A scoping review of the effectiveness, appropriateness and economic efficiency of the vacuum bell for pectus excavatum within the Swiss healthcare system

Introduction

Pectus excavatum (PE), also known as funnel chest, is the most common congenital deformity of the anterior chest wall, affecting approximately 1 in 400 to 1 in 1,000 live births (1). It is characterized by a sunken appearance of the sternum, which can displace the heart and lungs, leading to symptoms such as shortness of breath, chest pain, decreased exercise tolerance, and asthma (2). In addition to physical symptoms, many patients—particularly adolescents—experience significant psychological distress and body image concerns. Spontaneous correction is rare, and the deformity often worsens during puberty.

Historically, surgical correction has been the mainstay of treatment for severe PE. For many decades, the Ravitch procedure was the standard approach until it was gradually replaced by the minimally invasive repair of PE (MIRPE) introduced by Donald Nuss in the late 1990s. Since then, MIRPE has become the predominant technique, while other methods—such as Taulinoplasty by Carlos Bardají and implant-based correction by Jean-Pierre Chavoin—have been adopted more selectively (3). Although MIRPE provides reliable structural correction, it is associated with notable drawbacks, including the need for general anesthesia, risk of surgical complications, hospitalization, and postoperative pain—challenges that have not been fully resolved to date.

In the past two decades, vacuum bell therapy (VBT) (Figure 1) has emerged as a promising non-invasive alternative for selected PE patients, first gaining popularity in Germany and Switzerland before spreading internationally (4-8). The vacuum bell is a silicone device with a plexiglass dome that creates negative pressure to gradually lift the sternum. Applied over the deepest point of the depression, the device is operated manually by the patient via a suction pump, generating pressures typically between −100 and −300 mbar. Patients are instructed to increase duration and intensity gradually, with the goal of full sternal contact with the dome. Usage typically begins at 30 minutes twice per day and can extend to several hours. Five models are available, including rigid and flexible sizes, as well as a female-specific version.

Figure 1 Vacuum bell with pump (small size 16 cm).

Evidence indicates that VBT is most effective in young children (especially those under 12 years) with a flexible chest wall, mild deformity (depth <1.5 cm), and symmetric morphology (9). In such cases, VBT has been shown to achieve permanent sternal elevation, potentially avoiding the need for surgery altogether (10). In our clinical experience, VBT has largely replaced surgical repair as the first-line approach and has led to long-term correction in approximately 60% of patients. Consequently, we consider the failure of VBT—rather than the diagnosis of PE alone—as a decisive criterion for surgical referral, alongside standard clinical indicators.

Despite its clinical success, access to VBT remains limited in many healthcare systems. In Switzerland, for example, health insurance coverage is restricted to surgical interventions up to the age of 20 years and requires proof of pathological pulmonary or cardiac function, although few patients present with such severe findings (11). As a result, many families must pay out of pocket for VBT, creating financial barriers to care. The issue extends beyond Switzerland; for instance, the United Kingdom’s National Health Service (NHS) does not currently reimburse any form of PE treatment, reflecting an ongoing debate about the medical necessity and cost-effectiveness of such interventions.

Given these considerations, an updated and structured review of the literature is warranted to evaluate the effectiveness, appropriateness, and economic efficiency of VBT. The aim of this scoping review is threefold: (I) to synthesize existing evidence on the clinical outcomes of VBT; (II) to define optimal patient selection criteria; and (III) to compare VBT with MIRPE from a cost perspective. Based on this analysis, we also propose a framework for standardized reimbursement and an optimized treatment algorithm for PE management. We present this article in accordance with the PRISMA-ScR reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-380/rc) (12).

Methods

This scoping review was conducted to evaluate the effectiveness, appropriateness, and economic efficiency of VBT for PE. A formal review protocol was not registered.

Eligibility criteria and objectives

Studies were included if they reported clinical outcomes, economic data, or patient-reported measures related to VBT or MIRPE. Eligible designs included prospective or retrospective observational studies, cohort studies, and case series. Case reports, letters to the editor, conference abstracts, duplicates, and studies not primarily focused on VBT were excluded.

The primary objective was to map the available evidence on the effectiveness of VBT, defined as improvements in chest wall morphology. Secondary objectives included assessing treatment appropriateness (e.g., patient or deformity characteristics), economic efficiency, and safety (complication rates, classified by the Clavien-Dindo system when reported).

