Retrospective study on clinical outcomes and safety evaluation of da Vinci robot-assisted laparoscopy and endoscopic cooperative for small gastric stromal tumors resection: preliminary single-center experience

Introduction

Gastrointestinal stromal tumors (GISTs) are a group of submucosal neoplasms that originate from interstitial cells of Cajal in the mesenchymal tissue of the gastrointestinal tract (1). They predominantly occur in individuals aged >50 years, showing no significant gender differences, and the average annual incidence is approximately 1.5–2 per 100,000 people. Accounting for approximately 1.5% of gastrointestinal tract tumors and approximately 3% of gastric tumors, GISTs can also emerge in the soft tissues of the abdominal cavity, such as the omentum, mesentery, or retroperitoneum; however, their incidence in other locations is low. Clinically, the manifestations are often nonspecific, typically featuring gastrointestinal bleeding, pain, and dyspepsia (2). Notably, gastric stromal tumors make up roughly 60–70% of GISTs, trailed by the small intestine at approximately 25%, the colorectum at around 5%, and the esophagus at approximately 2%. On occasion, they may also surface in the omentum and mesentery (3-5).

GISTs that originate from the gastric region predominantly localize to the submucosa, followed by the subserosa, with a relatively infrequent incidence in the muscularis propria (3). These tumors display heterogeneous diameters and may present as solitary nodules or multifocal patterns (6,7). Morphologically, they generally exhibit distinct boundaries (6,8). Following the anatomical site of tumorigenesis, they are further partitioned into three categories: type I, occurring in the gastric fundus and greater curvature; type II, situated at the pylorus and antrum; and type III, positioned in the lesser curvature of the stomach and gastroesophageal junction (9). GISTs with a diameter of less than 2 cm are termed small stromal tumors (10,11).

GISTs manifest a spectrum of unfavorable biological characteristics, transitioning from benign to malignant phenotypes. Remarkably, even relatively minute GISTs, those with a diameter less than 2 cm, can evince invasive propensities, especially when harboring a high mitotic count (10). As a corollary, prompt identification and timely therapeutic intervention for these tumors are of cardinal importance. Currently, surgical resection of the primary tumor remains the first choice of treatment for non-metastatic GISTs. Available methods include open surgery (12), endoscopic surgery (13-16), laparoscopic surgery (17-19), and da Vinci robot-assisted surgery (20-23). Selecting the right surgical approach to fully excise the tumor is crucial. It directly impacts treatment efficacy, making a proper choice essential for positive patient outcomes. Given the fact that GISTs infrequently invade adjacent anatomical structures and surrounding lymph nodes, contemporary surgical regimens preponderantly advocate for the intact resection of the tumor entity while omitting routine lymph node resection (24-27). Laparoscopic-endoscopic cooperative surgery, with its advantages of minimal trauma, rapid postoperative recovery, and low incidence of postoperative complications (28-30), has been widely applied in the treatment of GISTs (31-33). Besides, endoscopic submucosal resection (ESR) has also been proven to be safe and effective for treating gastric stromal tumors (34-36). Compared to traditional surgical alternatives, ESR has several merits, including a lower incidence of complications, a curtailed risk of perioperative mortality, minimized hemorrhagic events during surgery, and shortened hospital stays.

Nevertheless, both combined laparoscopic and gastroscopic resection and ESR carry the inherent risk of disrupting the gastric mucosal layer, predisposing patients to postoperative gastrointestinal symptoms, such as epigastric pain, abdominal bloating, nausea, and vomiting. The reparative cascade of the gastric mucosa is intrinsically intricate. In cases where the repair process is suboptimal, pathological transformations such as gastric mucosal atrophy and intestinal metaplasia can be triggered, potentially impairing the digestive and absorptive functions of the stomach to some extent.

Consequently, the General Surgery Department, in collaboration with the Endoscopy Center of Tianjin Union Medical Center (The First Affiliated Hospital of Nankai University), endeavored to employ robotic-assisted laparoscopy integrated with endoscopy. The approach aims at enucleating small gastric stromal tumors while safeguarding the integrity of the mucosal layer. This retrospective study gathered the clinical records of 69 patients diagnosed with gastric stromal tumors through histopathological examination who had undergone surgical treatment in the General Surgery Department of Tianjin Union Medical Center (The First Affiliated Hospital of Nankai University) between June 2020 and December 2023. By comprehensively summarizing and meticulously analyzing the treatment outcomes of these 69 cases, this study sought to explore the application potential, safety profile, and efficacy of da Vinci robot-assisted resection of small gastric stromal tumors without inflicting damage to the mucosal layer. We present this article in accordance with the STROBE and SUPER reporting checklists (available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-718/rc).

