The Influence of Differences in Surgical Access on the Development of Early Asymptomatic DVT After Inguinal Hernia Surgery

Abstract

Objective

This study aimed to examine the effect of surgical approach on the incidence of early asymptomatic deep vein thrombosis (DVT) following inguinal hernia surgery and to evaluate additional factors influencing postoperative asymptomatic DVT formation. The study seeks to provide guidance and support for the diagnosis and treatment of early postoperative asymptomatic DVT.

Methods

The present study is a retrospective study. Our study finally included 565 patients with inguinal hernia divided into laparoscopic and open surgery groups. Bilateral lower extremity venous Doppler ultrasonography was performed on the second postoperative day to document the occurrence of asymptomatic DVT in the early postoperative period. A 1:1 matching was performed using propensity score matching (PSM). Independent factors affecting early postoperative asymptomatic DVT were determined using multivariate binary logistic regression analysis.

Results

There were 565 patients, in which 317 underwent laparoscopic surgery and 248 underwent open surgery. Propensity score matching yielded 102 matched pairs for further analysis. In multivariate analysis, bilateral hernias (OR = 50.546, 95% CI 2.277-1122.159, P = 0.013) and total length of stay (OR = 1.807, 95% CI 1.239-2.634, P = 0.002) were identified as independent risk factors for early postoperative asymptomatic DVT, whereas preoperative length of stay (OR = 0.341, 95% CI 0.162-0.719, P = 0.005) and operation time (OR = 0.965, 95% CI 0.936-0.995, P = 0.021) served as protective factors. There was no significant impact of laparoscopic or open surgery on the incidence of early postoperative asymptomatic DVT (OR = 1.808, 95% CI: 0.288-11.361, P = 0.528).

Conclusion

The choice of laparoscopic vs open inguinal hernia repair did not significantly affect the incidence of early postoperative asymptomatic DVT. In this study, effective perioperative management, whether through preoperative admission to manage significant comorbidities or a reduced overall length of stay, lowered the incidence of early postoperative asymptomatic DVT, particularly in patients with bilateral inguinal hernias.

Keywords

inguinal hernia asymptomatic deep vein thrombosis surgical approach propensity score matching

Key Takeaways

• In this study, the incidence of asymptomatic DVT after inguinal hernia surgery was significantly higher than that of symptomatic DVT.

• With the development of modern medical technology, there is no significant difference in the risk of early asymptomatic DVT after inguinal hernia surgery between laparoscopic surgery and open surgery, which further proves the safety of laparoscopic surgery.

• In this study, effective perioperative management, whether through preoperative admission to manage significant comorbidities or a reduced overall length of stay, lowered the incidence of early postoperative asymptomatic DVT, particularly in patients with bilateral inguinal hernias. However, it needs to be further verified by combining research data from other countries and regions.

Introduction

Inguinal hernia is a common and frequent disease. Currently, surgery is the only treatment for inguinal hernia in adults. Surgical methods for inguinal hernia are open, laparoscopic, or robotic.^1,2 With the development of laparoscopic technology and its widespread application in hernia surgery, the rate of laparoscopic inguinal hernia surgery has gradually increased. Some studies have demonstrated that laparoscopic surgery can reduce acute and chronic pain and allow for quicker recovery.³ In practice, open surgery is preferred for certain high-risk elderly patients who cannot tolerate general anesthesia.⁴ However, previous studies have reported that both laparoscopic and open surgeries may increase the risk of postoperative deep vein thrombosis (DVT).^5,6

Deep vein thrombosis is one of the complications of all types of surgical procedures.⁷ Clinical signs and symptoms of DVT mainly include leg pain, redness, swelling, edema, fever, and localized tenderness of the affected limb.⁸ In clinical practice, we often focus on and detect symptomatic DVT while ignoring asymptomatic DVT. Some studies have reported that about 70%-80% of DVTs are asymptomatic in clinical practice.⁹ A study of foot and ankle surgeries found that the incidence of postoperative DVT was nearly 14.7%, with the vast majority of these clots being of the asymptomatic type.¹⁰ These asymptomatic DVTs often go undetected, but if left untreated, they can lead to more serious complications, such as pulmonary embolism (PE), which can jeopardize a patient’s life and health.