Information sources and search strategy

A comprehensive literature search was conducted in PubMed, Embase, Scopus, MEDLINE, and the Cochrane Library, covering human studies published between 2005 and 2024. No restrictions were applied regarding language or publication date. The search strategy combined MeSH terms and free-text keywords related to PE, VBT, suction cup, effectiveness, scoping review, and health economics. The complete electronic search strategy for PubMed is provided in Table 1. The final search was executed on December 31, 2024.

Selection of sources of evidence

All retrieved records were imported into a reference management system and screened in two stages by two reviewers (S.B.S., N.S.): first by title and abstract, then by full-text review using predefined eligibility criteria. Disagreements were resolved through discussion or with input from a third reviewer (F.M.H.). The selection process is illustrated in the PRISMA-ScR flow diagram (Figure 2).

Figure 2 Flowchart of the literature search. VB, vacuum bell.

Data charting process

A standardized charting form was developed and pilot-tested on a sample of studies to ensure consistency. Two reviewers (S.B.S, N.S.) independently extracted data in duplicate. Any disagreements were resolved as above. Contact with the study authors was not necessary, as all relevant data were sufficiently reported in the included publications.

Data items

The following variables were extracted from each study, where available: author, year, country, study design, sample size, patient demographics (age, sex, PE symmetry, severity), intervention details (type, protocol, pressure), and outcome measures. These included morphological changes [e.g., pectus depth, Haller index (HI)], rate of full or near correction, follow-up duration, patient-reported outcomes, complications, and cost-related data. Similar outcome types were grouped under unified categories to improve comparability. Data were only charted when explicitly reported; no assumptions were made for missing values.

Synthesis of results

Charted data were summarized descriptively and organized into structured tables. Studies were grouped by intervention type, study design, and population characteristics. Quantitative data were synthesized using frequency counts, ranges, and medians where applicable. Narrative synthesis was used to highlight patterns in treatment effectiveness, economic findings, and patient characteristics. Data extraction and summary were performed using Microsoft Excel.

Critical appraisal of sources of evidence

As this was a scoping review, no formal critical appraisal or risk of bias assessment was conducted. The primary aim was to map the scope and characteristics of the available evidence, rather than to evaluate study quality or perform a quantitative synthesis. No randomized controlled trials (RCTs) or meta-analyses were identified in the existing literature.

Results

Study selection and summary of included evidence

The literature search identified a total of 41 records. After screening titles and abstracts, 27 articles met the inclusion criteria and were selected for full-text review. These included 26 studies evaluating VBT as a conservative treatment for PE, and 1 study focusing on the cost-efficiency of MIRPE. Fourteen studies were excluded for the following reasons: case reports (n=5), editorials or letters (n=3), duplicates (n=2), and studies not directly assessing VBT effectiveness (n=4). The selection process is illustrated in the PRISMA-ScR flow diagram (Figure 2).

The included studies, published between 2005 and 2024, represent 2,271 patients treated with VBT. The studies were conducted across multiple countries, including the USA, Switzerland, China, the Netherlands, Italy, Spain, Korea, Japan, and the UK. Sample sizes ranged from 15 to 450 patients, with most cohorts being predominantly male (>80%). Ages ranged from 2 to 24 years, with several studies focused specifically on preschool children, adolescents, or young adults. Study designs were primarily retrospective cohort or observational studies, although prospective cohorts (e.g., Deng 2020, Lopez 2016) and a narrative review (Patel 2019) were also included (7,13,14). The sample sizes varied considerably, from small pilot studies (e.g., Furuta 2020, n=15) to large retrospective series (e.g., van Braak 2025, n=259) (15,16). Most studies reported follow-up periods between 6 months and 4 years.

Several studies (16-20) also reported specific clinical indications and contraindications for the use of VBT. VBT was described as a conservative treatment for PE, used either as a primary therapy or as an adjunct in the perioperative setting. Indications included mild to moderate PE (symmetric or asymmetric), as well as preoperative preparation, intraoperative sternal elevation during MIRPE, and postoperative correction of mild recurrence. Contraindications included coagulopathy and persistent pain (absolute), as well as severe asymmetry, chest wall defects narrower than the vacuum bell, a pectus depth >3 cm, and significant costal flaring (relative).