Methods

Basic patient demographics

A retrospective analysis was performed on the clinical records of 69 patients diagnosed with gastric stromal tumors through histopathological examination. These patients were admitted and received surgical treatment in the General Surgery Department of Tianjin Union Medical Center (The First Affiliated Hospital of Nankai University) between June 2020 and December 2023. They were categorized into two groups based on the surgical approach employed: laparoscopic (n=46) and robotic resection (n=23). Prior to undergoing either da Vinci robot-assisted surgery or laparoscopic surgery, all patients were obligated to sign informed consent forms specific to the surgical procedure. Subsequently, a retrospective case series was initiated by leveraging the information retrieved from the patient’s medical charts. Data concerning the patients’ baseline characteristics, tumor features, pathological findings, and follow-up outcomes were meticulously collected.

Inclusion criteria: (I) diagnosis of gastric stromal tumors was made using preoperative gastroscopy and endoscopic ultrasonography, and the patients met the surgical indications. (II) Absence of esophageal and intestinal stromal tumors. (III) Enhanced computed tomography (CT) of the entire abdomen revealed no metastases in distant organs, including the liver, spleen, biliary tract, and pancreas. (IV) The diagnosis of gastric stromal tumor was pathologically confirmed after surgery. (V) The patients provided their consent and signed an informed consent form. (VI) Patients with complete perioperative clinical data were included in the study.

Exclusion criteria: (I) patients with a combined insufficiency of vital organs, such as the heart, lungs, and kidneys, are at a high risk of developing severe complications. (II) Patients with malignant tumors accompanied by multiple organ metastases or disseminated lesions. (III) Endoscopic examination suggested the presence of ulcers on the tumor surface, which posed a risk of rupture and dissemination. (IV) Patients with a history of gastric resection were excluded.

Ethical approval and registration

The study was approved by the Ethics Committee of Tianjin Union Medical Center, The First Affiliated Hospital of Nankai University on March 3, 2025 (approval No. 2025-B20) and individual consent for this retrospective analysis was waived. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Surgical methods

To ensure the quality and consistency of the surgeries, all operations are performed by the same surgeon.

Laparoscopic and endoscopic cooperative partial gastrectomy

After successful general anesthesia, the patient was placed in the supine position. The surgery was performed laparoscopically, and the surgical methods were selected according to the location and diameter of the tumor lesion, including gastric wedge resection, gastric structural resection, digestive tract reconstruction, etc.

Robot-assisted laparoscopic and endoscopic cooperative resection for gastric stromal tumors

After successful general anesthesia, the patient was placed in the supine position, and robotic arms were installed as shown in Figure 1. During the operation, the tumor was located by gastroscopy, and 0.9% normal saline (or with indocyanine green) was injected submucosally around the tumor and between the tumor and mucosa under gastroscopy (Figure 2). Surgery proceeded if the mucosal lifting sign was positive; wedge resection was performed if negative. (I) GISTs ≤1 cm in diameter: the permanent cautery hook and Fenestrated bipolar forceps were used to incise the gastric serosa and resect the tumor from the muscular layer. Owing to the minimal wound, serosa suturing was avoided to reduce gastric wall damage (Figure 3). (II) GISTs >1 cm in diameter: when the GIST diameter exceeded 1 cm, the Maryland bipolar forceps were used to resect the tumor with assistance from Cadiere forceps. After resection, the serosa was continuously or intermittently sutured using the Maryland bipolar forceps (Figure 4). Repeated gastroscopy was performed to ensure mucosal integrity (Figure 2C). Submucosal injection of normal saline facilitated tumor protrusion toward the serosal layer, thereby avoiding mucosal injury. The purpose of performing a second gastroscopy is to observe whether there is leakage or bleeding at the surgical site.

Figure 1 Trocar position with da Vinci robot-assisted laparoscopic and endoscopic cooperative resection for gastric stromal tumors. R1–R4: operating ports for da Vinci robot’s robotic arms; A: assistant’s auxiliary operating port.

