadvertent staining of lymphatic channels proximal to the node, migration of ink between nodes causing inadvertent staining of additional nodes.	One tattoo wasn’t visualized. Authors believe that may be due to the injection being a small volume. For 3 patients the pigment was detected during surgery, but not during histology. Staining of a lymph node that was not a sentinel node occurred in one patient.
Hwang [18] 2010 Korea	Spot	Localization of colonic lesions	20 patients	Local leakage was seen with one patient (without peritonitis or abdominal pain). No other adverse events.	India ink does not diffuse through the mesentery and is thus permanent.
Park [20] 2008 Korea	Spot	Localization of colorectal tumors	63 patients	1 patient had ink diffused extensively. 6 patients had localized diffusion of ink; 1 patient had chills.	Patient with extensive diffusion made lesion hard to see.
Cipe [16] 2016 Turkey	Spot	Localization of distal surgical margin for rectal cancer	40 patients received marking; 25 patients were controls.	None	None
Aboosy [15] 2005 Netherlands	Rotring	Localization of soft colorectal lesions	19 patients with small lesions	None	5 patients had India ink particles present in lymph nodes
McArthur [19] 1999 USA	Koh-I-Noor,	Localization of colonic lesions	195 patients: 50 marked before surgery and 145 marked for future localization	No patients reported any incidence of fever or persistent abdominal pain and no examinations revealed evidence of abdominal tenderness.	Ink was injected through the bowel wall in a few cases.
Salomon [21] 1993 USA	Koh-I-Noor (& homemade)	Localization of colonic lesions	20 patients; 12 had undergone resection.	2 patients had pigmented histiocytes and mild chronic inflammation. Others had superficial mucosal ulceration, granulation of tissue containing ink stained histiocytes, ink staining of macrophages in local lymph nodes.	They were unable to keep the homemade ink in suspension so only Koh-I-Noor was used.