Currently, there is a significant lack of research on asymptomatic DVT after inguinal hernia surgery worldwide. The aim of our study was to investigate whether different surgical approaches affect the occurrence of early asymptomatic DVT after inguinal hernia surgery and to investigate the factors influencing the formation of early postoperative asymptomatic DVT, so as to provide guidance and support for the diagnosis and treatment of asymptomatic DVT in clinical practice.

Methods

Research Population

We collected clinical data on 565 patients with inguinal hernia who were hospitalized between January 2021 and December 2022 in the center participating in the study. Patients voluntarily participated in the clinical study and signed an informed consent form. The study was approved by the ethics committees of the participating research centers and followed the guidelines of the Declaration of Helsinki.

Data Adoption Standards

Inclusion criteria are as follows: (1) Complete case information; (2) age over 18 years; (3) use of synthetic mesh in all cases; (4) all patients were specifically admitted to the hospital to undergo inguinal hernia surgery; (5) including elective surgeries delayed due to underlying diseases (eg, coronary artery disease and diabetes mellitus); Exclusion criteria are as follows: (1) Emergency incarcerated hernia or urgent strangulated hernia; (2) preoperative diagnosis of DVT; (3) symptomatic DVT; (4) history of coagulopathy, hematologic disorders, or recent use of anticoagulant drugs.

Preoperative Preparation and Evaluation Criteria

Upon admission, patients were required to review their medical history and complete relevant preoperative tests to determine the presence of preoperative comorbidities. All surgical patients were scored strictly according to the Caprini scoring system. Color Doppler ultrasound is the diagnostic method of choice for DVT.¹¹ Therefore, we performed bilateral lower extremity venous Doppler ultrasound in patients preoperatively to rule out the presence of DVT. All patients included in this study did not undergo preoperative DVT prophylaxis. All patients with preoperative comorbidities were prepared in strict accordance with perioperative management measures.

Surgical Methods

Open Surgery Group: The skin and subcutaneous fascia were incised, the spermatic cord was isolated, the hernia sac was treated, and the repair material was inserted and fixed. The laparoscopic surgery group comprised laparoscopic transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) hernia repairs. All surgeries were conducted by surgeons holding at least the rank of associate chief physician.

Data Gathering

Demographic Data Included Age and Sex

Preoperative variables included site of disease (unilateral and bilateral), disease type (direct hernia, indirect hernia, femoral hernia, and composite hernia), preoperative comorbidities (hypertension, cerebrovascular disease, cardiology, malignant tumor, and diabetes), Caprini score, and preoperative length of stay. Surgical data included surgery type (laparoscopic surgery and open surgery), intraoperative blood loss, and operation time. Postoperative data included total length of stay.

All Patients are Given Sequential Compression Device (SCD)

All patients are given sequential compression device (SCD) for thromboprophylaxis on the day of surgery and are routinely out of bed on the first day after surgery. Because the hypercoagulable state of surgical patients usually lasts until 48 hours after surgery, during which the incidence of acute DVT peaks,¹² we used the results of bilateral lower extremity venous Doppler ultrasound performed on the second day after surgery as a final result to document the occurrence of asymptomatic DVT in the early postoperative period.

Management of DVT

Patients with early postoperative DVT were monitored for vital signs and initially treated with low-molecular-weight heparin calcium followed by a gradual transition to oral rivaroxaban. The duration of anticoagulation was prolonged as appropriate based on follow-up assessments.

