关于盆底超声的若干问题 Part2
Q6
QUESTION
为什么我们要用缩肛状态下的开-闭合中-闭合的TUI模式来诊断提肛肌撕脱伤?为什么我们不直接采用2D模式通过旁氏状切面扫描耻骨直肠肌呢?因为2D的分辨率比3D/4D的好。
Why do we use TUI mode with open-closing-closed image to diagnose the avulsion of levator ani muscle at contraction? Why don’t we scan the puborectalis directly with 2D mode through parasagittal scanning？because the resolution of 2D is better than that of 3D/4D.
ANSWER
Dietz
Yes, you can see the muscle on parasagittal 2D imaging. We tried that between 05 and 07, but there are obvious problems. Nobody has been able to show that this can be done reproducibly. There is no proper plane or point of reference. I can make everybody look highly abnormal on parasagittal imaging by simply going a bit too medial, and you can’t tell from the still image that the slice is too medial, that this is a false positive. if you produce a parasagittal image that looks normal, that is great and you can say that the muscle is fine. False negatives for avulsion are very unlikely.On the other hand, if the image looks abnormal, it means nothing because that image could easily be a false positive.
是的，您可以在旁矢状面2D图像上看到肌肉。在05到07年之间我们曾尝试扫描，但存在明显问题。到目前为止，没有人能够证明这是可重复的。没有合适的切面或位置点作参考， 探头仅仅是稍微偏向中间位置，就可以使每个人的旁矢状面图像看起来都异常，并且从静态图像上您无法确认该切面是位于中间位置，这就是假阳性。如果旁矢状面图像正常，说明肌肉很好，肛提肌断裂的假阴性可能性很小；另一方面，如果图像看起来不正常，那就什么都说明不了，因为有可能是假阳性。
Q7
QUESTION
如何规范直肠膨出的诊断?谢谢
How to standardize the diagnosis of enterocele? Thank you
ANSWER
Dietz
What the colleague probably means how far does the enterocoele have to come down for it to be called an enterocoele. What complicate the matter is that an enterocele can track down the back wall of the vagina or the front wall, or the entire vault comes down. These are very different situations. You just describe what you see: bowel that comes down to the reference line, or 10mm below,20 mm below, or 30 mm below. Whether that enterocoele matters or not, will depend on clinical findings. In a study last year we proposed a cut-off of 15 mm below the symphysis for ‘significant enterocele’.
这个题目的意思可能是说肠管必须下降多远才能被称为肠疝。肠疝复杂的地方在于下降的肠管从阴道的后壁或前壁膨出，或者整个穹顶掉下来。这些情况都非常不同。您只需描述一下您所看到的内容：肠管下降到参考线位置，或参考线以下10mm，参考线以下20mm或参考线以下30mm。所以肠疝严重与否，取决于临床发现。在去年的一项研究中，我们提出了“明显肠疝”诊断界值是在耻骨联合下15mm。
Q8
QUESTION
为什么您和IUGA只推荐经腹3D/4D探头，而不是经腹2D探头或2D/3D 经阴道探头？有些医生想用经阴道探头扫描肛门括约肌，用经腹探头扫描前腔室和中腔室，你有什么意见和建议吗？
Why do you and IUGA recommend transabdominal 3D/4D probe only, not transabdominal 2D probe or 2D/3D TVS probe? Some doctors would like use TVS probe to scan anal sphincter, and transabdominal probe to scan anterior and central compartments, do you have any comments & proposal?
ANSWER
Dietz
That is a misunderstanding, Both me and IUGA do recommend a transabdomial 2D probe, in fact, that is module 2 of our online teaching. I think I made my point regarding the transvaginal probe. These are not convenient, because they have a small footprint and you can not do a proper Valsalva maneuver. I truly can’t see why anybody would want to use a vaginal probe unless it is to save time after doing a transvaginal scan for pelvic pathology, as a shortcut. And then you can’t really do measurements of organ descent and hiatal area on Valsalva, and you can’t evaluate the perineum because you’re too close, and the sphincter is trickier, too. You should comply with international standardization in order to be reproducible, in order to produce valid data.
