Aluminum Potassium Sulfate and Tannic Acid - A New Option for the Treatment of Grade 3 Hemorrhoids

No abstract available.

Treatment Option for Aged, Multiparous Women With a Chronic Anal Fissure

No abstract available.

Role of the Delorme Procedure for Rectal Prolapse in Young Patients

No abstract available.

Clinical Characteristics and Surgical Safety in Patients Older than 80 Years with Inguinal Hernia

BACKGROUND: Inguinal hernia repair is a common surgical intervention in the elderly. The aim of this study was to describe the clinical characteristics and treatment outcomes in patients over 80 years of age undergoing inguinal hernia repairs. METHODS: We retrospectively reviewed the medical records of 150 patients older than 65 years of age who had undergone an inguinal hernia repair between January 2006 and December 2010. Dividing our subjects by age into two groups, 65 to 79 years and 80 years and older, we compared their clinical features and surgical outcomes. RESULTS: There were 122 patients (81.3%) in the 65 to 79 years group and 28 (18.7%) in the over 80 years group. Average body mass index was 22.8 kg/m2 in the 65 to 79 group and 21.8 kg/m2 in the over 80 group. Comorbidities were present in 63.9% of the cases in the 65 to 79 group and 67.9% in the over 80 group. American Association of Anaesthetists score was significantly higher in the over 80 group (1.6+/-0.3 vs. 1.9+/-0.3, p=0.046). Comparisons of operative time for each operative method were statistically not different. Postoperative hospital stay and analgesic use also showed no significant differences between the groups. Among the postoperative complications, wound hematoma was most prevalent in both groups but was not statistically different. There was no surgery-related mortality in either group. CONCLUSION: Our results indicate that inguinal hernia repair can be done safely in those older than 80 years, unless there is high surgical risk per se.

Clinical Characteristics and Surgical Safety in Patients with Acute Appendicitis Aged over 80

PURPOSE: The aim of this study was to evaluate the clinical characteristics and treatment outcomes, including surgical safety, in patients over 80 years of age who underwent an appendectomy. METHODS: This study involved 160 elderly patients who underwent an appendectomy for acute appendicitis: 28 patients over 80 years old and 132 patients between 65 and 79 years old. RESULTS: The rate of positive rebound tenderness was significantly higher in the over 80 group (P = 0.002). Comparisons of comorbidity, diagnostic tool and delay in surgical treatment between the two groups were not statistically different. American Society of Anesthesiologists score was significantly higher in the over 80 group than in the 65 to 79 group (2.4 +/- 0.5 vs. 1.6 +/- 0.5; P < 0.00005). Comparisons of operative times and use of drainage between the two groups were not statistically different. In the pathologic findings, periappendiceal abscess was more frequent in the over 80 group (P = 0.011). No significant differences existed between the two groups when comparing the results of gas out and the time to liquid diet, but the postoperative hospital stay was significantly longer in the over 80 group (P = 0.001). Among the postoperative complications, pulmonary complication was significantly higher in the over 80 group (P = 0.005). However, operative mortality was zero in each group. CONCLUSION: In case of suspicious appendicitis in elderly patients, efforts should be made to use aggressive diagnostic intervention, do appropriate surgery and prevent pulmonary complications especially in patients over 80 years of age.

Good Post-operative Results Depend on Strict Patient Selection and Strict Operative Procedure

No abstract available.

Laparoscopic Versus Open Appendectomy for Appendicitis in Elderly Patients

PURPOSE: The appendectomy is the most common emergent surgical procedure in elderly patients. The increasing number of elderly persons has been accompanied by an increase in the number of cases of acute appendicitis in the elderly. In order to understand the clinical significance of a laparoscopic appendectomy for elderly patients with appendicitis, we investigated the results of a laparoscopic appendectomy for treating patients over 60 years of age with appendicitis and compared them with the results for an open technique. METHODS: We studied retrospectively patients over 60 years of age who underwent an appendectomy with either a laparoscopic (LA) or open (OA) technique for appendicitis between July 2007 and December 2009. There were 30 patients in the LA group and 47 patients in the OA group. The demographic data, operative time, length of the hospital stay, bowel movement, pain control, cost, complications and pre-existing disease were assessed. RESULTS: There were no significant differences between the LA and the OA groups with respect to pre-existing diseases, gender, age, American Society of Anesthesiologists (ASA) score and the number of cases of complicated appendicitis, operative time, length of hospital stay, and times of analgesics use. However, the proportion of early gas out (within POD #2) was significantly greater in the LA group (80% vs. 57%, P < 0.05), and postoperative complications were significantly lower in the LA group (7% vs. 32%, P < 0.01). The costs for the two groups were not significantly different. CONCLUSION: A laparoscopic appendectomy is a safe and effective procedure in elderly patients and is not associated with any increase in morbidity. It can be recommended for routine use in treating elderly patients with appendicitis.