This review identified consistent evidence supporting the effectiveness of VBT in producing measurable improvement in chest wall morphology in patients with PE, particularly in children and adolescents. Notably, studies such as Togoro et al. report measurable sternal elevation even after short-term application, underscoring its potential for rapid clinical impact (21). Across studies, successful outcomes—defined by external depth reduction, improved HI, or complete correction—were reported in approximately 20–52% of patients. Several studies confirmed a clear association between early initiation of therapy, longer treatment duration, lower initial deformity depth, and greater daily usage with improved outcomes.

The following paragraphs summarize the main findings extracted from the included studies, grouped by thematic categories reflecting the review objectives.

Effectiveness of VBT

Reported success rates in the literature vary between 40% and 60% (6,16,22), yet the definition of “success” varies across studies. Some define it as complete sternal correction, while others consider patient satisfaction with improved appearance and symptom relief sufficient criteria. Obermeyer et al. proposed a classification of VBT success based on the final pectus depth, defining less than 0.51 cm as an “excellent result” (22). However, standardized measurement protocols for pectus depth remain lacking, making depth values unreliable.

Excellent correction was achieved in approximately 20–30% of patients in most pediatric-focused studies (22-24). Loufopoulos et al. observed improvement in 37% to 90% of patients, with 10% to 40% achieving complete correction (25). In a long-term cohort, van Braak et al. reported complete correction in up to 52% of patients who completed therapy (16). Improvements in sternal depth, both external and internal, were also consistently observed, with mean reductions ranging between 3 and 8 mm across studies. For example, Gao et al. documented a decrease in three-dimensional (3D)-measured depth from 12.1 to 5.7 mm (26), Deng et al. reported a depth ratio reduction of 0.057 (P<0.001) (13), and Arias et al. observed an average improvement of 0.43 cm—reaching up to 0.79 cm in patients using the device for six or more hours per day (17).

In terms of internal morphology, most studies reported average reductions in the HI ranging from 0.3 to 0.8, corresponding to a relative improvement of approximately 7–20%. For instance, St-Louis et al. documented a reduction from 3.9 to 3.6 (8). Additionally, imaging-based studies by Monti et al. and Stagnaro et al. demonstrated transient improvements in HI during active vacuum bell application (27,28).

Compliance with VBT varies widely across studies, with reported discontinuation rates ranging from 1.4% to 34% (6,14,29). In our 20-year clinical experience, dropout rates remain below 10%. VBT, like many patient-controlled therapies, relies heavily on patient motivation and perceived progress, and its effectiveness is closely linked to treatment compliance. Adherence tends to be high during the initial phase, when visible improvements are observed, but may decline as progress plateaus. Regular follow-up and objective monitoring tools, such as 3D-scanning, help maintain engagement and adherence (13,30). Approximately 20% of patients who discontinue VBT eventually proceed with surgical correction.

Physiological insights

Vacuum bell use has been shown to transiently improve cardiac function by elevating the sternum, leading to modest increases in stroke volume and ejection fraction, particularly in the right ventricle, although these effects are generally temporary and limited in magnitude (27,28).

Comparison effectiveness of VBT and MIRPE

Currently, only one study directly compares the effectiveness of VBT and MIRPE (9), and it is retrospective and non-randomized. No other head-to-head comparisons are available, which limits the reliability of indirect comparisons across individual studies. Jung et al. reported similar reductions in funnel depth between the VBT and MIRPE groups after one year (9). While MIRPE was associated with greater improvement in the HI, this must be weighed against its substantially higher complication rate. Given the inherently more invasive nature and elevated risk profile of surgical intervention compared to conservative therapy, direct comparisons between the two approaches remain methodologically and clinically challenging.

Safety profile of VBT

VBT is generally safe and well-tolerated, with mild, transient side effects such as skin irritation, discomfort, and bruising that typically resolve without medical intervention. Compared to MIRPE, VBT offers comparable benefits in symptom relief, anatomical correction, and quality of life, but with a significantly better safety profile and fewer complications. While complications for both treatments are rare, those associated with MIRPE may require additional interventions (18,31). VBT’s advantages include its non-invasive nature, affordability, and high patient acceptance, though its limitations include a long treatment duration, reduced effectiveness in older patients, and limited long-term outcome data. Dropout rates for VBT vary considerably (1–17%) and are mostly related to insufficient improvement or loss of motivation (16,22).

