Short-term outcomes of robotic- vs. television-assisted thoracoscopic segmental lung resection for early-stage non-small-cell lung cancer in the day surgery models

Introduction

According to 2024 data from the A Cancer Journal for Clinicians (CA), lung cancer remains the most prevalent malignant tumor worldwide (1). The standard surgical procedure for early-stage non-small-cell lung cancer (NSCLC) treatment has been lobectomy combined with lymph node dissection. Recently, sublobar resection (segmentectomy/wedge resection) has gained popularity for early-stage peripheral NSCLC due to its advantages in preserving more lung parenchyma, improving postoperative lung function, causing less trauma, and promoting quicker recovery (2). Additionally, segmentectomy is preferred for patients with poor lung function or advanced age who cannot tolerate lobectomy, making it an ideal option for early-stage lung cancer (3).

With technological advancements, video-assisted thoracic surgery (VATS) and robot-assisted thoracic surgery (RATS) have been increasingly used for early-stage NSCLC surgeries. Published reports indicate that VATS improves short-term functional recovery, reduces incision pain, shortens chest tube duration, and decreases hospitalization time compared to traditional thoracotomy (4). More studies are now comparing the efficacy of VATS and RATS. As a type of minimally invasive thoracic surgery, RATS and VATS are both safe and effective surgical modalities for performing lung surgery, and both are superior to open surgery in terms of the number of lymph node dissection stations and postoperative complications (5).

Day surgery is an efficient surgical model. The China Day Surgery Alliance defines day surgery as “patients completing surgery or procedures and being discharged within 24 hours”, with a suggestion to extend the discharge time based on patient condition changes, not exceeding 48 hours (6). Xie et al.’s study demonstrated the feasibility of day surgery in minimally invasive treatment of early-stage NSCLC and revealed that simple segmental surgeries (such as right upper lobe apical segment, lower lobe dorsal segment, right upper lobe posterior segment) had low postoperative air leakage rates. Although the study indicated that segment position might be linked to delayed discharge from day surgery, it did not further investigate other factors influencing delayed discharge (7). Other research has suggested the feasibility of RATS in the day surgery model but lacks supporting evidence (8).

Few articles compare the differences between VATS and RATS in the day surgery model. This study aims to establish the feasibility of RATS segmental lung resection in the day surgery model, compare the short-term efficacy of VATS and RATS in this context, and explore the risk factors influencing delayed discharge from day surgery. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1020/rc).

Methods

Patients characteristics

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This study was approved by the Ethics Committee of the First People’s Hospital of Changzhou City (approval No. 2023 technology 197) and informed consent was taken from all the patients.

A retrospective analysis was conducted on patients who underwent day surgery for lung segment resection using RATS and VATS between January 2021 and December 2023 in the Thoracic Surgery Department of the First People’s Hospital of Changzhou City. The patients were divided into RATS and VATS groups (both three-port procedures). The study included 204 patients, with 102 in the RATS group and 102 in the VATS group. The criteria for day surgery were as follows: (I) patients with well-developed lung fissures, in whom a definitive three-port thoracoscopic segmental lung resection could secure the tumor margins, were selected for daytime surgery according to the results of preoperative three-dimensional (3D) imaging and computed tomography (CT) examination and discussion within the treatment group. The decision to use RATS or VATS is based on the type of health insurance and subjective choice of patients. (II) Patients without history of intrathoracic inflammation in the past 1 month. (III) Absence of severe underlying diseases, including coronary heart disease with less than 70% coronary artery occlusion, and stroke patients (no recurrence within 1 year) with a history of respiratory diseases [forced expiratory volume in the first second (FEV1) >1.0 L]. (IV) Age below 75 years. (V) Postoperative pain manageable by oral medication. (VI) Preoperative imaging evaluation indicating no need for systematic lymph node dissection or only lymph node sampling.