Propensity Score Matching

Propensity score matching (PSM) was employed to create paired patient groups and compare the incidence of early postoperative asymptomatic DVT between laparoscopic and open surgery groups, thereby reducing selection bias. Propensity scores were calculated using variables such as age, sex, disease site and type, hypertension, cerebrovascular disease, cardiology, malignant tumor, diabetes, Caprini score, preoperative length of stay, intraoperative blood loss, operation time, and total length of stay. A 1:1 matching was conducted with a 0.1 caliper width, and the matched pairs were used for further analysis.

Statistical Analysis

Data analyses were conducted using R (Version 4.3.3) and SPSS (Version 27.0) software. Non-normally distributed continuous variables were represented as median and interquartile range, and analyzed using the Mann-Whitney U test. Categorical variables were presented as counts and percentages, with intergroup comparisons conducted using the chi-square or Fisher’s exact test. Multivariate analysis was conducted using a binary logistic regression model. A P-value below 0.05 was deemed statistically significant for all tests.

Results

Clinical Baseline Data of All Patients

This study analyzed 565 patients with inguinal hernias. The median age of the patients was 63 years, with the majority being male (90.6%, n = 512). Unilateral hernias accounted for 70.6% (n = 399), while bilateral hernias accounted for 29.4% (n = 166). 12.6% (n = 71) of the patients had direct inguinal hernias, 70.6% (n = 399) had indirect inguinal hernias, 3.5% (n = 20) had femoral hernias, and 13.3% (n = 75) had composite hernia. Preoperative comorbidities included hypertension in 23.9% (n = 135) of patients, cerebrovascular disease in 2.7% (n = 15), cardiology issues in 5.5% (n = 31), malignant tumors in 1.4% (n = 8), and diabetes in 4.2% (n = 24). The median preoperative length of stay was 2 days, operation time was 90 minutes, intraoperative blood loss was 5 mL, total length of stay was 6 days, and Caprini score was 2 points. Of these patients, 56.1% (n = 317) underwent laparoscopic surgery, and 43.9% (n = 248) chose open surgery. The total number of patients who developed early postoperative asymptomatic DVT was 22(3.9%), with no symptomatic DVT or PE detected. Clinical baseline data are shown in Table 1.

Table 1.

Demographic and Operative Characteristics (n = 565)

Characteristic	Value
Age (y)	63(53-71)
Sex
Male, n (%)	512(90.6%)
Female, n (%)	53(9.4%)
Site of disease
Unilateral, n (%)	399(70.6%)
Bilateral, n (%)	166(29.4%)
Disease type
Direct hernia, n (%)	71(12.6%)
Indirect hernia, n (%)	399(70.6%)
Femoral hernia, n (%)	20(3.5%)
Composite hernia, n (%)	75(13.3%)
Hypertension (+), n (%)	135(23.9%)
Cerebrovascular disease (+), n (%)	15(2.7%)
Cardiology (+), n (%)	31(5.5%)
Malignant tumor (+), n (%)	8(1.4%)
Diabetes (+), n (%)	24(4.2%)
Preoperative length of stay (d)	2(2-4)
Operation time (min)	90(70-120)
Intraoperative blood loss (ml)	5(5-10)
Total length of stay (d)	6(5-8)
Caprini	2(1-2)
Surgery type
Laparoscopic, n (%)	317(56.1%)
Open, n (%)	248(43.9%)
DVT (+), n (%)	22(3.9%)

DVT, deep vein thrombosis. Data are n (%) or median (interquartile range) unless otherwise specified.(+): Positive

Comparison of Pre-PSM Data

Table 2 presents the pre-matching clinical baseline data comparison between the laparoscopic and open surgery groups. Some baseline characteristics of the variables between the two groups were not similar. No significant differences were found in sex, hypertension, cerebrovascular disease, malignant tumor, diabetes, or preoperative length of stay. Significant differences were observed in age (P < 0.001), disease site (P < 0.001), disease type (P < 0.001), cardiology (P = 0.006), operation time (P < 0.001), intraoperative blood loss (P < 0.001), total length of stay (P < 0.001), and Caprini score (P < 0.001). Multivariate analysis identified total length of stay (OR = 1.421, 95% CI 1.216-1.662, P < 0.001) as an independent risk factor for early postoperative asymptomatic DVT, whereas preoperative length of stay (OR = 0.690, 95% CI 0.529-0.900, P = 0.006) was found to be a protective factor (Table 4).