Condition for Good Quality of Life after Surgery for Slow Transit Constipation

No abstract available.

Clinical Significance of Perineal Descent in Pelvic Outlet Obstruction Diagnosed by using Defecography

PURPOSE: The aim of this study was to evaluate the clinical significance of perineal descent (PD) in pelvic outlet obstruction patients diagnosed by using defecography. METHODS: One hundred thirty-six patients with pelvic outlet obstruction (POO; median age 49 years) had more than one biofeedback session after defecography. Demographic finding, clinical bowel symptoms and anorectal physiological studies were compared for PD at rest and PD with dynamic changes. RESULTS: Age (r = 0.33; P < 0.001), rectocele diameter (r = 0.31; P < 0.01), symptoms of incontinence (P < 0.05) and number of vaginal deliveries (r = 0.46; P < 0.001) were correlated with increased fixed PD. However, the female gender (P < 0.005), rectal intussusceptions (P < 0.05), negative non-relaxing puborectalis syndrome (P < 0.00005) and rectocele (P < 0.0005) were correlated with increased dynamic PD. Duration of symptoms, number of bowel movements, history of pelvic surgery and difficult defecation were not related with PD. There was no significant correlation between fixed and dynamic PD and success of biofeedback therapy. CONCLUSION: Age, vaginal delivery and diameter of the rectocele are associated with increased fixed PD. Female gender, rectal intussusceptions and a rectocele are correlated with increased dynamic PD. Biofeedback is an effective option for POO regardless of severity of PD.

The Roles of Anorectal Physiologic Tests and Treatment of Chronic Constipation

Patients with chronic constipation should be evaluated with physiological tests (defecography and cinedefecography, anal manometry, anal electromyography, and colon transit time) after structural disorders and extracolonic causes have been excluded. In the case of colonic inertia, at first, conservative treatment is necessary. If surgery is indicated, a subtotal colectomy with ileorectal anastomosis is the treatment of choice. Biofeedback is the best option for animus. For patients failing biofeedback, botulinum toxin injection of the puborectalis or sacral nerve stimulation may be indicated. Biofeedback treatment is also considered to be an option for moderate-degree rectoceles, rectal intussusception, and perineal descending syndrome. For the treatment of a severe rectocele, a surgical approach, including transrectal, transvaginal, and transperineal repair or stapled transanal rectal resection (STARR) should be considered. However, the long-term effects of a new technique including botulinum toxin injection, sacral nerve stimulation, and STARR remain to be established.

Prognostic Factors Associated with Poor Outcome of Biofeedback Therapy for Constipated Patients with Pelvic Outlet Obstruction

PURPOSE: The aim of this study was to identify the prognostic factors associated with poor outcome of biofeedback therapy. METHODS: One hundred thirty-seven (137) constipated patients with pelvic outlet obstruction (median age 49 years) had more than one biofeedback session after defecography. Follow-up data (mean follow-up: 14 months; range: 2~37 months) were obtained in 114 patients. Any differences in demographics, clinical symptoms, and parameters of an anorectal physiological study were evaluated between the success group and the failure group. RESULTS: At follow-up, 80 (70 percent) patients felt improvement in symptoms, but 34 (30 percent) patients did not. Pre-biofeedback presence of symptoms of difficult defecation predict poor outcome (88 vs. 69 percent for failure vs. success, P<0.05). The positive and the negative predictive values of difficult defecation for poor outcome were 35 percent and 86 percent, respectively. A negative mean pressure change on pre-biofeedback anal manometry was related to a poor outcome (65 vs. 26 percent for failure vs. success, P<0.001). The positive and the negative predictive values of negative mean pressure change for poor outcome were 51 percent and 83 percent, respectively. A negative electrical current change on pre-biofeedback anal electromyography was related to a poor outcome (23 vs. 9 percent for failure vs. success, P<0.05). The positive and the negative predictive values of negative electrical-current change for poor outcome were 53 percent and 74 percent, respectively. CONCLUSIONS: Difficult defecation, negative mean pressure change in pre-biofeedback anal manometry, and negative electrical current change in pre-biofeedback anal electromyography were predictors associated with poor outcome of biofeedback therapy for constipated patients with pelvic outlet obstruction.