The cases included patients who were discharged on time (within 24–48 hours post-operation) and those with delayed discharge (hospitalization exceeding 48 hours due to poor postoperative recovery or transfer to a community hospital for further observation). The inclusion criteria were: (I) pathologically confirmed NSCLC post-surgery, classified as stage IA according to the 8^th edition tumor-node-metastasis (TNM) classification by the International Association for the Study of Lung Cancer. (II) Patients who completed preoperative examinations and underwent surgery on the same day. (III) Patients who underwent lung segment resection using RATS and VATS. (IV) Patients with peripheral-type single pulmonary nodules located in the lung parenchyma and not invading the pleura and pulmonary hilum were selected for day surgery by preoperative 3D imaging and CT examination.

Surgical methods

All surgeries were performed by the same team. The lesion and the location of the bronchial arteries and veins were determined through 3D modeling and CT images preoperatively to decide the surgical scope. Both surgical methods used three operating ports, with the patient in a 90° lateral decubitus position and the hip joint fixed. Double-lumen endotracheal intubation was used for both methods.

RATS

For upper or middle lobe lung segments, a 0.8-cm incision at the right mid-axillary line of the 8^th intercostal space was used as the observation port, a 0.8-cm incision at the 8^th intercostal space below the scapula served as the robotic operation port, and a 4-cm incision at the 5^th intercostal space of the mid-axillary line functioned as both the auxiliary operation port and the robotic operation port. For lower lobe lung segments, the observation port was at the right mid-axillary line of the 9^th intercostal space, the robotic operation port was at the 9^th intercostal space below the scapula, and the 4 cm incision at the 6^th intercostal space of the mid-axillary line served as both the auxiliary operation port and the robotic operation port. The left side was a mirror image of the right side.

The Da Vinci robot was positioned at the head side of the patient, the assistant was at the abdominal side, and the main surgeon was away from the operating table. A Da Vinci robot-specific electric hook was utilized for separating pulmonary arteries, veins, and bronchi, while a linear stapler was employed for cutting. The specimen was extracted using a specimen bag through the 4 cm operation port, followed by rapid frozen pathological examination. The extent of lymph node dissection and sampling was determined based on preoperative imaging, intraoperative lymph node morphology, and rapid pathology results.

VATS

For upper or middle lobe lung segments, a 1-cm incision at the right mid-axillary line of the 7^th intercostal space was used as the observation port, a 1-cm incision at the 7^th intercostal space below the scapula served as the auxiliary operation port, and a 4-cm incision at the 4^th intercostal space of the mid-axillary line functioned as the main operation port. For lower lobe lung segments, the observation port was at the right mid-axillary line of the 8^th intercostal space, the auxiliary operation port was at the 8^th intercostal space below the scapula, a 3-cm incision at the 5^th intercostal space of the mid-axillary line served as the main operation port. The left side was a mirror image of the right side.

The surgery utilized the German STORZ thoracoscopy system, with the display located at the patient’s head side, the main surgeon and the second assistant at the abdominal side, and the first assistant at the back side. Pulmonary arteries, veins, and bronchi were separated using a standard electric hook. Other surgical methods were the same as RATS. A chest tube and a silicone ball were routinely placed post-operation.

Postoperative management

After regaining consciousness and spontaneous breathing post-anesthesia, the endotracheal tube was removed, and a multi-head chest band was used to secure the chest wall. The patient was then transferred to the intensive care unit (ICU) for symptomatic support treatment, including analgesia, fluid supplementation, and anti-infection measures, while monitoring vital signs.

Postoperative pain management

Patients’ postoperative pain scores were scored using the Visual Analogue Scale (VAS), and on the first postoperative day patients marked their pain scores on the scale, which was repeated twice; at the same time, patients were given another pain score before discharge, which was repeated twice, and the average of the four scores was recorded. Celecoxib capsules (celebrex) were administered every 12 hours post-surgery at a dose of 200 mg. After 24 hours postoperatively until discharge, if the patient’s pain is still not relieved, diclofenac sodium hydrochloride lidocaine injection, 100 mg/2 mL each time, intramuscularly, was used as needed. VAS is shown in the attached Figure 1.

Figure 1 Visual Analogue Scale.

Chest tube removal and postoperative complication determination

Twelve hours post-surgery, the conditions of the chest bottle and vital signs were observed. The criteria for chest tube removal were: (I) stable vital signs. (II) Less than 200 mL of drainage in the chest bottle within 12 hours post-surgery. (III) Light red drainage fluid. (IV) No significant air bubbles during breathing or coughing, and no significant abnormalities on bedside chest X-rays.