Table 2.

Comparison of Clinical Data in Patients Before PSM in the Laparoscopic and Open Surgery Groups

Variable	Laparoscopic(n = 317)	Open (n = 248)	P-Value
Age (y)	59(52-68.5)	65(57-73)	<0.001‡
Sex			0.024*
Male, n (%)	295(93.1%)	217(87.5%)
Female, n (%)	22(6.9%)	31(12.5%)
Site of disease			<0.001*
Unilateral, n (%)	184(58%)	215(86.7%)
Bilateral, n (%)	133(42%)	33(13.3%)
Disease type			<0.001*
Direct hernia, n (%)	60(18.9%)	11(4.4%)
Indirect hernia, n (%)	199(62.8%)	200(80.6%)
Femoral hernia, n (%)	8(2.5%)	12(4.8%)
Composite hernia, n (%)	50(15.8%)	25(10.1%)
Hypertension (+), n (%)	71(22.4%)	64(25.8%)	0.346*
Cerebrovascular disease (+), n (%)	6(1.9%)	9(3.6%)	0.203*
Cardiology (+), n (%)	10(3.2%)	21(8.5%)	0.006‡
Malignant tumor (+), n (%)	2(0.6%)	6(2.4%)	0.147†
Diabetes (+), n (%)	15(4.7%)	9(3.6%)	0.519*
Preoperative length of stay (d)	2(2-4)	2(2-4)	0.542‡
Operation time (min)	100(78-125)	80(60-100)	<0.001‡
Intraoperative blood loss (ml)	5(5-5)	5(5-10)	<0.001‡
Total length of stay (d)	5(4-7)	7(6-10)	<0.001‡
Caprini	1(1-2)	2(1-2)	<0.001‡

PSM, propensity score matching; (+), positive. Data are n (%) or median (interquartile range) unless otherwise specified.* Pearson’s chi-square test.† Fisher exact test.‡ Mann-Whitney U test

Comparison of Data after PSM

To minimize confounding factors, we employed PSM for one-to-one matching between patients in the laparoscopic and open surgery groups. Matching was performed based on age, sex, site of disease, disease type, preoperative comorbidities (hypertension, cerebrovascular disease, cardiology, malignant tumor, and diabetes), Caprini score, preoperative length of stay, intraoperative blood loss, operation time, and total length of stay variables, resulting in 102 patients successfully matched in each group. The 14 variables were well-balanced between groups, with all P-values exceeding 0.05 (Table 3). A comparison of the data before and after matching is shown in Figure 1. In multivariate analysis, bilateral hernia (OR = 50.546, 95% CI 2.277-1122.159, P = 0.013) and total length of stay (OR = 1.807, 95% CI 1.239-2.634, P = 0.002) were identified as independent risk factors for early postoperative asymptomatic DVT, while preoperative length of stay (OR = 0.341, 95% CI 0.162-0.719, P = 0.005) and operation time (OR = 0.965, 95% CI 0.936-0.995, P = 0.021) served as protective factors. Surgery type (OR = 1.808, 95% CI 0.288-11.361, P = 0.528) was not significantly linked to early postoperative asymptomatic DVT (Table 4).

Table 3.