Effect of Electrical Stimulation and Biofeedback Therapy for Constipated Patients with Impaired Rectal Sensation

PURPOSE: Biofeedback therapy is widely used for the management of constipation associated with pelvic outlet obstruction. Some patients have shown poor outcome after biofeedback alone. A subgroup of patients complains of absence of desire to defecate. The main pathophysiology of constipation may be impaired rectal sensation or compliance. This study evaluated the effect of electrical stimulation and biofeedback therapy (EST-BF) for this subgroup of constipated patients with impaired rectal sensation. METHODS: Of the 37 patients diagnosed with pelvic outlet obstruction by using cinedefecography, 9 patients (M:F=2:7, age=22~77 years, median=57 years) who had impaired rectal sensation (rectal desire threshold > or =100 ml) on anorectal manometry were selected. These patients were treated with EST-BF therapy 2~6 (median: 5) sessions, Kontinece, Multichannel system, HMT, Inc, Seoul, Korea). Treatment consisted of 20 minutes of variant-mode electrical stimulation and 20 minutes of EMG biofeedback therapy per week administered by a specialized colorectal surgeon. All patients were evaluated by using a standardized questionnaire and a threshold for rectal sensation based on balloon distention before and after treatment. RESULTS: At post EST-BF, six (67%) patients had experienced an improvement in symptoms, including five (56%) patients with complete symptom relief. Significant improvement in rectal sensation, especially the rectal defecation desire threshold (pre-EST-BF vs. post- EST-BF: 181.0+/-38.7 vs. 88.3+/-29.1) was achieved. CONCLUSIONS: EST- BF may be an effective option for use in the treatment of functional constipation with impaired rectal sensation.

Outcome and Predictors of Success of Biofeedback for Descending Perineum Syndrome

Purpose: To determine the outcome and identify predictors of success of biofeedback for descending perineum syndrome (DPS). Methods: 103 patients diagnosed with DPS by defecography were evaluated by standardized questionnaire, before, immediately after treatment, and at follow-up. Clinical bowel symptoms and anorectal physiological studies were also analyzed. Results: At post- biofeedback, 81 patients felt improvement in symptoms, including 29 with complete symptom relief. At follow-up (median: 13 months, n=82), 58 patients felt improvement in symptoms, including 12 with complete symptom relief. There was a significant reduction in difficult defecation (from 78 to 34, 37%, from pre-biofeedback to post-biofeedback, and at follow-up respectively; P<0.001), incomplete defecation (from 88 to 44, 41%; P<0.001), hard stool (from 63 to 25, 0%; P<0.01), small caliber stool (from 63 to 0,0%; P<0.001, P<0.005), fecal incontinence (from 10 to 1,1%; P<0,01), anal pain (from 21 to 2, 6%; P<0.001, P<0.05), laxative use (from 30 to 11, 6%; P<0.001), enema use (from 16 to 0, 1%; P<0.001) and digitation (from 11 to 1%, from pre-biofeedback to at follow-up; P<0.05). Normal spontaneous bowel movement was increased from 47% pre-biofeedback to 79% post-biofeedback (P<0.001), 86% at follow-up (P<0.001). Difficult defecation predict poor outcome (96 vs. 66%; failure vs. success, P<0.01). Positive mean pressure change predict good outcome (69 vs. 35%; success vs. failure, P<0.05). Conclusions: Biofeedback is an effective option for DPS.