Figure 2 Intraoperative endoscopic examination. (A) Submucosal injection was performed under endoscopy. (B) After the completion of injection. (C) The mucosa remained intact following the stripping and suturing procedures.

Figure 3 Robot-assisted operation during the operation for ≤1 cm GISTs. (A) Open the serosa and completely remove the tumor mass under the mucosa. (B) Completely remove the tumor intact. (C) Keep the mucosal surface intact. GISTs, gastrointestinal stromal tumors.

Figure 4 Robot-assisted operation during the operation for >1 cm GISTs. (A) Open the serosa and completely remove the tumor mass under the mucosa. (B) Completely remove the tumor intact. (C) Keep the mucosal surface intact. (D) Close the wound on the serosa continuously or intermittently by suturing. GISTs, gastrointestinal stromal tumors.

All patients were administered the same dosage and the same type of acid-suppressing drugs and painkillers in accordance with the enhanced recovery after surgery (ERAS) principle after the operation, and received the same postoperative nursing care.

Observation metrics

General clinical data

General clinical data include age, gender, lesion diameter, involved site, depth of invasion, clinical manifestations, hemoglobin, fibrinogen-to-albumin ratio (FAR), platelet-lymphocyte ratio (PLR), and neutrophil-lymphocyte ratio (NLR).

Surgery-related metrics

This category includes operative time, intraoperative blood loss volume, time interval until postoperative ambulation, time to the first postoperative flatus, time required for postoperative dietary resumption, and length of postoperative hospital stay.

Intraoperative adverse events

It encompasses massive bleeding, conversion to open laparotomy, and episodes of tumor rupture.

Postoperative complications

The incidence of postoperative complications in both groups was meticulously documented. Complications include gastric bleeding, anastomotic fistula or perforation, surgical site infection, and delayed gastric emptying.

Postoperative pathology and follow-up

Pathological risk stratification was categorized as very low-, low-, intermediate-, or high-risk. For patients with very low- or low-risk tumors after complete resection, CT scans and gastroscopies were scheduled every 6 months. For intermediate- and high-risk tumors, CT scans and gastroscopies were performed every 3 months. In cases of suspicious lesions, repeat biopsy was performed for histopathological analysis. The recurrence and metastasis status of the patients within 1 year after surgery were monitored. The follow-up termination date was December, 2024.

Statistical analysis

All data were analyzed using SPSS 27.0 software. Categorical data were presented as number of cases (percentage) [n (%)] and compared between groups using the χ² test or Fisher’s exact test. Normally distributed quantitative data are expressed as mean ± standard deviation (SD), with the independent-samples t-test and Mann-Whitney U test used for between-group and within-group comparisons, respectively. For skewed data represented by the median (interquartile range), non-parametric tests were applied. The non-parametric rank sum test was used to compare ordinal data between groups. Covariance analysis was performed to exclude the influence of other factors on postoperative outcomes. Statistical significance was set at P<0.05.

Results

Comparison of general clinical data

This study included 69 patients diagnosed with gastric stromal tumors. Among them, 46 patients underwent laparoscopic resection and 23 patients were treated with robotic resection. When comparing the two groups in terms of age, sex, symptoms, comorbidities, and tumor locations, no statistically significant differences were detected, suggesting that the two groups were well balanced and comparable. The detailed information is presented in Table 1. In both groups, the gastric fundus was the most prevalent site of tumor occurrence, followed by the gastric body and cardia. In the robotic resection group, abdominal pain and distension (47.83%) were the predominant presenting symptoms. In contrast, abdominal pain and distension (45.65%) and asymptomatic patients (39.13%) were also frequently observed in the laparoscopic resection group.

Surgery-related indicators

In comparison with the laparoscopic resection group (Table 2), no significant statistical difference was observed in the mean operative time of the robotic resection group (120.43±35.89 min, P=0.30). Nevertheless, several postoperative parameters demonstrated favorable outcomes in the robotic resection group. The postoperative bed rest duration was notably shorter (1.96±0.56 days, P=0.006), as was the time to the first postoperative flatus (15.74±5.92 h, P<0.001), the postoperative fasting period (20.52±6.24 h, P<0.001), postoperative suture removal time (4.87±1.01 days, P<0.001), overall mean hospital stay (10.74±2.36 days, P<0.001), and mean postoperative hospital stay (5.04±1.72 days, P<0.001). Additionally, the average intraoperative blood loss was substantially lower in the robotic resection group (18.48±11.62 mL, P=0.02). Notably, both groups successfully achieved en bloc resection and complete tumor excision.

