Abstract
Background and objectives:
Enhanced recovery after surgery (ERAS) recommends avoiding enteral nutrition (EN) due to undesirable sequelae such as pulmonary aspiration and infections. Not using of EN in nongastric resections under ERAS pathways is often successful. However, parenteral nutrition (PN) alone followed by early postoperative oral feeding in gastric cancer patients, recommended by the ERAS guidelines, has unclear benefit and is only adopted after gastric resection. This study aimed to compute the postoperative outcomes of EN and PN compared to those of the ERAS-recommended nutritional pathway. Our secondary objective was to compare postoperative complications between the two groups.
Materials and methods:
Of 173 gastrectomy patients, 116 patients were in the combined group (EN and PN), whereas 57 patients were in the PN alone group. Statistical analysis was performed with the Statistical Package for the Social Sciences (SPSS) version 26.0.0 software. The data were analyzed by one-way ANOVA, the independent sample t-test, or, in the case of several independent samples, by the Kruskal–Wallis test. Categorical data were analyzed by Pearson’s χ2 test or Fisher’s exact test.
Results:
The observed indices included C-reactive protein (CRP), platelet (PLT), white blood cells (WBC), hemoglobin (Hb), albumin, and PRE-albumin. The secondary outcomes included length of hospital stay (LOS), cost, incidence of pulmonary infection, and total incidence of infection.
Conclusion:
The combined mode of nutrition is feasible and is not associated with postoperative complications in gastric cancer patients under ERAS.
Keywords: EN feeding tubes, ERAS, gastric cancer, PN
Introduction
Highlights
Enhanced recovery after surgery (ERAS) recommends the elimination of enteral nutrition (EN) due to undesirable sequelae such as pulmonary aspiration and infections. Benign neglect of EN in nongastric resections under ERAS pathways is often successful. However, parenteral nutrition (PN) alone followed by early postoperative oral feeding in gastric cancer patients recommended by ERAS guidelines is indistinct and merely adopted in gastric resections. This study’s objective was to compute the postoperative outcomes of EN and PN compared to the ERAS-recommended nutritional pathway. Our secondary objective was to observe postoperative complications between the two groups.
This study recommends a combination of EN and PN immediately after gastric resections in ERAS pathways.
Combined nutrition (EN and PN) is necessary, innocuous, feasible, and more beneficial in gastric cancer resections under the ERAS guidelines. We propose that EN elimination lacks significant evidence in gastric resections.
EN and PN does not increase the incidence of postoperative complications in patients and is beneficial for postoperative recovery
Adenocarcinoma is the most common type of gastric cancer, accounting for up to 90% of all stomach cancers1. Surgery is the only curative pathway for treating gastric cancer, but its insult usually results in catabolism due to surgical stress2,3. However, compared with previous surgical standards, the advent of enhanced recovery after surgery (ERAS) conveys a favorable prognosis4–7. Comparative studies between ERAS and conventional methods have shown that ERAS is superior to conventional methods. Hence, ERAS protocols are recommended in several surgical departments8–10. Despite extensive acclaim, some of its pathways are difficult to comply with.
Enteral nutrition (EN) and parenteral nutrition (PN) are expected to serve the same purpose, but they have differences. EN is believed to preserve the mucosal structure, microbiota, and gut-associated lymphoid tissue; stimulate early gut function; and improve both hepatic and pulmonary functions11,12. PN is chiefly recommended when the gastrointestinal tract is dormant or when it is urgent to restore nutritional status13,14.
It is necessary to integrate EN and PN in gastric resections within the ERAS pathway, as they significantly impact patient outcomes and play a crucial role in recovery. The difference between EN and PN under ERAS pathways is not often evaluated since eliminating EN after surgery is recommended.
The current ERAS guidelines suggest that patients be given oral fluids immediately after surgery to avoid EN. Mortensen et al.15 concluded that a nasogastric tube should not be placed in patients with gastric cancer. Unfortunately, the amount of food consumed orally consumed shortly after gastric surgery is minimal. Therefore, an alternative approach to eliminating nutritional risks and improving patient outcomes in patients with gastric malignancies, beyond the ERAS guidelines, is imperative. PN alone is the most common routine under ERAS guidelines.
EN has advantages over PN16, but EN might be associated with a burden of tube-related pulmonary infections, which could provoke an immune response, delay recovery, prolong hospital stays, and raise costs. Furthermore, it is well understood that PN is recommended mainly for patients with severe or prolonged ileus17,18. Due to its fewer postoperative complications, ERAS can reduce patient hospitalization costs19,20. Another study on ERAS in colorectal cancer patients suggested that ERAS can increase cost-effectiveness and improve the quality of medical care21.