Key predictors of success

Several studies have identified consistent predictors of successful outcomes with VBT. The most robust positive predictors include younger age (≤11 years) (6,24,25), initial pectus depth ≤1.5–1.8 cm, treatment duration longer than 12–24 months, and daily usage of at least 2–4 hours (16,30). Overnight application (16) and a visible reduction in the HI during an initial vacuum bell-computer tomography (CT) trial (ΔHI ≥0.5) (32) have also been shown to predict favorable outcomes. In contrast, some factors were found to be inconsistent or non-predictive, including sex, chest wall symmetry, and flexibility. While objectively assessed flexibility was associated with better outcomes (6), subjective assessments were less reliable and, in some cases, misleading (16).

In van Braak et al.’s study, the authors found—unexpectedly—that a flexible chest wall was associated with poorer outcomes in VBT. Flexibility was assessed subjectively, based on clinical impression during consultation and possibly patient-reported ease of sternal movement during vacuum bell use. The authors explain this discrepancy with the available literature by the fact that subjectivity and variability in how flexibility was assessed may have introduced bias or misclassification. They suggest that flexibility might have been overestimated in some cases, leading to inaccurate predictions of who would respond well and false optimism about vacuum bell effectiveness. In contrast to other studies (e.g., Obermeyer 2018), which found objective flexibility via the Nuss maneuver to be a positive predictor, van Braak et al. highlight the importance of standardized and objective methods for assessing flexibility (16,22).

Contrary to van Braak et al.’s findings, we believe that chest wall elasticity enhances VBT success. Moreover, even patients with a stiff chest can benefit from VBT if the treatment period is extended to at least 12–18 months.

Appropriateness of VBT

VBT has become widely accepted as a first-line treatment for PE in many clinical settings. The technique was initially introduced by Schier et al. in 2005 (4), followed by further development by Haecker et al. in 2006 (5). Notably, by 2016, the inventor of the MIRPE procedure publicly supported the integration of VBT into the treatment algorithm for PE (33). Since 2018, efforts have been made to define clear patient selection criteria to optimize treatment outcomes. These include age under 12 years, symmetric deformity, pectus depth less than 1.8 cm, and consistent use of the device for at least 12 months (6,22). Current evidence suggests that the most suitable candidates for VBT are young, motivated patients with mild to moderate, symmetric, and flexible chest wall deformities. In addition, pre-treatment assessments—such as observing sternal elevation during vacuum bell-assisted chest CT—have been shown to reliably predict therapeutic responsiveness (32).

The characteristics and key outcomes of the included studies are summarized in Tables 2-5.

Economic efficiency of VBT and cost comparison

MIRPE is an inpatient procedure classified under the Swiss Classification of Procedures (CHOP) as code 34.74—correction of chest wall deformity. Based on an average base rate of Confoederatio Helvetica Franken (CHF) 10,000, the total cost amounts to approximately CHF 20,050 for patients aged 10–15 years [diagnosis related group (DRG) E06B] and CHF 18,960 for those over 15 (DRG E06C). These estimates exclude additional expenses such as complications, extended hospitalization, anesthesia, and post-operative care. Furthermore, the increasingly used cryoanalgesia, which is more expensive than standard epidural anesthesia, is not included.

In contrast, a 36-month cost comparison shows that VBT is significantly more economical, with an estimated cost of CHF 4,300, compared to over CHF 25,500 for MIRPE (Tables 6,7). VBT also avoids indirect costs such as loss of productivity, as it does not require prolonged recovery or time away from school or work. Notably, the cost analysis excludes surgical complications—such as infections, bar displacement, or pleural effusion—which would further increase MIRPE’s financial burden.

While surgery remains essential for severe cases with significant physiological symptoms, VBT is effective in mild to moderate deformities, particularly in younger patients, and may prevent the need for surgery (24). According to NHS guidelines, surgical correction is reserved for severe cases but is recognized as more expensive due to procedural complexity and extended recovery.

To date, no formal cost-benefit analyses of VBT have been published. The most recent analysis related to MIRPE, conducted in the Netherlands in 2019 (40), concluded that the procedure is not cost-effective within one year postoperatively, neither in the Netherlands nor in the USA.