Covariance analysis and Subgroup analysis were performed to mitigate the potential confounding effects of age, tumor size, clinical manifestations, and hemoglobin level on postoperative results. After adjusting for these variables, the operative time, hospital stay, and postoperative fasting time were significantly shorter in the robotic resection group than in the laparoscopic resection group, with statistically significant differences (Tables 3,4).

Furthermore, all 23 patients in the robotic enucleation group underwent follow-up gastroscopy and non-contrast CT on the 5^th postoperative day. No significant mucosal injuries (e.g., mucosal laceration, perforation, hemorrhage) were observed in any case (Figure 5).

Figure 5 Postoperative day 5 follow-up findings of gastroscopy and CT in the robotic enucleation group. (A) Gastroscopy and CT examination were performed before surgery. (B) Gastroscopy and CT examination were conducted on the 5^th postoperative day (the same patient). CT, computed tomography.

Occurrence of intraoperative accidents and postoperative complications

In both groups, no accidental situations such as conversion to open surgery or tumor rupture occurred during surgery. In the robotic resection group, one case of infection was observed, whereas in the laparoscopic resection group, there were two cases of bleeding, one case of perforation, two cases of postoperative infection, and one case of poor wound healing. Comparison of the overall complication rates between the two groups (4.35% vs. 13.04%, P=0.70) showed no statistically significant difference (Table 5). No statistically significant difference was observed; however, the small robotic sample size limits the precision of safety estimates.

Postoperative pathology

The mean tumor diameter in the robotic resection group (2.68±1.55 cm) was significantly smaller than that in the laparoscopic resection group (5.14±3.77 cm, P<0.001). Among the patients in the robotic resection group, 9 (39.13%) were very low-risk, 6 (26.09%) were low-risk, 7 (30.43%) were intermediate-risk, and 1 (4.35%) was high-risk. In the laparoscopic resection group, 14 cases (30.44%) were very low-risk, 5 (10.87%) were low-risk, 11 (23.91%) were intermediate-risk, and 16 (34.78%) were high-risk. There was a statistically significant difference in the risk stratification between the two groups (P=0.04). Regarding the mitotic count and positive expression rates of CD34 (P=0.55), CD117 (P=0.55), and Dog-1 (P=0.61), no statistically significant differences were observed between the two groups, as shown in Table 6.

Follow-up results

During the follow-up period, 4 patients were lost to follow-up, including 3 from the laparoscopic resection group and 1 from the robotic resection group. A total of 27 months (range, 11–46 months) of follow-up was achieved. In both groups, 17 high-risk patients received imatinib (400 mg/day) postoperatively. During the follow-up, three cases of lesion recurrence were detected in the laparoscopic resection group and one case in the robotic resection group (Table 7).

Limitations

Given the retrospective, non-randomized design, analyses were exploratory and aimed to assess associations rather than causal effects. Due to the limitation of sample size, power analysis was not performed in this study, and a multicenter randomized controlled trial (RCT) is warranted in future research. The robotic cohort (n=23) limits statistical power, especially for uncommon complications, and wide confidence intervals cannot exclude clinically meaningful differences. The robotic group had smaller tumors, which may partially explain faster recovery; residual confounding remains even after adjustment. Moreover, with a median follow-up of only 27 months, long-term oncological outcomes such as the 5-year survival rate remain unevaluated, necessitating additional studies in this regard.

Discussion

The most common site of occurrence for GISTs is the stomach (3-5). The incidence of small GISTs originating in the stomach is substantially higher than that in their larger counterparts. Nevertheless, a contentious issue persists regarding whether surgical resection is warranted for small gastric GISTs (37). Due to the fact that GISTs have a certain malignant potential, the NCCN guidelines (38) advocate that for localized lesions with a diameter exceeding 2 cm, prompt surgical excision should be instituted. For GISTs with a diameter of ≤2 cm, in the absence of high-risk features such as ulcers, echo enhancement, heterogeneity, and irregular boundaries under endoscopic ultrasonography, regular follow-up is advised. Nevertheless, European experts (39) propose that even GISTs with a diameter less than 2 cm should be resected expeditiously. In summary, for GISTs with well-defined boundaries, complete surgical resection without tumor rupture is the optimal treatment strategy.