There are unanswered questions about feeding tubes under ERAS pathways. First, is it necessary to insert EN combined with PN under ERAS guidelines? Second, is EN feasible in the ERAS setting? Third, are complications associated with EN combined with PN inevitable? We designed this research to analyze postoperative manifestations in patients administered either EN and PN combined or PN alone after surgery under the ERAS guidelines to determine whether combined EN and PN is necessary, feasible and safe. In this study, we analyzed two groups of patients treated with different nutritional administration methods under the ERAS guidelines. In the combined group, patients were administered EN via the nasojejunal route and/or PN via the intravenous route. None of the patients in this retrospective study underwent percutaneous endoscopic gastrostomy, because patients given percutaneous endoscopic gastrostomy often have chronic underlying disease or vulnerable general conditions or are unable to receive EN through nasogastric or nasojejunal feeding tubes22.
Materials and methods
Medical records of patients who underwent resection for gastric malignancies between February 2020 and November 2021 were searched. Two groups of surgeons who randomly performed the surgeries could be distinguished in the patients’ medical records: one group used both EN and PN combined, while the other group eliminated EN. Perioperative patient data, including nutritional mode, could also be retrieved from their respective medical records. A total of 740 gastrointestinal resection case reports were detected, and only 173 patients met the inclusion criteria (Image 1). A total of 116 patients were included in the combined group, whereas 57 patients were included in the PN group (Image 1). All these patients had histologically confirmed gastric malignancies.
Image 1.
Consolidated standards of reporting trials flow diagram.
Inclusion and exclusion criteria
Inclusion criteria: (1) aged 18–80 years; (2) did not receive chemotherapy or other antitumor treatments before surgery; (3) underwent elective D2 surgery; (4) underwent ERAS; (5) received nasojejunal tubes such as EN combined with PN, indicated as the nutrition tube group (NTG), or did not use EN or the nonenteral nutrition tube (NeTG) (Table 1); and (6) provided informed consent from the patients and their families.
Table 1.
ERAS protocols employed in the study hospital
| Preoperative | Operative | Postoperative | |||||
|---|---|---|---|---|---|---|---|
| After surgery | POD 1 | POD 2-4 | POD 5 | ||||
| Multidepartment team screening (MDT) | Screening | Surgical approach | Screening | Follow-up | Screening | ||
| Carbohydrates | 600 ml 2–4 h prior to surgery | ||||||
| Fluid | Balanced iv fluid | (NeTG) 2000–3000 ml PN (NTG) EN was administered depending on patients weight |
|||||
| Nutrition | Regular diet | Clear fluids 2 h before anesthesia | (NTG) Combined EN and PN: Enteral Nutritional Suspension (SP) (NeTG) PN alone |
Commencement of oral fluid diet until discharge | |||
| Evaluation of gastric retention | Yes | Evaluated in both groups | |||||
| Prophylaxis | Antibiotic prophylaxis 1 g cefmetazole sodium iv | If the operation is over 2 h, 1 g cefmetazole sodium iv | 1 g cefmetazole sodium iv for the first 3 days | ||||
| Temperature | (MDT) | Intraoperative temperature monitoring | After every 4 h until discharge | ||||
| Bowel preparation | No | ||||||
| Surgical approach | (MDT) | Minimal invasive is preferred unless otherwise | |||||
| Feeding tubes | Randomly selected | (NTG) or (NeTG) | Remove | ||||
| Drainage tube | Yes | » | » | Remove | |||
| Urinary catheter | Yes | » | Remove | ||||
| Analgesia | NSAIDs (IM) | Low opiate dose and TAP | Iv NSAIDs every 12 h for the first 3 days | ||||
| Ambulation | Bed activities | Bedside walking | Walking in hospital corridor | Normal ambulation | |||
Exclusion criteria: (1) gastric cancer causes complications (bleeding, obstruction, or perforation) and obstructive symptoms; (2) major cardiovascular disease, respiratory, and renal dysfunction, history of myocardial infarction or cerebrovascular accident within the past 6 months, and history of upper abdominal surgery; (3) gastric cancer recurrence, distant metastasis, combined organ resection; (4) severe obesity (BMI >30 kg/m2) or severe malnutrition (BMI <15 kg/m2).