After chest tube removal, a chest X-ray was routinely performed. If no abnormalities were found, the patient could be discharged after 24 hours of observation. The criteria for silicone ball removal included: (I) less than 100 mL of drainage in the silicone ball within 24 hours post-chest tube removal, with light red drainage fluid. (II) No re-inflation of the silicone ball within one minute after deflation.

Patients not meeting the criteria were discharged with the silicone ball and rechecked at the outpatient clinic after 3 days for possible removal. Postoperative complications included: (I) fever: body temperature above 38.5 ℃ 12 hours post-surgery. (II) Infection: fever with a white blood cell count ≥15×10⁹/L and elevated inflammatory markers such as C-reactive protein. (III) Postoperative air leakage: persistent postoperative bubbles in the chest tube or bulging after deflation of the negative pressure drainage ball. (IV) Abnormal drainage fluid: unusual color (e.g., bright red, chylous fluid) or drainage volume exceeding 400 mL within 12 hours post-surgery.

Discharge criteria

Discharge criteria included: (I) general good condition of the patient with no significant abnormalities in blood tests and biochemistry results. (II) No discomfort after chest tube removal and satisfactory lung re-expansion on chest X-ray. (III) Good wound healing with no significant purulent exudate.

Postoperative follow-up

After discharge, the patient was instructed to go to our hospital for review in 1 month, which included general and physical examination, blood routine and inflammation index, chest X-ray, and wound recovery. Patients who develop complications within 1 month after discharge and are diagnosed in our hospital or another hospital should provide relevant information including “Whether they have received treatment?”, “How is it treated?”, and the outcome of the treatment. Patients who did not show any significant abnormality on the above tests were given a good postoperative recovery grade; if the test results suggested the presence of a complication but did not require special treatment or if the patient had recovered from a recently occurring complication, a moderate postoperative recovery grade was given; and if reintroducing closed thoracic drainage was recommended, a poor postoperative recovery grade was given.

Criteria for reintroducing closed thoracic drainage post-discharge included: (I) moderate or large pleural effusion indicated by ultrasound. (II) Significant dyspnea or chest tightness affecting daily life, with lung compression over 30% or significant subcutaneous emphysema indicated by chest X-ray.

Statistical analysis

Statistical analysis was conducted using IBM SPSS Statistics 26. Baseline clinical data from the original dataset including age, gender, history of cardiovascular diseases (hypertension, coronary heart disease), respiratory diseases (emphysema, tuberculosis history), cerebrovascular diseases (stroke), tumor history, diabetes history, smoking history, FEV1, diffusion capacity for carbon monoxide of the lung (DLCO), tumor size on CT, body mass index (BMI), and lung segment positions were assessed for statistical significance. The data were used for further statistical analysis, which were categorized into two subgroups based on delayed discharge status. Logistic regression analysis was performed to identify risk factors. Normal distribution data were analyzed using independent sample t-tests, non-normal distribution data using non-parametric tests, and count data using χ² tests. A P value <0.05 indicated statistical significance.

Results

Results of statistical analysis of clinical baseline data

Baseline clinical data from the original dataset including age, gender, history of cardiovascular diseases (hypertension, coronary heart disease), respiratory diseases (emphysema, tuberculosis history), cerebrovascular diseases (stroke), tumor history, diabetes history, smoking history, FEV1, DLCO, tumor size on CT, BMI, and lung segment positions were statistically analyzed in all the patients. The data satisfied the normal distribution, and the two groups of various clinical baseline data did not have statistically difference (age: P=0.11; gender: P=0.44; history of cardiovascular diseases: P=0.07; respiratory diseases: P=0.12; cerebrovascular diseases: P=0.17; tumor history: P=0.08; diabetes history: P=0.25; smoking history: P=0.84; FEV1: P=0.10; DLCO: P=0.22; tumor size on CT: P=0.90; BMI: P=0.11; lung segment positions: P=0.31). The specific results are shown in Table 1.