Some investigations posit that small gastric GISTs generally manifest with benign clinical progression. Surgical intervention, while subjecting patients to additional trauma, might concurrently increase the risk of implantation metastasis, thereby precluding patients from deriving benefits from the surgery. Consequently, surgical resection is discouraged, and a preference is given instead to close surveillance (38,40). However, recent studies have demonstrated that, although tumor volume correlates with risk classification, it fails to comprehensively determine the malignancy and prognosis of GISTs. Recurrence and metastasis can occur even in cases characterized by fewer mitotic figures and smaller tumor dimensions (41). Hence, for small GISTs with a conclusive diagnosis, surgical excision should be performed to attain R0 resection ought to be implemented. This enables a sound evaluation of the malignant potential of small GISTs based on postoperative pathology and can mitigate the risks of recurrence and metastasis associated with further growth of these tumors (11,41). In recent years, a growing number of clinicians have directed their attention towards ensuring complete capsule integrity (R0 resection) during the removal of small gastric GISTs, with the dual aim of minimizing surgical trauma and patient burden, and to truly confer benefits to patients from the standpoints of ERAS and minimally invasive surgery.

Currently, the surgical modalities predominantly employed in the minimally invasive treatment of small gastric GISTs can be broadly categorized into three groups: endoscopic surgery, laparoscopic surgery, and laparoscopic and endoscopic cooperative surgery (LECS) (30). LECS represents a revolutionary surgical technique that synergizes endoscopic and laparoscopic skills to perform the resection of gastric GISTs. Specifically, incisions are made around the tumor under endoscopic surveillance to demarcate the resection boundaries, after which minimally invasive excision is performed under laparoscopic guidance (30). Currently, the documented LECS procedures primarily consist of three variants: classic LECS (30,42), clean non-exposed technique (CLEAN-NET) (43,44), non-exposed endoscopic wall-inversion surgery (NEWS) (45,46), and closed-LECS (47). A wealth of existing research outcomes has demonstrated that, given that radical surgery for GISTs does not customarily necessitate lymph node resection, LECCS surgery has emerged as an eminently suitable operative approach for the resection of small stromal tumors situated within the proper muscle layer of the stomach.

In 2010, Buchs et al. (48) pioneered robotic-assisted laparoscopic surgery for the resection of gastric GISTs in five patients. Complete resection (R0) was achieved in each patient, and neither postoperative complications nor mortality were recorded. Subsequently, a team from the Massachusetts General Hospital in the United States, Lwin et al. (49), employed a robot-assisted surgical system to perform partial gastrectomy in 25 gastric GIST patients with anatomically challenging lesions. Their study ascertained that robot-assisted procedures could augment the safety and feasibility of function-preserving gastrectomy without compromising the integrity of tumor removal. Concurrently, in a multicenter case series study conducted in Italy, Solaini et al. (50) juxtaposed robotic, open, and laparoscopic approaches for the management of gastric GISTs. By scrutinizing 14 open surgeries, 63 laparoscopic surgeries, and 24 robotic surgeries, they posited that robotic assistance could yield superior outcomes in cases where laparoscopic manipulation proved to be difficult. However, this advantage was accompanied by an increase in operative duration and surgical costs. Collectively, the robotic surgical system, endowed with a clear three-dimensional surgical field of view, flexible robotic arm movements, and tremor-filtering design, is highly conducive to executing delicate maneuvers within complex anatomical frameworks and facilitating intricate suturing procedures. Particularly when confronted with GISTs situated in anatomically demanding locations, the merits of robotic surgery become even more conspicuous, facilitating the accomplishment of function-preserving gastrectomies such as pylorus- or cardia-preserving procedures.

However, whether it is laparoscopic surgery, the LECS, or robot-assisted resection of gastric GISTs, they inevitably cause damage to the mucosal layer. Therefore, a gastric tube needs to be indwelled for gastrointestinal decompression for 2 to 7 days after the operation. Grounded in the relatively mature LECS technique for excising gastric stromal tumors, our research team, by considering the anatomical idiosyncrasies and biological propensities of small gastric stromal tumors and under the precondition of guaranteeing radical resection, has devised a novel surgical modality: da Vinci robot-assisted laparoscopic and endoscopic cooperative resection for small gastric stromal tumors.