Data recording and collection
The EN tube was placed mechanically at the end of each surgery by specialists. Imaging studies confirmed the correct positioning of the lesion at a level beyond the anastomotic plane, aiming to minimize the incidence of infections and anastomotic leakage. Immune and inflammatory indices were collected before surgery, followed by morning blood sample collection during the entire inpatient period. All the clinical indices presented in this article were laboratory analyzed from blood samples.
The accumulated data from the patients’ medical records were searched manually for significant variables, including patient age, sex, weight, BMI, inflammatory markers, immune cells, length of hospital stay (LOS), pulmonary infections, total incidence of complications, and cost.
A thin nasojejunal polyurethane feeding tube (size 10F, Flocare, Beijing L&Z Medical Technology Development Co., Ltd.) was placed on the well-ventilated side of the nasal cavity in all NTG groups immediately after surgery. The tube was flushed every 8 h with 25–50 ml of warm water to avoid pipeline blockage.
The EN contents included water, maltodextrin, whey protein hydrolysate, vegetable oil, vitamins, minerals, microelements, and other essential nutrients. Each patient was administered ~2000 kcal/day, which is equivalent to four bottles (500 ml/bottle/day), though this amount varied according to the patient’s weight. The initial starting dosage was 1000 kcal/day, equivalent to two bottles with 500 ml/bottle. Treatment was stopped if the patient had gastrointestinal failure, complete intestinal obstruction, or severe intraperitoneal infection.
Statistical analysis
Statistical analysis was performed with the Statistical Package for the Social Sciences (SPSS) version 26.0.0 software (SPSS, Inc.). The normality of data distributions were tested with the Kolmogorov–Smirnov test. Normally distributed data were analyzed by one-way ANOVA or the independent sample t-test and are presented as the mean±SD. Nonparametric data were analyzed by the Mann–Whitney U test (two independent samples) or the Kruskal–Wallis test (≥3 independent samples). Categorical data were analyzed by Pearson’s χ2 test or Fisher’s exact test.
Results
Among the 173 patients in the combined group, 116 met the inclusion criteria, whereas 57 patients in the PN alone group met the inclusion criteria. The patients’ preoperative parameters are indicated in Table 2. Of the 116 patients in the combined group, 40 were female and 76 were male, whereas 57 patients in the PN alone group consisted of 25 females and 32 males. The preoperative and postoperative parameters that were observed included C-reactive protein (CRP), white blood cell (WBC) count, platelet (PLT) count, hemoglobin (Hb), albumin, pre-albumin, hospital cost, LOS, total incidence of complications, and pulmonary infection. For the preoperative parameters, no significant differences were observed between the two groups in patient age, sex, weight, BMI, CRP, or pre-albumin. There was a significant difference in Hb and PLT between the two groups (Table 2).
Table 2.
Demographic parameters of patients included in the study
| Characteristics | Mode of nutrition | N | Mean±SD | P-value of significance |
|---|---|---|---|---|
| Age (years) | Combined | 116 | 66.67±8.22 | 0.271 |
| PN | 57 | 65.12±9.53 | ||
| Sex (F/M) n | Combined | 116 | 40/76 | 0.246 |
| PN | 57 | 25/32 | ||
| Weight (kg) | Combined | 114 | 63.13±10.40 | 0.118 |
| PN | 57 | 66.07±13.56 | ||
| BMI (kg/m2) | Combined | 114 | 23.58±2.98 | 0.275 |
| PN | 57 | 24.15±3.56 | ||
| CRP (mg/l) | Combined | 89 | 2.69±5.75 | 0.480 |
| PN | 35 | 3.87±12.67 | ||
| WBC (X 109) | Combined | 110 | 6.26±1.88 | 0.520 |
| PN | 53 | 6.60±4.75 | ||
| Hb (g/l) | Combined | 110 | 119.70±23.98 | 0.006 |
| PN | 53 | 130.60±22.16 | ||
| PLT (X 109) | Combined | 111 | 233.90±89.26 | 0.019 |
| PN | 52 | 200.60±71.06 | ||
| Albumin (g/l) | Combined | 110 | 38.06±3.63 | 0.578 |
| PN | 53 | 38.47±5.70 | ||
| Pre-Albumin (mg/l) | Combined | 15 | 183.30±57.50 | 0.901 |
| PN | 10 | 186.40±65.84 |
Clinical indices
WBC
Compared with that in the PN alone group, the WBC count was lower on the third postoperative day in the combined group (P<0.05). These results indicate that the patients in the combined group had improved inflammation and infection levels (Table 3).
