Minimally Invasive Transanal Surgery (TAMIS) for a Giant Villous Adenoma of the Rectum: A Case Report

Minimally Invasive Transanal Surgery (TAMIS) for a Giant Villous Adenoma of the Rectum: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Minimally Invasive Transanal Surgery (TAMIS) for a Giant Villous Adenoma of the Rectum: A Case Report Alessandro Verbo, Giuseppe De Rito, Danilo Di Giorgio, Mattia Bez, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6723914/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Transanal minimally invasive surgery (TAMIS) is increasingly used for local excision of rectal lesions, especially when conventional endoscopy is not feasible. While its primary indications include benign and early malignant lesions, few reports exist on its use for large-volume rectal tumors. Case Presentation: We report a case of a 69-year-old male with a giant villous adenoma of the rectum showing focal areas of high-grade dysplasia. The patient underwent successful resection via TAMIS. The lesion measured approximately 11 cm in craniocaudal length and occupied two-thirds of the rectal circumference. Surgical time was 90 minutes, blood loss was minimal (50 mL), and hospital stay lasted 3 days. No intraoperative or postoperative complications occurred. Histopathology confirmed a tubular-villous adenoma with low-grade dysplasia and focal high-grade dysplasia, staged as pT1N0M0. No recurrence was observed at 6-month follow-up. Conclusion: TAMIS is a feasible, safe, and cost-effective approach for large rectal adenomas with early malignant transformation. It offers favorable perioperative outcomes, minimal morbidity, and short hospitalization when applied in appropriately selected patients. Transanal minimally invasive surgery TAMIS rectal adenoma early rectal cancer local excision Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Traditionally, transanal excision techniques were limited to lesions within 6 cm of the anal verge. However, the advent of TAMIS has expanded the possibilities of full-thickness local excision for rectal lesions located up to 15–18 cm from the anal verge. TAMIS combines the benefits of minimal invasiveness with precise oncologic resection, offering an alternative to radical surgery in select cases. Despite these advantages, its use in large lesions remains debated due to concerns about sphincter preservation, incomplete resection, bleeding, and local recurrence. Case Presentation Patient Profile A 69-year-old male presented with asthenia, rectal bleeding, mucus discharge, and tenesmus persisting for over 6 months, with worsening in the previous month. He had a significant smoking history and comorbidities including chronic pancreatitis and diabetes mellitus. Physical examination and digital rectal exam identified a soft, bleeding, posterior rectal wall mass located approximately 5 cm from the anal verge. Diagnostic Workup Colonoscopy revealed a vegetative lesion on the posterolateral wall of the rectum, 7 cm from the anal verge, extending cranially for 7 cm and occupying two-thirds of the lumen circumference (Fig.1). Histology showed a villous adenoma with low-grade dysplasia and a focal area of high-grade intraepithelial neoplasia. CT imaging showed an endoluminal mass measuring 11 cm with no signs of local invasion or lymphadenopathy (Fig.2). Cardiopulmonary function and anesthesia risks were deemed acceptable for surgery. Surgical Procedure After standard bowel preparation and preoperative antibiotics (cefmeazole and metronidazole), TAMIS was performed using a GelPOINT® Path transanal access port. CO₂ insufflation was maintained at 15 mmHg and 12 L/min. The tumor, located at 3–9 o'clock, measured approximately 10×5 cm² with a 4×5 cm² base (Fig.3). Full-thickness excision was achieved using monopolar electrocautery (Fig.4). Frozen biopsies at all margins confirmed negative resection borders. The rectal defect was closed with two running sutures using Stratafix 3/0 (Fig.5). Postoperative Course Postoperative recovery was uneventful. The patient resumed clear fluids on day one and a soft diet on day two. No complications (bleeding, incontinence, urinary retention) were observed. The patient was discharged on postoperative day three. Final pathology confirmed a tubular-villous adenoma with low-grade dysplasia and focal high-grade dysplasia. No invasive carcinoma was present. The pathological stage was pT1N0M0. Follow-up at 3 and 6 months showed no recurrence on rectoscopy or imaging. Discussion TAMIS offers a compelling alternative to conventional transanal excision and radical surgery for benign and early malignant rectal tumors. Its main indications include: T1 rectal cancers without adverse features (poor differentiation, lymphovascular invasion) Large benign adenomas not amenable to endoscopic resection Neoplasms located 5–15 cm from the anal verge In our case, TAMIS successfully enabled full-thickness excision of an 11-cm villous adenoma, a procedure traditionally requiring laparotomy or