Although formal cost-effectiveness analyses are limited, current evidence supports VBT as a cost-saving, non-invasive first-line treatment for appropriately selected patients with mild to moderate PE. Its favorable safety profile and patient-controlled use further justify its integration into clinical practice. To ensure broader access, standardized reimbursement criteria should be established (9).

Monitoring tools and innovations in VBT

3D-scanners (6,33,34) enable safe and accurate follow-up of VBT progress, while tools such as the distance-pressure measuring device (34) and the vacuometer (35) enhance patient motivation, support treatment standardization, and improve the safety of home-based use.

The distance-pressure measuring device is attached to the top of the VB and uses internal sensors to continuously measure both the applied pressure and the distance between the sternum and the device. It provides objective data to track treatment progress, identify early plateaus, and adjust therapy as needed.

The vacuometer, placed between the vacuum bell and the pump, monitors the pressure applied during use. It helps patients control and limit the suction pressure, reduce the risk of overtreatment or injury, ensure consistent and safe pressure levels in line with clinical recommendations (typically −100 to −300 mbar), and facilitate standardization of VBT, particularly in home-use settings.

To support objective follow-up and improve standardization of VBT assessment, we propose the use of a scaled rod (Figure 3), measured in supine position at end-expiration with arms positioned along the body (34).

Figure 3 Special scaled rod.

Discussion

This scoping review aimed to evaluate the existing literature on the effectiveness, appropriateness, and economic efficiency of VBT for the treatment of PE within the Swiss healthcare system. The included studies, encompassing 2,271 patients across multiple continents, show a growing international interest in VBT as a non-invasive, effective, safe, and cost-efficient alternative or adjunct to surgical correction, particularly in children and adolescents with mild to moderate and symmetric deformities with a flexible chest wall.

Effectiveness of VBT

Across studies, VBT demonstrated the capacity to reduce chest wall deformity in a significant proportion of patients. Complete or excellent correction (defined variably as normalized sternal position, depth <5.1 mm, or HI ≤3.25) was achieved in approximately 20–52% of patients (16,22-24). Studies using 3D-scanning, magnet resonance imaging (MRI), and CT consistently reported reductions in pectus depth and HI after several months to years of therapy (8,27,28). Importantly, the degree of improvement was directly correlated with daily usage duration, total treatment time, and younger age at initiation. These findings support VBT as a clinically effective therapy when applied consistently and in appropriately selected patients.

Appropriateness and patient selection

The reviewed literature emphasizes that patient selection is critical for successful VBT outcomes. Several studies identified key predictors of favorable response, including (16,22-24,30,32):

• Age ≤11 years;
• Initial sternal depth ≤1.5–1.8 cm;
• Symmetric and flexible chest wall morphology;
• Treatment duration >12–24 months;
• Overnight or high daily usage (>2–4 h/day).

In contrast, adolescents with severe or asymmetric deformities, or poor adherence to the treatment protocol, were less likely to achieve meaningful correction. Some studies also introduced objective measures—such as sternal elevation on CT during initial vacuum bell application—to predict therapy success (32). This highlights the importance of structured baseline assessment and patient/caregiver motivation in optimizing VBT outcomes.

Economic and practical considerations

While formal cost-effectiveness analyses were not conducted in the reviewed literature, several authors noted that VBT may delay or eliminate the need for surgery in selected patients, thereby potentially reducing healthcare costs, hospital stays, and operative risks. Vacuum bell devices are generally well tolerated, do not require general anesthesia, and can be applied at home, making them an economically appealing first-line option in appropriate candidates.

Proposed criteria for reimbursement and clinical integration

We propose the following standardized criteria for VBT reimbursement:

• Initial daily usage of at least 60 minutes, gradually increasing as tolerated during the first weeks of therapy;
• No predetermined treatment duration, allowing flexibility based on individual progress;
• If no improvement is observed after three to six months, surgical options should be discussed for patients who meet at least two of the six surgical criteria defined by Nuss et al. (41).

By integrating VBT into standard PE treatment algorithms, healthcare systems can ensure better patient selection for MIRPE while prioritizing conservative management.