Table 3.
Comparison of CRP levels, WBC counts, PLTs, and HBs
| CRP | WBC | PLT | HB | |||||
|---|---|---|---|---|---|---|---|---|
| Day | Mean±SD | P | Mean±SD | P | Mean±SD | P | Mean±SD | P |
| 1 | ||||||||
| Combined | 50.17±29.39 | 0.0415 | 14.64±11.79 | 0.1591 | 216.30±79.90 | 0.0212 | 116.60±19.09 | 0.0666 |
| PN | 61.39±40.39 | 12.38±3.30 | 189.40±49.52 | 122.10±15.86 | ||||
| 3 | ||||||||
| Combined | 54.63±40.35 | 0.0416 | 8.57±2.61 | 0.0349 | 210.90±75.79 | 0.0446 | 112.10±19.07 | 0.0579 |
| PN | 70.66±49.85 | 9.56±3.05 | 187.90±46.52 | 118.20±18.05 | ||||
| 5 | ||||||||
| Combined | 29.89±34.36 | 0.7315 | 6.89±2.42 | 0.9688 | 231.30±91.75 | 0.0686 | 112.10±15.43 | 0.0758 |
| PN | 31.98±26.11 | 6.92±4.86 | 204.20±67.30 | 117.20±14.72 | ||||
| 7 | ||||||||
| Combined | 15.59±20.35 | 0.4748 | 6.95±2.76 | 0.3389 | 249.60±99.68 | 0.1549 | 112.30±15.25 | 0.1511 |
| PN | 18.63±19.94 | 6.48±2.09 | 225.50±60.59 | 116.70±14.41 | ||||
Creatinine reactive protein (CRP); hemoglobin (Hb); platelets (PLTs); white blood cells (WBCs).
CRP
Compared with that in the PN alone group, the CRP level was lower on the first and third postoperative days in the combined group (P<0.05). This specific marker was used to equate the levels of inflammation after surgery. These results indicate that patients in the combined group had improved inflammation and infection levels (Table 3).
PLT
A significant difference between the two study groups was observed. Patients in the combined group had more PLTs than those in the PN alone group on the first and third postoperative days (P<0.05) (Table 3).
Hb
When we compared the Hb levels of the two groups at the first, third, fifth, and seventh postoperative days, there was no significant difference (Table 3).
Albumin
While a significant difference was obvious between the groups on the third, fifth, and seventh postoperative days (P<0.05), the albumin levels increased in both groups. Due to the nature of gastric cancer resection, most patients have higher inflammatory levels associated with disease and nutritional risks even before surgery. However, these levels were remedied after tumor resection and the commencement of feeding tubes. On postoperative Day 1, the PN alone group had similar albumin levels to those of the EN+PN group (Table 4).
Table 4.
Comparison of nutritional parameters
| Albumin g/l | PRE-Albumin mg/l | |||
|---|---|---|---|---|
| Day | Mean±SD | P | Mean±SD | P |
| 1 | ||||
| Combined | 34.16±3.64 | 0.1024 | 192.00±46.91 | 0.8096 |
| PN | 33.20±2.70 | 189.90±50.12 | ||
| 3 | ||||
| Combined | 34.46±3.67 | 0.0321 | 159.00±44.67 | 0.0437 |
| PN | 33.12±.54 | 140.5±36.55 | ||
| 5 | ||||
| Combined | 34.27±3.21 | 0.0251 | 172.20±42.34 | 0.0405 |
| PN | 32.98±3.01 | 151.20±47.34 | ||
| 7 | ||||
| Combined | 34.99±3.41 | 0.0270 | 176.10±58.69 | 0.0273 |
| PN | 33.42±3.87 | 138.00±242.56 | ||
Pre-albumin
On the third, fifth, and seventh postoperative days, pre-albumin in the pEN+PN group was significantly higher than that in the PN group. This finding is consistent with the change trend of albumin (Table 4).
The secondary outcomes included postoperative pulmonary infections, LOS, and total incidence of infections.
Cost
The postoperative hospital cost was calculated, excluding the preoperative or operative cost. The currency used was the Chinese yuan, which had an estimated rate of 1 USD=6.5 Chinese yuan. The patients in the combined group spent less during the postoperative period than the PN alone group (mean±SD=6000.46±1338.88 and 7958.21±1762.77) (P<0.05) (Table 5).