laparoscopic segmental resection. Operative time (90 minutes), minimal blood loss (50 mL), and rapid recovery (3-day stay) highlight its clinical advantages. Key intraoperative considerations include: Maintaining stable pneumorectum. In our case, the stabilizing balloon of the port eliminated the need for gauze packing, reducing risk of mucosal trauma. Ensuring negative margins through intraoperative frozen section. Concerns with TAMIS in large or high-risk tumors: Sphincter damage: Risk is minimized by avoiding over-distension and limiting resection near the dentate line. Bleeding and infection: Proper closure of rectal defect and prophylactic antibiotics mitigate these risks. Recurrence or residual disease: Regular postoperative surveillance is critical, especially in T1 cancers. Although some reports raise concerns regarding higher rates of local recurrence or anastomotic fistulae when wounds are left open, closure of the defect appears to reduce these risks [1,2]. Recommendations for optimal use of TAMIS include: Careful patient selection (T1 tumors <3 cm, well-differentiated, no nodal disease) Preoperative MRI for local staging Intraoperative frozen sections for margin evaluation Postoperative surveillance at 3, 6, and 12 months Conclusion TAMIS is a safe and effective approach for resecting large villous adenomas and early rectal cancers. In experienced hands, it offers excellent oncologic and functional outcomes while minimizing morbidity. Further prospective studies and longer follow-up are needed to assess its long-term oncologic safety in larger lesions [ 3 , 4 , 5 ]. Declarations I declare that the participant/patient/legal guardian has consented to the publication of their clinical case. The authors did not receive support from any organization for the submitted work. The authors have no relevant financial or non-financial interests to disclose. Author Contribution Alessandro Verbo, Giuseppe De Rito and Danilo Di Giorgio wrote the main manuscript text. Mattia Bez, Francesco Mansueto, and Iacopo Verbo conducted the literature research and prepared the figures. All authors reviewed the manuscript. References Atallah S, Albert M, DeBeche-Adams T, et al. Transanal minimally invasive surgery: a giant leap forward. Surg Endosc. 2010;24(9):2200–2205. doi:10.1007/s00464-010-0931-5 Hompes R, Mortensen NJ. Transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS) in early rectal cancer. Ann Gastroenterol. 2015;28(1):9–14. Lee L, Burke JP, deBeche-Adams T, et al. Transanal minimally invasive surgery for rectal cancer: a multicenter experience. Dis Colon Rectum. 2015;58(6):950–956. doi:10.1097/DCR.0000000000000422 Marks JH, Myers EA, Zeger EL, et al. Transanal minimally invasive surgery for rectal lesions: lessons learned from our first 100 cases. Surg Endosc. 2013;27(2):383–387. doi:10.1007/s00464-012-2469-x Caycedo-Marulanda A, Lee L, Chadi SA, et al. Transanal minimally invasive surgery in Canada: a National Survey. Surg Endosc. 2019;33(9):2912–2917. doi:10.1007/s00464-018-6606-y Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6723914","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":461673886,"identity":"4672df9d-e5e8-4867-939c-1ce3eefeb1e4","order_by":0,"name":"Alessandro 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06:01:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":77110,"visible":true,"origin":"","legend":"\u003cp\u003eAbdominal CT scan showing a rectal endoluminal mass\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6723914/v1/86b1b929350fe602f6287669.png"},{"id":83591341,"identity":"104b4fc8-d35d-45b9-aacd-7c4c3d847793","added_by":"auto","created_at":"2025-05-29 06:17:52","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":270100,"visible":true,"origin":"","legend":"\u003cp\u003eVillous adenoma after the surgical excision\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6723914/v1/3cfe13ea042a960c96c5b49a.png"},{"id":83590409,"identity":"82d76772-f14e-44f1-8b5d-219dfb4be14c","added_by":"auto","created_at":"2025-05-29 06:01:52","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":238286,"visible":true,"origin":"","legend":"\u003cp\u003eThe rectum after the full-thickness excision\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6723914/v1/0a371552c912baa8f8a1952d.png"},{"id":83590405,"identity":"8d6dc0d7-8d56-4f04-b4eb-0d4f9cb952df","added_by":"auto","created_at":"2025-05-29 06:01:52","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":201995,"visible":true,"origin":"","legend":"\u003cp\u003eThe rectum after surgical suture\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6723914/v1/fff9fc35296df5addb2e29ab.png"},{"id":83939584,"identity":"c7bc22e0-1584-46a8-91da-48fbb98201a8","added_by":"auto","created_at":"2025-06-04 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However, the advent of TAMIS has expanded the possibilities of full-thickness local excision for rectal lesions located up to 15\u0026ndash;18 cm from the anal verge. TAMIS combines the benefits of minimal invasiveness with precise oncologic resection, offering an alternative to radical surgery in select cases. Despite these advantages, its use in large lesions remains debated due to concerns about sphincter preservation, incomplete resection, bleeding, and local recurrence.