Intraoperative features and pathologic features

Results indicated that RATS had a significantly shorter average operation time compared to VATS (58.59±12.20 vs. 66.12±21.56 min, P<0.001). Additionally, intraoperative blood loss in the RATS group was significantly less than in the VATS group (98.77±51.50 vs. 128.87±65.79 mL, P=0.02). The differences in them are shown in Table 2. What’s more, there is no difference in the pathological characteristics between RATS and VATS groups, as shown in Table 3.

Postoperative features

Postoperative characteristics showed no significant difference between the RATS and VATS groups regarding the mean 12 hours postoperative drainage volume (130.26±76.06 vs. 166.49±97.29 mL, P=0.20). The total postoperative drainage volume in the RATS group was lower than that in the VATS group (185.44±109.14 vs. 268.70±147.99 mL, P=0.007). Postoperative drainage time was significantly shorter in the RATS group compared to the VATS group (1.74±0.30 vs. 2.29±0.98 days, P=0.045). Pain scores and postoperative analgesic use were also significantly lower in the RATS group, indicating more effective pain management (111.76±40.52 vs. 167.74±67.20 mg, P<0.001; 3.29±0.66 vs. 4.31±0.81, P=0.003). At the same time, there was no significant difference in the postoperative inflammatory indexes including the percentage increase in leukocyte count and the percentage increase in neutrophil count between the two groups (percentage increase in leukocyte count: 1.18%±0.84% vs. 1.34%±1.40%, P=0.27; percentage increase in neutrophil count: 2.16%±1.25% vs. 2.18%±1.32%, P=0.92). The number of delayed discharges in the RATS group was much lower than in the VATS group (11 in the RATS group and 39 in the VATS group, P<0.001), and the incidence of postoperative complications was lower in the RATS group (nausea and vomiting: 3.9% vs. 3.9%, fever: 4.9% vs. 13.5%, pulmonary atelectasis: 0% vs. 2.0%, infection: 1.0% vs. 2.9%, air leakage: 6.9% vs. 8.8%, abnormal drainage fluid: 0% vs. 8.8%, P=0.002), as shown in Table 4.

Factors influencing delayed discharge from day surgery

After propensity score matching, data were divided into two subgroups: delayed discharge from day surgery and on-time discharge. These subgroups were subjected to one-way logistic regression analysis, followed by multifactorial logistic regression analysis, which suggested that tumor history, choice of surgical approach, intraoperative bleeding, use of analgesic medication in the 24-hour postoperative period and duration of surgery are the risk factors for delayed discharge from day surgery (tumor history: P=0.047; choice of surgical approach: P<0.001; intraoperative bleeding: P<0.001; use of analgesic medication in the 24-hour postoperative period: P<0.001; duration of surgery: P=0.02). Details are shown in Table 5.

This was followed by a multifactorial logistic regression analysis of these indicators, which resulted in the findings that history of tumor, intraoperative bleeding, use of analgesic medication in the 24-hour postoperative period, and duration of surgery were risk factors for delayed discharge from day surgery (tumor history: P=0.04; intraoperative bleeding: P=0.005; use of analgesic medication in the 24-hour postoperative period: P=0.001; duration of surgery: P=0.008). Details are shown in Table 6.

Postoperative follow-up of the RATS group vs. the VATS group

After 1 month of postoperative follow-up, it was found that a higher percentage of patients in the RATS group than in the VATS group were healthy after surgery (92.2% vs. 85.3%), and a lower percentage of patients in the RATS group than in the VATS group developed fever, pneumothorax, and pleural effusion during the first month after surgery (fever: 4.9% vs. 5.9%; pneumothorax 1.0% vs. 2.9%; pleural effusion 1.0% vs. 5.9%). A higher percentage of patients in the RATS group developed pneumonia than in the VATS group (1.0% vs. 0%). In terms of recovery within 1 month after surgery, the percentage of good recovery was higher in the RATS group than in the VATS group, but the percentage of moderate as well as poor recovery was lower than in the VATS group (good: 92.2% vs. 85.3%; moderate: 6.9% vs. 11.8%; poor 1.0% vs. 2.9%). There was no statistically significant difference between the two groups on the follow-up results including complications and recovery (complications: P=0.23; recovery: P=0.27), as shown in Table 7.