Comparison of Clinical Data in Patients After PSM in the Laparoscopic and Open Surgery Groups

Variable	Laparoscopic(n = 102)	Open (n = 102)	P-Value
Age (y)	65(54.75-72)	63.5(55-71)	0.732‡
Sex			0.818*
Male, n (%)	92(90.2%)	91(89.2%)
Female, n (%)	10(9.8%)	11(10.8%)
Site of disease			0.734*
Unilateral, n (%)	79(77.5%)	81(79.4%)
Bilateral, n (%)	23(22.5%)	21(20.6%)
Disease type			0.867†
Direct hernia, n (%)	11(10.8%)	9(8.8%)
Indirect hernia, n (%)	73(71.6%)	78(76.5%)
Femoral hernia, n (%)	4(3.9%)	4(3.9%)
Composite hernia, n (%)	14(13.7%)	11(10.8%)
Hypertension (+), n (%)	25(24.5%)	25(24.5%)	1.000*
Cerebrovascular disease (+), n (%)	5(4.9%)	6(5.9%)	0.757*
Cardiology (+), n (%)	9(8.8%)	8(7.8%)	0.800*
Malignant tumor (+), n (%)	1(1%)	2(2%)	1.000†
Diabetes (+), n (%)	3(2.9%)	4(3.9%)	1.000†
Preoperative length of stay (d)	3(2-4)	2(2-4)	0.355‡
Operation time (min)	85(65-102.75)	85(64.75-110.5)	0.706‡
Intraoperative blood loss (ml)	5(5-6.25)	5(5-10)	0.054‡
Total length of stay (d)	6(5-8)	6(5-7)	0.963‡
Caprini	2(1-2)	2(1-2)	0.969‡

PSM, propensity score matching; (+), positive. Data are n (%) or median (interquartile range) unless otherwise specified.* Pearson’s chi-square test.† Fisher exact test.‡ Mann-Whitney U test

Figure 1.

PSM Before and After Comparisons

Table 4.

Multifactorial Logistic Regression Analyses Were Performed on all Patients and Those After PSM to Identify Predictors of DVT

Variable	All patients (n = 565)			Patients after PSM (n = 204)
Variable	OR	95% CI	P Value	OR	95% CI	P-Value
Age (y)	1.014	0.933-1.101	0.746	1.068	0.892-1.280	0.474
Sex: Female (vs male)	0.374	0.054-2.579	0.318	—	—	0.998
Site of disease: Bilateral(vs unilateral)	4.972	0.801-30.844	0.085	50.546	2.277-1122.159	0.013
Disease type
Indirect hernia (vs direct hernia)	2.817	0.289-27.440	0.372	14.702	0.327-661.186	0.166
Femoral hernia (vs direct hernia)	7.856	0.357-172.657	0.191	—	—	0.998
Composite hernia (vs direct hernia)	2.117	0.175-25.638	0.556	4.538	0.131-157.172	0.403
Hypertension (vs none)	0.903	0.267-3.054	0.870	1.199	0.187-7.705	0.848
Cerebrovascular disease (vs none)	—	—	0.998	—	—	0.997
Cardiology (vs none)	2.323	0.489-11.041	0.289	6.690	0.575-77.768	0.129
Malignant tumor (vs none)	—	—	0.999	—	—	0.999
Diabetes (vs none)	0.465	0.025-8.522	0.605	—	—	0.999
Preoperative length of stay (d)	0.690	0.529-0.900	0.006	0.341	0.162-0.719	0.005
Operation time (min)	0.981	0.962-1.001	0.063	0.965	0.936-0.995	0.021
Intraoperative blood loss (ml)	0.948	0.820-1.095	0.466	0.947	0.730-1.229	0.681
Total length of stay (d)	1.421	1.216-1.662	<0.001	1.807	1.239-2.634	0.002
Caprini	1.831	0.619-5.419	0.274	3.652	0.326-40.879	0.293
Surgery type: Open(vs laparoscopic)	1.082	0.281-4.164	0.908	1.808	0.288-11.361	0.528

OR, odds ratio; 95 % CI, 95% confidence interval; DVT, deep vein thrombosis; PSM, propensity score matching.