Table 5.
Postoperative cost and hospital stay
| N | Mean±SD | P-value of significance | |
|---|---|---|---|
| Postoperative cost | |||
| Combined | 116 | 6000.46±1338.88 | 0.00 |
| PN | 57 | 7958.21±1762.77 | |
| Postoperative LOS | |||
| Combined | 116 | 13.56±4.99 | 0.029 |
| PN | 57 | 17.04±11.45 | |
Length of hospital stay (LOS) and hospital cost in Chinese RMB.
Postoperative cost and LOS
The patients in the combined group spent fewer postoperative days than those in the PN alone group (mean±SD=13.56±4.99 and 17.04±11.45, respectively), and the pooled result was significant (P-value=0.029) (Table 5). A shorter duration of hospital stay was a result of limited postoperative complications. Generally, the expenditures of the patients in the combined group were far less than those in the PN alone group. This strategic approach of implementing combined feeding tubes in ERAS pathways has led to the use of buoyed EN, as it is both more beneficial and less expensive. Evidently, this low-cost method was also associated with fewer complications, a reduction in medications and early discharge. This cost-efficient model is crucial to patient prognosis, financial capabilities, and patient satisfaction and plays a vital role in managing hospital resources (Table 5).
Postoperative complications
The probability of any postoperative complication in the combined group was significantly lower than that in the control group, though there was no significant difference in the incidence of pulmonary infection between the two groups. This finding indicates that placing a feeding tube during the operation does not increase the probability of pulmonary infection after the operation (Fig. 1). The Clavien–Dindo complication grades are given in Table 6.
Figure 1.
Comparison of the total incidence of complications and of pulmonary infection between the combined group and parenteral nutrition group.
Table 6.
Clavien–Dindo classification of postoperative complications
| Determinant | Combined | PN | χ2 -value | P |
|---|---|---|---|---|
| 0.670 | ||||
| Grade I | 9 | 11 | ||
| Grade II | 7 | 6 | ||
| Grade III | 2 | 2 | ||
| Grade IV | 2 | 0 |
Discussion
Albumin and pre-albumin levels are only used to assess inflammation in the context of malnutrition risk and not explicitly to determine the malnutrition risk. It was previously suggested that the serum albumin level is associated with the acute-phase response to tissue catabolism and inflammation. Another study confirmed the significance of the serum ALB concentration for inflammation and postoperative prognosis. The authors also demonstrated the importance of EN after surgery23,24.
In our study, the albumin in the PN group was not significantly different 1 day after surgery from that in the combined group. However, a few days after surgery, the patients in the combined group had improved levels of albumin and pre-albumin compared to those in the PN alone group.
ERAS recommends EN omission due to the presupposed distress of irritation, incidence of pulmonary aspiration, infections, and tube malpositioning25. These dogmas have influenced ERAS studies, leading them to advocate eliminating the use of EN in theory. For this reason, some ERAS studies reject the use of EN or EN combined with PN. Remarkably, our study showed no significant difference between the two groups in terms of EN-related side effects, such as pulmonary infections. This could be caused by the mechanical placement of the EN tube during the intraoperative period and observation of the tube guided by imaging studies.
It is unquestionable that decreased infection rates, nutritional risk, inflammation, and complications followed by enhanced immunity and tissue healing increase patient mobility and reduce the LOS and cost7,26–28. This typical benefit was also observed in our study and other previously recorded data from non-ERAS studies29–33.
To address potential biases of our study, surgeries selected for retrospective analysis were randomly chosen from among those performed by two experienced surgeons (NTG and NeTG), where the severity of malignancy, age, sex, or metastasis did not play any role in grouping the patients between the two surgical units. Other related biases could be linked to disease progression in different individuals and to the study duration.
Studies have reported incidences of postoperative nasogastric tube-associated complications resulting from patient discomfort, anxiety, depression, and delirium30,34,35. Moreover, EN alone has been reported to increase postoperative immune T-cell levels and improve patients’ nutritional status and energy levels at a lower cost. Furthermore, a meta-analysis showed no significant difference between EN alone and PN alone in terms of postoperative EN-related pulmonary infections36,37. Dorota et al. reported the beneficial effect of combined nutritional treatment on significant improvements in inflammatory biomarkers, such as albumin and pre-albumin. Two separate meta-analyses concluded that combining EN and PN increased the albumin and pre-albumin levels38,39. Several studies have shown that EN combined with PN is feasible and safe and improves immunological function compared to EN or PN alone40,41. Even though several studies favor EN or EN combined with PN, stringent ERAS evaluation of gastric malignancies is challenging, as ERAS studies limit EN administration, making our rationale exceptional within the ERAS literature.