Barriers to access and reimbursement reform in the Swiss context

Beyond clinical outcomes, VBT raises broader questions of healthcare access and policy fairness—particularly in the Swiss context, where reimbursement criteria currently limit its use. In Switzerland, the healthcare system operates on a trust-based reimbursement model, assuming that treatments meet criteria for effectiveness, appropriateness, and economic efficiency unless contested. MIRPE is reimbursed up to age 20 years if symptoms are objectified by pathological findings in pulmonary and/or cardiac function tests, while VBT is not routinely covered and only reimbursed in exceptional cases. This creates a significant access gap, as many patients report symptoms such as exercise intolerance or psychological distress, even though pulmonary and/or cardiac function tests often remain within normal limits.

To improve access and promote conservative treatment, we recommend recognizing VBT as a reimbursable first-line option for mild to moderate PE. Moreover, current reimbursement criteria relying on fixed percent predicted values (PPVs) for pulmonary function tests interpretation should be reconsidered. PPVs are limited by lack of standardization, age and height bias, population differences, and inconsistent thresholds, often leading to misclassification of PE severity by the insurance provider (42).

In contrast, Z-scores, jointly recommended by the American Thoracic Society, the European Respiratory Society and the Global Lung Function Initiative, offer a more statistically robust and individualized assessment by accounting for age, sex, height, and ethnicity (42). Adopting Z-scores over PPVs would reduce diagnostic variability and allow more equitable access to PE treatment, especially for patients whose functional impairments are not reflected in outdated cutoff models.

Safety and complications

The safety profile of VBT is consistently favorable across studies (36,37). The most commonly reported side effects were minor and self-limiting, such as skin erythema, petechiae, and mild discomfort. No major adverse events were reported (5,18,19,22). In contrast, surgical correction via MIRPE carries a well-documented risk of serious complications (38,39), including pneumothorax, bar displacement, and wound infections, which were not observed in the VBT cohorts.

Ethical considerations and shared decision-making

The only conservative treatment alternative to MIRPE is VBT. The availability of VBT guarantees the patient’s autonomy of choice. Respecting this autonomy allows patients to make their own decisions about which health care interventions they prefer or do not prefer. The indication for treatment of PE is determined with close consideration of the patient’s preferences. Involving patients to better understand decisions is crucial and leads to several benefits, such as higher levels of satisfaction with care, more realistic expectations about the benefits and harms of therapeutic options, better adherence to treatment, and in some cases, even improved health outcomes (30). We believe that involving patients in decision-making is more appropriate and economical than seeking reimbursement.

Limitations of the evidence

The overall quality of evidence on VBT remains low. Most included studies were retrospective, single-center, and showed substantial heterogeneity in patient populations, deformity types, treatment protocols, follow-up duration, and outcome definitions. No RCTs or systematic reviews/meta-analyses on the long-term efficacy of VBT are currently available, and only a few narrative reviews have been published to date (15,25,37). Additionally, the absence of standardized success criteria and the lack of objective tools to monitor home use further limit comparability across studies.

Despite these limitations, available studies consistently support the effectiveness of VBT, with van Braak et al. providing the first long-term follow-up data (median 64 months) (16). Notably, the evidence base for MIRPE is similarly limited, with no RCTs evaluating its long-term effectiveness or economic efficiency since its introduction in 1988.

As this review followed the PRISMA-ScR framework, no formal risk of bias assessment was conducted. However, key methodological features of the included studies were reported to support readers’ critical appraisal. Future research should prioritize multicenter RCTs, standardized outcome definitions, and cost-effectiveness analyses to better inform clinical and policy decisions.

Conclusions

VBT is a safe, effective, and cost-efficient treatment for PE, particularly in younger patients with flexible chest walls. It significantly reduces healthcare costs compared to MIRPE and represents a viable, non-invasive alternative to surgery. As VBT success depends heavily on patient compliance, structured follow-up and motivation support are essential.

We recommend that healthcare systems reconsider reimbursement policies to include VBT as a first-line treatment for eligible patients. This would improve access, enhance shared decision-making, reduce unnecessary surgeries, and optimize resource use.

Future studies should focus on the long-term outcomes of VBT, directly compare it with MIRPE in controlled trials, and evaluate its cost-effectiveness over time. However, these findings are based on the Swiss healthcare context and may not be directly generalizable to countries with different reimbursement frameworks.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA-ScR reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-380/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-380/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-380/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.

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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