— The number of positive samples was too small resulting in OR and 95% CI being too large or too small.

Discussion

In recent years, the development of minimally invasive surgical principles has greatly promoted the global adoption of laparoscopic techniques. Consequently, laparoscopic inguinal hernia repair (LIHR) has been recognized by international guidelines as one of the recommended surgical options for the diagnosis and treatment of inguinal hernia.⁴ However, controversy still exists as to whether laparoscopic surgery increases or decreases the risk of postoperative DVT. Some researchers believe that abdominal insufflation inhibits femoral vein blood flow, which may lead to a higher risk of DVT after laparoscopic surgery than open surgery.⁵ However, some scholars have found that laparoscopic surgery allows patients to get out of bed earlier after surgery than open surgery, which may reduce the risk of hypercoagulable state and DVT.¹³ With the continuous advancement of science and technology, medical concepts, and perioperative management, it is necessary to further investigate the effect of laparoscopic vs open surgical approaches on the incidence of postoperative asymptomatic DVT. In this study, we investigated the effect of surgical approach on the incidence of early asymptomatic DVT after inguinal hernia surgery using the propensity score matching method to provide guidance for the clinical management and treatment of asymptomatic postoperative DVT.

Deep vein thrombosis is one of the common postoperative complications in clinical practice. Symptomatic DVT is often easy to detect in the clinic, thus allowing patients to be treated early with appropriate therapeutic measures. However, previous studies have shown that asymptomatic DVT is more common than symptomatic DVT and can be easily overlooked.^9,10 If DVT is not detected in time and progresses to the central vein, massive pulmonary embolism may occur.¹⁴ Previous studies have found that asymptomatic DVT increases both post-thrombotic syndrome (PTS) and all-cause mortality (ACM).^15,16

In this study, we found that the incidence of asymptomatic DVT was 3.9%, and no symptomatic DVT was detected. The incidence of asymptomatic DVT was significantly higher than that of symptomatic DVT, which proves that the incidence of asymptomatic DVT after inguinal hernia surgery should not be ignored. Therefore, we recommend that patients undergoing inguinal hernia surgery should undergo ultrasound screening, and if asymptomatic DVT is detected, appropriate antithrombotic therapy should be performed, and the treatment program should be adjusted according to the follow-up results. We also compared the incidence of early asymptomatic DVT in patients undergoing laparoscopic and open surgery. No significant difference was found in the incidence of asymptomatic postoperative DVT between the two groups, both before and after PSM adjustment. This suggests that the difference in early asymptomatic DVT incidence between laparoscopic and open surgical approaches is narrowing. Deep vein thrombosis prevention previously focused on early postoperative mobilization and mechanical prophylactic measures, including elastic stockings and intermittent pneumatic compression pumps. The integration of pharmacological prophylaxis, including low-molecular-weight heparin and novel oral anticoagulants like dabigatran, rivaroxaban, and apixaban, is now a standard practice. Patients are even assessed for risk according to the surgical Caprini scale, which is constantly updated, and then individualized preventive programs are implemented. This shows that medical concepts need to be constantly innovated, and with the development of modern medicine, the gap between the risk of DVT after laparoscopic or open surgery for inguinal hernia is narrowing. Patients who were previously unable to freely choose their surgical approach due to fear of postoperative DVT now have more surgical options, which may also provide evidence for the safety support of laparoscopic inguinal hernia surgery.