Total oral intake is mostly feasible 1–2 weeks after surgery. The surgical patient already has a cancerous physique and only depends on a small amount of clear fluid during the early postoperative days; this amount is nutritionally insufficient and further diminishes patients’ nutritional values and immune responses, stimulating inflammation, and delaying recovery. A prior ERAS study revealed that the recommended early postoperative intake of clear fluid alone might not improve patient outcomes36. We can argue that gastric cancer patients undergoing ERAS protocols might be at risk of malnutrition after gastric cancer resection. Therefore, EN elimination should not be routinely recommended in gastric resections3. Notably, benign omission of EN after nongastrointestinal resection under ERAS guidelines is often successful. However, the use of early postoperative oral feeding and the exclusion of feeding tubes in gastric cancer patients has uncertain benefits and has rarely been tried.
This study recommends a combination of EN and PN immediately after gastric resection via the ERAS pathway. Our results can be summarized as follows: when EN and PN are combined, there are fewer anorexigenic features, an enhanced response to surgery and immunity, fewer postoperative complications, and greater recovery after surgery, as well as a shorter LOS and lower cost compared to EN omission as proposed by the current ERAS guidelines. These findings demonstrated that the patients in the combined group improved in both pathological and physiological responses to surgery, as the levels of surgical stress-related inflammation and infections decreased in the combined group compared to the PN alone group.
Conclusion
Combined nutrition (EN and PN) is necessary, innocuous, feasible and more beneficial in gastric cancer resections under the ERAS guidelines. We propose that EN omission is not backed by strong evidence after gastric resection. Furthermore, mechanical placement of the EN tube supported by imaging studies can limit complications of EN. ERAS policy-makers should further evaluate the necessity of EN in select patients who have undergone gastric cancer resection, as the need to maintain and improve patient physiology outweighs the burden accompanying its use.
Study limitations
This study included a few ERAS patient samples, as patients who could tolerate early oral feeding did not need any form of tube feeding. Some patients had EN interruption due to GI dysfunctions. Preoperative parameters were compared between the PN+EN group and the PN group, and differences in Hb and PLT were detected, which affected the comparability of the comparison groups and may have resulted in confounding bias. Moreover, we did not consider the magnitude of the effect sizes when explaining the results, which could affect the credibility of the results. The study was also limited to a single center, the sample was small, and the number of patients analyzed for each variable was not consistent. All the qualitative studies that used EN were not performed under ERAS protocols.
Ethical approval
Ethical approval for this study (Ethical number: 2016035) was provided by the Ethics Committee of Jiangbin Hospital on 02 March 2016. The address of the ethics committee: 438 Jiefang Road, Jingkou District, Zhenjiang City, Jiangsu Province, China. All procedures used in this study complied with the WMA Declaration of Helsinki ethical principles for medical research involving human subjects. All patients under ERAS protocols in Jiangbin Hospital were adequately informed about their involvement in this research program and willingly gave their consent. This study has been registered at the Chinese Clinical Trials Registry (ChiCTR2300068532).
Consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
Sources of funding
Jiangsu Commission of Health (Grant numbers: LKZ2023012).
Social Development Project of Zhenjiang City(Grant numbers:SH2022061).
Author contribution
J.C.: study design; X.F.: writing the paper; Y.X., R.W., L.Z., and H.H.: research design, implementation of specific measures, and data collection; H.H.: data analysis and interpretation.
Conflicts of interests disclosure
The authors declares no conflicts of interests for this article.
Research registration unique identifying number (UIN)
ChiCTR2300068532. https://www.chictr.org.cn/showproj.html?proj=180393
Guarantor
Xin fan, Chief Physician of Jiangsu University Affiliated Hospital, E-mail: drfanxin@163.com.
Data availability statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
Provenance and peer review
Not commissioned, externally peer-reviewed.
Animal studies
None.
Footnotes
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Published online 24 January 2024
Contributor Information
Xin Fan, Email: drfanxin@163.com.
Yachen Xu, Email: one755@sina.com.
Rong Wan, Email: 1023623184@sina.com.
LiWen Zhang, Email: 1356573444@qq.com.
He Han, Email: 514354713@qq.com.
Jixiang Chen, Email: jsdxfsyycjx@163.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.