Discussion

In this study, we retrospectively analyzed the differences in intraoperative characteristics, the incidence of postoperative complications, and the early postoperative follow-up between two groups of patients who underwent pulmonary segmental resection with RATS and pulmonary segmental resection with VATS in the day surgery mode. The results indicate that the average operation time for patients in the RATS group under the day surgery mode was shorter than that of the VATS group, and the intraoperative bleeding was less in the RATS group, consistent with results from studies under non-day surgery modes (9,10). This outcome is closely linked to the precise intraoperative operations afforded by robotic surgery. From an ergonomic perspective, the Da Vinci robotic system reduces the probability of accidental injury due to the surgeon’s hand trembling. Additionally, the Da Vinci surgical robotic system’s thoracoscopy provides a high-definition 3D stereoscopic field of view that can be magnified by 10–15 time. The robotic arm’s ability to rotate 360° significantly broadens the surgeon’s operating range, allowing for more detailed visualization of the intersegmental blood vessels and hilar structures of the lungs, thus reducing the chance of bleeding. In this study, we found that the operation time of RATS in the daytime operation mode is significantly shorter than that in the VATS group, which is contrary to some previous studies (11,12). The patients selected for this day surgery were those with stage T1 NSCLC, judged to be less difficult to operate on after preoperative 3D imaging. Some complex combined lung segment surgeries were excluded compared to other studies, allowing the less invasive robotic surgery to effectively manage intraoperative complications, such as intraoperative hemorrhage and air leaks during lung surgery, while also saving time on suturing. We also found no significant difference in the lymph node clearance rate between the RATS group and the VATS group in the day surgery mode, which contrasts with the results of many previous studies conducted in non-day surgery modes (11-13). The reason may be related to the fact that most of the patients included in this study had intraoperative rapid pathology suggesting adenocarcinoma in situ (AIS), minimally invasive adenocarcinoma (MIA), and adherent subtype dominated invasive adenocarcinoma (IAC), which did not require mediastinal lymph node dissection (14), and the number of Intrapulmonary lymph nodes disseminated in the current study was not clearly defined. As a result, the number of pulmonary lymph node dissection is random. In contrast, the above studies in the non-day surgery mode have certain requirements for mediastinal and Intrapulmonary lymph node clearance, leading to different conclusions.

In addition, this study found that the total postoperative drainage volume was less in the RATS group, the drainage time was shorter, and postoperative pain management was better than in the VATS group. The shorter drainage time in the RATS group, also observed in previous studies (11,15), suggests that RATS surgery is less traumatic in the day surgery mode and that postoperative efficacy is superior under the same condition. This indirectly proves the feasibility of lung segmental resection with RATS in a day surgery setting. The reduction in pleural effusion can be attributed to better visualization during the surgical procedure in the RATS group, which avoids excessive trauma to intrathoracic tissues, thereby reducing inflammation and excessive pleural fluid production (5). Less drainage volume and shorter drainage times can reduce patients’ postoperative pain. Prolonged chest tube drainage can cause pain, affect postoperative lung reopening and sputum expectoration, and increase the chances of postoperative lung atelectasis and lung infection (16). However, the trauma caused by simple lung segmental resections of low surgical difficulty is relatively minor, and the probability of these complications is low. Additionally, we found that the number of patients with delayed discharge from day surgery in the RATS group was lower than in the VATS group. This was related to the lower complication rate in the RATS group compared to the VATS group. This finding differs from previous studies, which concluded that there was no significant difference between RATS and VATS in the incidence of postoperative complications (17-19). We believe that the difference in outcomes is because most studies involve a mix of complex and simple segmental resections. Simple segmental resection refers to surgery dealing with only one intersegmental plane, such as the dorsal segment of the lower lobe or the apical segment of the upper lobe of the right lung. In contrast, complex segmental resection involves handling multiple intersegmental planes. It has been found that the probability of air leakage and fever after complex segmental resection is higher than that after simple lung segmentectomy (16). The selection criteria for day surgery in this study were based on simple lung segmentectomy, where the probability of complications, especially postoperative air leakage and fever, was greatly reduced due to the low intraoperative trauma in the RATS group.