Our study results indicate that patients with bilateral hernias are more likely to develop early asymptomatic postoperative DVT compared to those with unilateral hernias. This may be related to the fact that bilateral inguinal hernia surgery is generally more complex and invasive than unilateral inguinal hernia surgery. Additionally, the recovery process following bilateral hernia surgery may be more complicated, with patients experiencing longer periods of bed rest or limited mobility. These factors may increase the risk of DVT. While direct studies linking bilateral hernias to increased DVT risk are limited, research indicates that surgical complexity and prolonged bed rest are associated with a higher risk of DVT.¹⁷ Our study identified a shorter preoperative length of stay as an independent risk factor for early asymptomatic postoperative DVT. A longer preoperative hospital stay is associated with a reduced risk of early asymptomatic DVT post-surgery. Since the patients with inguinal hernias in this study were relatively older and some had comorbidities, extending the preoperative length of stay to better manage preoperative comorbidities (such as hypertension, diabetes, and cardiology) may reduce the risk of postoperative DVT. Prior research indicates that effective perioperative management can lower the rate of postoperative complications.¹⁸ Therefore, in elderly patients with inguinal hernia, it is crucial to manage perioperative comorbidities well before considering surgical treatment. This study found that prolonged surgery time was associated with a reduced risk of early postoperative DVT, which contradicts traditional views. It may be related to the fact that our institution will have closer monitoring and early preventive measures for patients with longer and more complex surgeries. Longer surgeries may require higher levels of intraoperative monitoring and care, including more frequent position changes and continuous anticoagulation measures, which could help reduce the risk of DVT. Moreover, longer surgeries are likely to be more complex, leading to closer postoperative monitoring and early preventive measures, which help in preventing DVT. Future research should include large-scale, multicenter prospective studies to explore this further. Our findings indicate that extended hospital stays elevate the risk of postoperative DVT. Longer hospital stays usually indicate prolonged bed rest and the occurrence of complications, and these patients typically have a higher risk of DVT. Therefore, preoperative education, perioperative thromboembolic risk assessment, complication management, and the use of appropriate anticoagulant prophylaxis become particularly crucial.

Although the Caprini score has been validated as an effective tool for predicting DVT risk in multiple studies, some research has reported its limitations and inaccuracies in prediction.¹⁹ This study’s findings align with previous research, indicating a need for further exploration and optimization of DVT risk assessment tools for inguinal hernia surgery. In addition, previous studies have demonstrated that the variables included in this study are associated with venous thrombosis, so multivariate regression analyses were performed directly on the included variables.

There are some limitations to this study. This is a single-center study of an Asian population, the prevalence of DVT may be different from populations in other regions and ethnicities, the comorbidities associated with inguinal hernia disease may be deficient, and future studies will need to incorporate these differentiating factors into further exploration. Although previous studies have shown that most asymptomatic DVT after surgery is distal DVT, further stratified analysis of the location of DVT is needed in the future.²⁰ In addition, due to the limited sample size and data collection in this study, some confounding bias could not be completely avoided despite the PSM analysis. Therefore, prospective trials with larger sample sizes are needed to validate these findings.

Footnotes

ORCID iDs

Chao Zhang

Xiaohua Lei

Ethical Considerations

This study was performed in line with the principles of the Declaration of Helsinki. The Yueyang Central Hospital Ethics Committee authorized this study.

Author contributions

NZ: Conceptualization, methodology, formal analysis, and writing—original draft. CZ: Software, data curation, validation, and writing—original draft. YS: Investigation, formal analysis, and writing—original draft. MF: Validation, visualization, and writing—original draft. JL: Validation, visualization, and writing—original draft. CH: Software, data curation, and writing—original draft. XL: Conceptualization, funding acquisition, resources, supervision, and writing—review and editing.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the Natural Science Foundation of Hunan Province (Grant No. S2023JJMSXM2503), the Hunan Provincial Department of Science and Technology (Grant No. 2021SK51825), and the Scientific Research Foundation of Hunan Provincial Education Department (Grant No. 22C0227).

Declaration of conflicting interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: We confirm that this work is original and has not previously been published. None of the authors have any financial disclosures or conflict of interest. Approval for this study was obtained from the Ethics Committee of the participating hospitals. Should the article be accepted, all authors agree to transfer copyright to your journal.

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