Massive Bleeding from Multiple Jejunal Diverticulosis

Jejunoileal diverticulosis is formed by herniation of mucosa and submucosa through the muscular layer of the bowel wall. The condition usually consists of multiple diverticula at the mesenteric border, in contrast to the true congenital Meckel's diverticulum. Small bowel diverticulum is a rare disease that can give rise to unexpected problems such as malabsorption, perforation, diverticulitis, obstruction and bleeding. Since the reported complication rate is low, uncomplicated small bowel diverticula are generally recommended to be left untreated. Bleeding from a diverticulum is often sudden and massive. We report herein a case of a 43-yearold women who presented with massive bleeding from multiple jejunal diverticula. She had been admitted to hospital one day previously with the chief complaint of severe whole abdominal pain which was aggravated progressively. On physical examination, she showed an acute, ill appearance. The abdomen was slightly distended and tender with rebound tenderness. On the abdomen CT, the jejunal wall was thickened and the mesenteric lymph nodes were enlarged. An emergency laparotomy was performed. Multiple jejunal diverticula, distributed from 20 to 100 cm distal to the ligament of Treitz, were found, along with massive bleeding from diverticulosis. A segment of the jejunum containing all diverticula was resected and end to end anastomosis was performed. Due to the relative rarity of these lesions and their complications, diagnosis is often difficult and delayed. Awareness of their tendency to cause nonspecific abdominal symptoms and serious complications may lead to earlier diagnosis and timely treatment.

Small Bowel Obstruction due to Incarcerated Obturator Hernia

An obturator hernia is a rare but important cause of small bowel obstruction, due to the difficulty of its diagnosis and the high mortality rate. Elderly, multiparous and debilitated women with comorbid illnesses are most often affected, and this hernia, coupled with a delay in the diagnosis and operative intervention, results in the high mortality rate, which represents both diagnostic and therapeutic challenges to the surgeon. Recently, we experienced two unusual obturator hernia cases, where incarceration had lead to a small bowel obstruction. One patient was an 82-year-old woman with a compression fracture of the lumbar spine, which presented with left inguinal pain and abdominal distension. The abdominal plain X-ray showed evidence of a small bowel obstruction. The hernia was diagnosed by a computed tomography (CT) scan and repaired using the lower midline transperitoneal approach. To prevent a recurrence, the hernial defect was enforced with a polypropylene plug and mesh. The other patient was a 92-year old woman with fracture of the neck of the left femur, which presented with defecation difficulty and abdominal distension. The abdominal plain X-ray showed multiple distended small bowel loops consistent with small bowel obstruction. A contrast-enhanced CT scan of the abdomen and pelvis showed a right obturator hernia with strangulation. We recommended an emergency operation, but the patient refused the operative procedure. With on going conservative management, the symptom was fortunately resolved. Herein, we report these findings with a brief review of the literature.

Appendicocolic Fistula

An appendicocolic fistula is a rare disease. It seems likely that the appendix becomes adherent to the viscus either before or after its perforation due to appendicitis, so surgeons may become confused when an emergency appendectomy in done. We report one case of an appendicocolic fistula to draw attention to the importance of this fistula and to describe the clinical, the diagnostic, and the therapeutic aspects of the disease.

Role of Anorectal Physiologic Studies for the Diagnosis and Treatment of Non- relaxing Puborectalis Syndrome

PURPOSE: To assess the effectiveness of cinedefecography (CD), anal electromyography (EMG), and anal manometry (ARM) for the diagnosis of non-relaxing puborectalis syndrome (NRPR) and to compare the outcomes for patients after biofeedback therapy (BF). METHODS: The clinical criteria used in this study for NRPR included straining, incomplete evacuation, tenesmus, and the need for enemas, suppositories, or digitation. Patients who satisfied the clinical criteria were evaluated by use of anorectal physiology tests: CD, EMG, and ARM. The EMG criteria included failure to achieve a significant decrease in the electrical activity of the puborectalis (PR) during attempted evacuation. The ARM criteria included failure to achieve a significant decrease in intra-anal pressure during attempted evacuation. The CD criteria included either paradoxical contraction or failure of the PR to relax together with incomplete evacuation. Other possible etiologies for incomplete evacuation, such as rectal intussusception or rectocele, were excluded in all cases. Fifty-eight constipated patients diagnosed as having NRPR by at least one of anorectal physiolosic tests had more than one BF session. The outcomes for fifty-one patients (mean age, 44.8 years; male-to-female ratio, 22:29) were reported as either improved or unimproved at a mean follow-up of 12.7 (range, 2~30) months. The sensitivities, the specificities, and the positive and negative predictive values for the CD, EMG, and ARM diagnoses of NRPR were calculated to assess the diagnostic accuracy of each test and to identify predictors associated with the outcome of BF. RESULTS: The sensitivities of EMG, CD, and ARM were 96%, 89%, and 85%, respectively (P>0.05). The positive predictive values of the three tests were 63% for EMG, 52% for ARM, and 51% for CD (P>0.05). The negative predictive values of the three tests were 90% for EMG, 43% for ARM, and 25% for CD (P0.05). CONCLUSIONS: A combination of the CD and the EMG tests is suggested for the diagnosis of NRPR.