From the perspective of postoperative follow-up, there was no statistically significant difference between them in terms of the probability of complications and recovery within 1 month after surgery, which also indicates that the short-term outcomes within 1 month after surgery were similar between the VATS group and the RATS group in the daytime surgery mode, and this also indicates the feasibility of segmental resection with RATS in the daytime surgery mode. The results of this study also showed that the proportion of patients with poor and moderate recovery was higher in the VATS group than in the RATS group, suggesting that the likelihood of complications and thus recovery in the first month after surgery was higher in the VATS group than in the RATS group, but this result still needs to be verified by a large amount of clinical data. Many studies (8,20) have proven the safety and feasibility of VATS surgery in day surgery mode. The results of the present study indicate that RATS surgery in day surgery mode shares similarities with VATS surgery in intraoperative and postoperative characteristics. Moreover, RATS surgery outperforms VATS surgery in certain aspects, proving its feasibility and safety.

The present study also investigated the factors influencing delayed discharge from day surgery. The results of the study found that tumor history, intraoperative bleeding, use of analgesic medication within 24 hours postoperatively, and duration of surgery were risk factors for delayed discharge from day surgery. The duration of surgery indirectly reflects the complexity of the patient’s surgery. As the duration of surgery and anesthesia increases, the incidence of postoperative complications and the risk of accidents increases, as well as the probability of increased intraoperative bleeding, the increase in the duration of surgery as well as the increase in intraoperative bleeding suggests that trauma during surgery will increase, and the amount of postoperative analgesic medication used indirectly measures the severity of intraoperative trauma (20-22). Unlike other studies, in this study we also found that tumor history was also an influential factor in delayed discharge from day surgery. The authors believe that this is related to the extent to which patients with a history of tumor experience subsequent treatment, that the probability of intraoperative hemorrhage is higher in patients who have undergone chemotherapy or radiotherapy, and that thoracic surgery leads to the presence of pleural adhesions in the operative field, and that all of these factors contribute to the prolongation of the duration of the operation. Interestingly, we found that choice of surgical approach did not affect delayed discharge from day surgery, suggesting that the same risk factors that affect delayed discharge in patients undergoing day surgery for VATS also apply to patients undergoing day surgery for RATS.

Given the widespread development of thoracic laparoscopic day surgery and the promising future of robotic surgery in thoracic surgery, our study provides strong evidence for the feasibility and safety of performing daytime robotic surgery. The superiority of RATS segmental lung resection compared with VATS segmental lung resection in the day surgery mode was confirmed, and the risk factors affecting the delayed discharge from day surgery were initially explored to provide a basis for the selection of patients for subsequent day surgery, while the effective control of the risk factors can also ensure the postoperative recovery of the patients. However, the limitation of our study is the insufficient sample size, which only allows for a preliminary investigation of the risk factors for delayed discharge from day surgery and the differences in recovery and complications between the two groups in the first month after surgery. Additionally, the few cases of day surgery for complex segmental resection in our study cannot prove the feasibility of day surgery for these more complex procedures.

Conclusions

In the day surgery model, RATSs showed better outcomes compared to VATSs, including shorter surgical duration, reduced intraoperative blood loss, lower postoperative drainage volume, shorter drainage duration, and fewer postoperative complications. At the same time, we further demonstrated the feasibility and reliability of pulmonary segmentectomy in RATS in the daytime mode. What’s more, we also found that history of tumor, intraoperative bleeding, use of analgesic medication in the 24-hour postoperative period, and duration of surgery were risk factors for delayed discharge from day surgery.

Acknowledgments

This research received the guidance and help of Professor Qianyun Wang from Soochow University for data processing.

Funding: This funding was supported by the Changzhou Science and Technology Bureau (CJ20241104).

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1020/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1020/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1020/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1020/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 conducted in accordance with the Declaration of Helsinki (as revised in 2013). This study was approved by the Ethics Committee of the First People’s Hospital of Changzhou City (approval No. 2023 technology 197) and informed consent was taken from all the patients.

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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