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003e\u003cstrong\u003ePatient Profile\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 69-year-old male presented with asthenia, rectal bleeding, mucus discharge, and tenesmus persisting for over 6 months, with worsening in the previous month. He had a significant smoking history and comorbidities including chronic pancreatitis and diabetes mellitus. Physical examination and digital rectal exam identified a soft, bleeding, posterior rectal wall mass located approximately 5 cm from the anal verge.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiagnostic Workup\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eColonoscopy revealed a vegetative lesion on the posterolateral wall of the rectum, 7 cm from the anal verge, extending cranially for 7 cm and occupying two-thirds of the lumen circumference (Fig.1). Histology showed a villous adenoma with low-grade dysplasia and a focal area of high-grade intraepithelial neoplasia.\u003c/p\u003e\n\u003cp\u003eCT imaging showed an endoluminal mass measuring 11 cm with no signs of local invasion or lymphadenopathy (Fig.2). Cardiopulmonary function and anesthesia risks were deemed acceptable for surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter standard bowel preparation and preoperative antibiotics (cefmeazole and metronidazole), TAMIS was performed using a GelPOINT\u0026reg; Path transanal access port. CO₂ insufflation was maintained at 15 mmHg and 12 L/min. The tumor, located at 3\u0026ndash;9 o\u0026apos;clock, measured approximately 10\u0026times;5 cm\u0026sup2; with a 4\u0026times;5 cm\u0026sup2; base (Fig.3). Full-thickness excision was achieved using monopolar electrocautery (Fig.4). Frozen biopsies at all margins confirmed negative resection borders.\u003c/p\u003e\n\u003cp\u003eThe rectal defect was closed with two running sutures using Stratafix 3/0 (Fig.5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative Course\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePostoperative recovery was uneventful. The patient resumed clear fluids on day one and a soft diet on day two. No complications (bleeding, incontinence, urinary retention) were observed. The patient was discharged on postoperative day three. Final pathology confirmed a tubular-villous adenoma with low-grade dysplasia and focal high-grade dysplasia. No invasive carcinoma was present. The pathological stage was pT1N0M0. Follow-up at 3 and 6 months showed no recurrence on rectoscopy or imaging.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTAMIS offers a compelling alternative to conventional transanal excision and radical surgery for benign and early malignant rectal tumors. Its main indications include:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eT1 rectal cancers without adverse features (poor differentiation, lymphovascular invasion)\u003c/li\u003e\n \u003cli\u003eLarge benign adenomas not amenable to endoscopic resection\u003c/li\u003e\n \u003cli\u003eNeoplasms located 5\u0026ndash;15 cm from the anal verge\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eIn our case, TAMIS successfully enabled full-thickness excision of an 11-cm villous adenoma, a procedure traditionally requiring laparotomy or laparoscopic segmental resection. Operative time (90 minutes), minimal blood loss (50 mL), and rapid recovery (3-day stay) highlight its clinical advantages.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKey intraoperative considerations include:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eMaintaining stable pneumorectum. In our case, the stabilizing balloon of the port eliminated the need for gauze packing, reducing risk of mucosal trauma.\u003c/li\u003e\n \u003cli\u003eEnsuring negative margins through intraoperative frozen section.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eConcerns with TAMIS in large or high-risk tumors:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eSphincter damage:\u003c/strong\u003e Risk is minimized by avoiding over-distension and limiting resection near the dentate line.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eBleeding and infection:\u003c/strong\u003e Proper closure of rectal defect and prophylactic antibiotics mitigate these risks.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eRecurrence or residual disease:\u003c/strong\u003e Regular postoperative surveillance is critical, especially in T1 cancers.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAlthough some reports raise concerns regarding higher rates of \u003cstrong\u003elocal recurrence or anastomotic fistulae\u003c/strong\u003e when wounds are left open, closure of the defect appears to reduce these risks [1,2].