Outcome and Prognostic Factors Associated with Poor Outcome of Biofeedback Therapy for Constipated Patients with Non- relaxing Puborectalis Syndrome

PURPOSE: Biofeedback is a major treatment method for constipated patients with non-relaxing puborectalis syndrome. However a significant percent of patients still showed poor outcome, and little has been known about the predictors associated with outcome of biofeedback. The aim of this study was to determine the outcome and identify predictors associated with poor outcome of biofeedback therapy for constipated patients with non- relaxing puborectalis syndrome. METHODS: Fifty-two constipated patients with non-relaxing puborectalis syndrome (median age, 47 years) who had more than one biofeedback session after defecography were evaluated by standardized questionnaire, before, immediately after treatment, and at follow-up. Clinical bowel symptoms and anorectal physiological studies were analyzed. Any differences in demographics, clinical symptoms, and parameters of anorectal physiological study were evaluated between success group (patients felt improvement in symptoms at follow-up) and failure group (patients felt no improvement). RESULTS: Follow up (mean follow-up; 17 months) results were evaluated by an independent observer in 45 patients. At post-biofeedback, 42 (81 percents) patients felt improvement in symptoms, including 7 (13 percents) with complete symptom relief. At follow-up, 25 (56 percents) patients felt improvement in symptoms, including 1 (2 percents) with complete symptom relief. There was a significant reduction in difficult defecation (from 81 to 44, 53 percent, from pre-biofeedback to post-biofeedback, and at follow up respectively; P<0.005, P<0.01), sensation of incomplete defecation (from 90 to 50, 40 percent; P< 0.00001, P<0.000005), laxative use (from 25 to 10, 11 percent; P<0.05), and enema use (from 13 to 0, 2 percent; P<0.01, P<0.05). Normal spontaneous bowel movement was increased from 42 percent pre-biofeedback to 81 percent post-biofeedback (P<0.0001), 80 percent at follow up (P<0.0005). Pre-biofeedback presence of symptoms of bowel habit change predict poor outcome (15 vs. 0 percent; failure vs. success, P<0.05). High pressure zone in prebiofeedback manometry was longer in failure group than in success group (2.80 vs 2.01 cm, P<0.05). In the success group, 11 (44 percent) had a rectocele, 1 (4 percent) had a rectal intussussception, 18 (72 percent) had a descending perineal syndrome, and 3 (12 percent) had a sigmoidocele. In the failure group, 4 (20 percent) had a rectocele, and 1 (5 percent) had a rectal intussusception, 14 (70 percent) had a descending perineal syndrome, and a sigmoidocele was not accompanied (P<0.05). Accompanied rectocele, rectal intussusception, descending perineal syndrome, and sigmoidocele did not influence outcome. CONCLUSIONS: Biofeedback is an effective option and should be considered as the first line therapy. Bowel habit change and long high pressure zone in pre-biofeedback manometry were predictors associated with poor outcome of biofeedback therapy for constipated patients with non-relaxing puborectalis syndrome.

Outcome and Predictors of Biofeedback Therapy for Patients with Internal Rectal Intussusception