这是一个误解，我和IUGA都推荐经腹部二维探头。事实上，这是在线教学的模块2。我想对经阴道探头提出我的观点， 经阴道探头确实不方便，因为探头表面与皮肤接触面很小，没法做正确的Valsalva动作。我真的不明白为什么有人会想使用经阴道探头，除非这样做是为了简化经阴道探头扫描盆底后进行盆腔病理检查以节省时间。然后，您无法真正测量Valsalva状态下器官下降幅度和裂孔面积，也无法评估会阴部，因为太近了，对于括约肌也更棘手。您确实应遵循国际标准化以保证重复性和数据有效性。
Q9
QUESTION
当我们发现肛门括约肌有缺损时，该怎样描述呢？部分还是完全损伤？残存损伤？或者是表浅/皮下/深部损伤？什么是明显损伤？为什么用损伤大于或等于30度，累积2/3以上的肛管定义明显损伤？如果不满足这个标准或只有肛门外括约肌损伤，您是怎样写报告的？
When we found a defect of the anal sphincter, how do we describe it? Partial or complete defect? Residual defect? Or we should use superficial/subcutaneous /deep to describe the defect? What’s significant defect? Why you define the significant defect using ≥ 300 in 2/3 length of anal canal? Is there any clinical significance? if ≤ 300 or less 2/3 length of anal canal or there is only external sphincter muscle defect, how do you document it?
ANSWER
Dietz
That question shows very nicely the need for the standardization, and for the importance of testing validity and reproducibility. The 2/3 rule, that is to have 4 out of six slices abnormal, stems from an arbitrary decision by Dr Sultan, who defined residual defects on endoanal ultrasound as a defect of 30 degrees circumference that is visible in 2 out of 3 slices. We adapted that rule to translabial scanning and validated it. We found that a defect in 4 out of 6 slices or more was strongly associated with anal incontinence, so the 2/3 or 4/6 rule is validated. The 30 degree angle definition was also based on an arbitrary decision of Abdul Sultan’s describing a residual defect on endo-anal ultrasound. We have tried to validate that rule and failed. The size of the defect or defect angle may not matter that much. Many of those with smaller defect angles are repaired tears, which means there has been a lot of damage to that muscle which has only been partly repaired. Until such time as we know more, you describe what you find, for example, to say: “there is a defect of the external sphincter in 2 out of 6 slices at defect angles of above 30 degrees, and on current evidence, this is not rated as a residual defect.” A ‘significant residual defect’ is a defect of the external sphincter in >= 4 out of 6 slices at defect angle of >=30 degree, and until somebody produces a better definition, that is it.
这个问题很好地说明了为什么需要标准化以及验证有效性和重复性的重要性。2/3法则，即每6个切面中有4个切面异常，是由Sutan医生自行决定的，Sutan医生采用肛门内超声扫描，定义了残存损伤，即累计范围在圆周上达30度，长度上达2/3的切面。我们将该法则用于经会阴扫描并验证其有效性。我门发现4/6或更多切面损伤与与肛门失禁密切相关，因此2/3或4/6法则是有效的。30度角的定义是基于Abdul Sultan医生对肛管内超声诊断残存损伤的任意决定。我们试图验证该法则，但失败了。损伤的大小或角度可能没那么重要。许多小角度的损伤是曾被修复过的。这意味着许多肌肉损伤仅部分被修复。在我们深入了解之前，描述您的发现。例如：“肛门外括约肌存在缺损，其角度大于30度，长度累及2/6切面。并且根据当前证据，不能被评为残存损伤”。 “显著残存损伤”是外括约肌的损伤累及4/6个切面或更多，角度大于等于30度，除非有人给出更好的定义，否则就使用该定义。
Q10
QUESTION
在肛门括约肌的多平面模式中，为什么称A平面图像为“冠状面”？
In multiplanar mode of the anal sphincter, why do you call image of A plane ”coronal plane”?
ANSWER
Dietz
If you go on Google and bring up anatomic body planes, you can see the sagittal and transverse and coronal plane, and transverse is really axial. The anal canal is not aligned vertically, often anatomical illustrations are rather incorrect in this regard. A cross section of the anal canal is an oblique coronal plane, and this plane is represented in the A plane on exo-anal sphincter imaging.
如果您在Google上打开人体解剖平面图，则可以看到矢状面、横断面和冠状面，而横断面实际上是轴向的。因为肛管不是垂直向下走行的，通常解剖学图谱在此方面是不正确的。肛管的横截面是人体的斜冠状平面。肛门外括约肌切面在A平面区域显示。