The operative strategy devised by our group entails endoscopic localization, submucosal puncture, and water injection to form a colored water cushion between the small stromal tumor and submucosa. This maneuver not only enables more precise positioning by the robot-assisted laparoscope to incise the serosal aspect of the stromal tumor, but also facilitates submucosal resection, thus fulfilling the objective of safeguarding the epithelial layer. Concurrently, owing to the presence of a submucosal water cushion, the integrity of the false capsule during the resection process can be effectively maintained.

Robotic-assisted laparoscopic and gastroscopic combined resection of gastric stromal tumors represents a pioneering surgical approach innovatively devised by our research team and purposefully tailored for the management of gastric stromal tumors. This novel technique evolved from the relatively established practice of laparoscopic and gastroscopic combined wedge resection of such tumors. Meticulously safeguarding the integrity of the gastric mucosal layer to the greatest extent possible effectively precludes the postoperative requirement of inserting a gastric tube to await mucosal recuperation. As a result, this advancement not only substantially truncates the patients’ overall recovery period, but also, in virtue of excellent mucosal preservation, affords an enhanced observational vista for conducting follow-up gastroscopic examinations in the postoperative phase.

In our research group, for the 23 cases involving cooperative laparoscopic and endoscopic enucleation of small gastric stromal tumors, no gastric tube was retained postoperatively. The patients were able to resume a liquid diet within 24 h following the surgery and were discharged 3–6 days thereafter. In our current retrospective study, compared with the traditional cases of laparoscopic and endoscopic cooperative wedge resection of gastric stromal tumors, robotic surgery is also safe and feasible for the management of small-diameter gastric stromal tumors, with favorable postoperative recovery outcomes achieved. Nevertheless, as an entirely novel surgical approach, systematic evaluation of its safety and efficacy remains lacking. Moreover, the retrospective design inherently limits causal inference; surgical approach selection is affected by tumor size, and the small sample size of the robotic group (n=23) reflects our team’s preliminary stage of technical implementation.

However, as an innovative surgical technique, its clinical application still has several aspects that need improvement. Firstly, there is a lack of support from large-sample, long-term prospective study data. The sample size of 23 cases in the robotic group only reflects the outcomes of the initial stage of technical application, and its long-term oncological outcomes (such as 5-year recurrence-free survival rate and overall survival rate) still require longer-term follow-up verification. Secondly, the selection of surgical methods is affected by factors such as tumor size and location. In this study, the average tumor diameter in the robotic group was smaller. Although covariance analysis was used to adjust for confounding factors, it may still have a certain impact on postoperative recovery indicators. In the future, matching design or RCTs are needed to further eliminate bias. On the other hand, although the postoperative hospital stay in the robotic group (mean, 5.04 days) was nearly half shorter than that in the laparoscopic group (mean, 9.43 days) in this study, saving part of the hospitalization costs, economic evaluation was not included in the current data, so it cannot be confirmed whether the savings from the reduced hospital stay can offset these additional costs (49). In the future, on the one hand, multi-center, large-sample RCTs should be carried out to systematically evaluate the efficacy and safety of this surgical method in small gastric stromal tumors of different tumor stages and anatomical locations; on the other hand, health economic research should be strengthened to quantify its cost-effectiveness ratio through long-term follow-up data.

Conclusions

This technique appears feasible in selected patients; however, due to the retrospective design and baseline imbalance, the results should be interpreted cautiously and validated in larger prospective or matched studies.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE and SUPER reporting checklists. Available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-718/rc

Data Sharing Statement: Available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-718/dss

Peer Review File: Available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-718/prf

Funding: This work was supported by the Tianjin Key Medical Discipline (Specialty) Construction Project (No. TJYXZDXK-058B) and the Scientific Research Project of Tianjin Union Medical Center (Nos. 2022PWXK05 and 2022PWXK03).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-718/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was approved by the Ethics Committee of Tianjin Union Medical Center, The First Affiliated Hospital of Nankai University on March 3, 2025 (approval No. 2025-B20) and individual consent for this retrospective analysis was waived. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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