\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eRecommendations for optimal use of TAMIS include:\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003eCareful patient selection (T1 tumors \u0026lt;3 cm, well-differentiated, no nodal disease)\u003c/li\u003e\n \u003cli\u003ePreoperative MRI for local staging\u003c/li\u003e\n \u003cli\u003eIntraoperative frozen sections for margin evaluation\u003c/li\u003e\n \u003cli\u003ePostoperative surveillance at 3, 6, and 12 months\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTAMIS is a safe and effective approach for resecting large villous adenomas and early rectal cancers. In experienced hands, it offers excellent oncologic and functional outcomes while minimizing morbidity. Further prospective studies and longer follow-up are needed to assess its long-term oncologic safety in larger lesions [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cspan\u003eI declare that the participant/patient/legal guardian has consented to the publication of their clinical case.\u003c/span\u003e\u003c/p\u003e\u003cp\u003eThe authors did not receive support from any organization for the submitted work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u0026nbsp;\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAlessandro Verbo, Giuseppe De Rito and Danilo Di Giorgio wrote the main manuscript text. Mattia Bez, Francesco Mansueto, and Iacopo Verbo conducted the literature research and prepared the figures. All authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAtallah S, Albert M, DeBeche-Adams T, et al. Transanal minimally invasive surgery: a giant leap forward. \u003cem\u003eSurg Endosc.\u003c/em\u003e 2010;24(9):2200\u0026ndash;2205. doi:10.1007/s00464-010-0931-5\u003c/li\u003e\n \u003cli\u003eHompes R, Mortensen NJ. Transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS) in early rectal cancer. \u003cem\u003eAnn Gastroenterol.\u003c/em\u003e 2015;28(1):9\u0026ndash;14.\u003c/li\u003e\n \u003cli\u003eLee L, Burke JP, deBeche-Adams T, et al. Transanal minimally invasive surgery for rectal cancer: a multicenter experience. \u003cem\u003eDis Colon Rectum.\u003c/em\u003e 2015;58(6):950\u0026ndash;956. doi:10.1097/DCR.0000000000000422\u003c/li\u003e\n \u003cli\u003eMarks JH, Myers EA, Zeger EL, et al. Transanal minimally invasive surgery for rectal lesions: lessons learned from our first 100 cases. \u003cem\u003eSurg Endosc.\u003c/em\u003e 2013;27(2):383\u0026ndash;387. doi:10.1007/s00464-012-2469-x\u003c/li\u003e\n \u003cli\u003eCaycedo-Marulanda A, Lee L, Chadi SA, et al. Transanal minimally invasive surgery in Canada: a National Survey. \u003cem\u003eSurg Endosc.\u003c/em\u003e 2019;33(9):2912\u0026ndash;2917. doi:10.1007/s00464-018-6606-y\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Transanal minimally invasive surgery, TAMIS, rectal adenoma, early rectal cancer, local excision","lastPublishedDoi":"10.21203/rs.3.rs-6723914/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6723914/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003eTransanal minimally invasive surgery (TAMIS) is increasingly used for local excision of rectal lesions, especially when conventional endoscopy is not feasible. While its primary indications include benign and early malignant lesions, few reports exist on its use for large-volume rectal tumors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation:\u003c/strong\u003e We report a case of a 69-year-old male with a giant villous adenoma of the rectum showing focal areas of high-grade dysplasia. The patient underwent successful resection via TAMIS. The lesion measured approximately 11 cm in craniocaudal length and occupied two-thirds of the rectal circumference. Surgical time was 90 minutes, blood loss was minimal (50 mL), and hospital stay lasted 3 days. No intraoperative or postoperative complications occurred. Histopathology confirmed a tubular-villous adenoma with low-grade dysplasia and focal high-grade dysplasia, staged as pT1N0M0. No recurrence was observed at 6-month follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003eTAMIS is a feasible, safe, and cost-effective approach for large rectal adenomas with early malignant transformation. It offers favorable perioperative outcomes, minimal morbidity, and short hospitalization when applied in appropriately selected patients.\u003c/p\u003e","manuscriptTitle":"Minimally Invasive Transanal Surgery (TAMIS) for a Giant Villous Adenoma of the Rectum: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-29 06:01:48","doi":"10.21203/rs.3.rs-6723914/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"14e45e4e-2963-4320-b4f9-25cb740537de","owner":[],"postedDate":"May 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-04T17:38:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-29 06:01:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6723914","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6723914","identity":"rs-6723914","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}