PURPOSE: The aim of this study was to determine the outcome and identify predictors of success of biofeedback therapy for patients with internal rectal intussusception. METHODS: Twenty-one patients (median age. 54 years, 15 female, 6 male) diagnosed with internal rectal intussusception by using cinedefecography were evaluated by standardized questionnaire, before, immediately after treatment, and at follow-up. Clinical bowel symptoms and anorectal physiological studies were also analyzed. RESULTS: Follow up (median: 15, range 2~24 months) results were evaluated by an independent observer in 20 patients. At post-biofeedback, 20 (95%) patients felt improvement in symptoms, including 7 (33%) with complete symptom relief. At follow-up, 17 (85%) patients felt improvement in symptoms, including 7 (35%) with complete symptom relief. There was a significant reduction in difficult defecation (from 90 to 29, 10 percent, from pre-biofeedback to post-biofeedback, and at follow up respectively; P<0.001), sensation of incomplete defecation (from 90 to 24, 35 percent; P<0.001), enema use (from 29 to 0, 0 percent; P<0.01), and anal pain (from 19 to 0, 0 percent; P<0.05). Digitation (from 19 to 0 percent, from pre- biofeedback to at follow up; P<0.05) and laxative use (from 29 to 5 percent; P<0.05) were also decreased. Normal spontaneous bowel movement was increased from 52 percent, at pre-biofeedback to 86 percent, at post- biofeedback (P<0.05), 95 percent at follow up (P<0.005). Low bowel frequency, at pre-biofeedback (P<0.01), and hard stool (P<0.05) predicted poor outcome. Long puborectalis length during push (P<0.05) and dynamic descent (P<0.05) on defecography also predicted poor outcome. Low electrical activities of puborectalis and anal sphincter muscle during rest (P<0.001), squeeze (P<0.01) and push (P<0.005) on pre-biofeedback electromyography were related to poor outcome. No patient developed full rectal prolapse during follow up. CONCLUSIONS: Biofeedback is an effective option and should be considered as the first line therapy especially for patients that don't have low bowel frequency, long puborectalis during push, and dynamic descent before treatment.

Clinical Presentation and Surgical Outcome in Patients with Solitary Rectal Ulcer Syndrome

PURPOSE:Solitary rectal ulcer syndrome (SRUS) is a poorly understood clinical condition and its scheme of treatment has not been defined yet. The aim of this investigation was to review the clinical spectra and outcome of various surgical treatments in patients with SRUS, thus to define more rational approach to the management of this ambiguous condition. METHODS:The study population was composed of 49 patients, among whom 20 patients (18 females and 2 males; median age, 55) were diagnosed primarily as SRUS histopathologically (=primary SRUS). Reviewing all pathologic reports and slides from specimens resected surgically in patients with rectal prolapse, another 20 cases were diagnosed to be combined with SRUS. Other 9 patients included those who were diagnosed histologically as or to be combined with SRUS after the operation for an indication other than SRUS. The latter 29 cases (26 females and 3 males; median age, 72) were defined as secondary SRUS, and then differences in clinical features and outcome of surgical treatment between 2 groups were reviewed retrospectively. The median follow-up was 24 months (range, 5-49 months). RESULTS:Ulcerative morphology was predominant in primary SRUS (70 percent), whereas erythematous (45 percent) and polypoid (34 percent) in the secondary ones. This difference in morphologic distribution between two groups was significant statistically (P=0.0025). No statistical difference was observed for symptomatologic distributions between two groups. The most common problem associated with evacuation was rectal bleeding in both groups (85 percent and 76 percent, respectively). In primary SRUS, clinical and defecographic studies revealed a rectal prolapse in 5 patients (25 percent), intussusception in 11 patients (55 percent), sigmoidocele (2 degrees) in 4 (20 percent), and paradoxical puborectalis contraction (PPC) in 3 (15 percent) to be combined. Beside rectal prolapse in secondary group, other defecographic findings associated with possible evacuatory problem included sigmoidocele (2 degrees) in 5 (25 percent), rectocele and intussusception in 2 (10 percent), respectively. Clinical improvement after surgery was obtained in 14 of 19 procedures (74 percent) in 17 patients with primary SRUS and 23 of 29 (79 percent) in secondary SRUS, the difference of which was not significant. Though statistically not significant, transabdominal rectopexy was superior to local excision for symptomatic relief in primary SRUS without overt prolapse (86 percent vs. 33 percent). Neither of changes in the percentage of symptoms before and after the operation between two groups showed significance. Clinical and pathologic variables were compared between two treatment result groups of 'improvement' and 'no improvement' and manifestations as tenesmus and digitation correlated with a poorer outcome after surgery (P=0.0065 and 0.02, respectively). CONCLUSIONS:SRUS is rather a clinical condition associated with functional anorectal evacuatory disorders than an independent disorder. This study shows optimistic role of a surgical treatment against underlying functional disorders in the improvement of secondary SRUS. Proper surgical option, however, for treatment in variable clinical spectra of primary SRUS is still not established, which awaits a conclusion from extensive prospective randomized trials.