Progress of Clinical Application of Esketamine in Abdominal Tumor Surgery in Elderly Patients

Dexmedetomidine as an adjunct to epidural analgesia after abdominal surgery in elderly intensive care patients: A prospective, double-blind, clinical trial

Elbow joint release surgery is commonly used to treat elbow joint stiffness. Though it can restore elbow joint mobility, some patients may still experience range of motion (ROM) loss after surgery. Therefore, this study aims to explore the factors influencing ROM loss after elbow joint release surgery in elderly patients with traumatic elbow stiffness. This retrospective study included 122 elderly patients with traumatic elbow stiffness who underwent elbow joint release surgery at Hanzhong Central Hospital from January 2023 to April 2024. The patients with range of motion loss were included in the observation group (n = 41), and those without range of motion loss were placed in the control group (n = 81). The general data of the two groups were compared, and Logistic regression analysis was performed to identify factors influencing the loss of ROM after elbow joint release surgery in elderly patients with traumatic elbow stiffness. A risk prediction model was also established based on the identified risk factors. Multivariate Logistic regression analysis unveiled that high-energy injury (odds ratio (OR) = 4.632, 95% confidence interval (CI) = 1.363∼15.737), open injury (OR = 3.967, 95% CI = 1.308∼12.029), passive rehabilitation method (OR = 10.115, 95% CI = 1.113∼91.924), injury-to-release surgery time of ≥6 months (OR = 5.983, 95% CI = 1.677∼21.350), heterotopic ossification traumatic factors (OR = 5.409, 95% CI = 1.316∼22.224), and complex elbow joint damage (OR = 5.658, 95% CI = 1.457∼21.962) were all independent risk factors for ROM loss following elbow joint release surgery in elderly patients with traumatic elbow stiffness (p < 0.05). A risk prediction model was developed based on these factors, indicating a predictive sensitivity of 73.17%, a specificity of 69.14%, and an area under the curve (AUC) of 0.767. Clinically, the independent risk factors identified in this study should be closely monitored. Furthermore, treatment should be tailored based on the specific conditions of the patient, and high-risk factors should be effectively controlled to reduce the risk of ROM loss after elbow joint release surgery in traumatic elbow joint stiffness elderly patients.

Background. Acute occlusion of lower limb arteries is one of the most common indications for emergency vascular surgery in elderly and senile patients. Neuroaxial anesthesia is common for these procedures. The main disadvantage of traditional spinal anesthesia is hypotension, and methods of its correction (infusion therapy and vasopressors) are not always acceptable in elderly patients. At the same time, perioperative normotension is the best option to prevent acute kidney and myocardial damage. Objective. To justify the feasibility of unilateral spinal anesthesia (ULSA) in elderly patients with acute arterial ischemia of the lower extremities. Material and methods. The study included 2 groups of patients by 52 people who underwent surgical treatment: group 1 — bilateral spinal anesthesia (BLSA), group 2 — ULSA. We used a 0.5% solution of Bupivacaine Spinal Heavy in all cases. Effectiveness of motor block was assessed using the Bromage scale. We estimated hemodynamic parameters (blood pressure, heart rate, stroke index, peripheral vascular resistance index) using rheography. Laboratory monitoring included markers of renal damage (creatinine, urea, lipocalin, cystatin C) and myocardial damage (troponin I, MB-kinase, myoglobin). Results. Unilateral technique provides more stable central hemodynamic parameters compared to traditional spinal anesthesia and no need for vasopressors. Unilateral blockade was followed by positive dynamics in indicators of renal damage and lower markers of myocardial damage compared to bilateral blockade. Conclusion. ULSA may be preferable for urgent vascular surgery in elderly patients.

PurposeAnastomotic leakage after rectal cancer surgery in elderly patients is a critical challenge. Many risk factors have been found and many interventions tried, but anastomotic leakage in elderly patients remains difficult to deal with. This study aimed to create a nomogram for predicting anastomotic leakage after rectal surgery in elderly rectal cancer patients with dysfunctional stomata.MethodsWe collected data from 326 consecutive elderly patients with dysfunctional stomata after rectal cancer surgery at the Sixth Affiliated Hospital, Sun Yat-Sen University from January 2014 to December 2019. Risk factors of anastomotic leakage were identified with multivariate logistic regression and used to create a nomogram. Predictive performance was evaluated by the area under the receiver-operating characteristic (ROC) curve.ResultsAmerican Society of Anesthesiologists score ≥3, male sex, and neoadjuvant radiotherapy were identified as significantly associated factors that could be combined for accurate prediction of anastomotic leakage on multivariate logistic regression and development of a nomogram.The area under the ROC curve for this model was 0.645. The C-index value for this model was 0.645, indicating moderate predictive ability of the risk of anastomotic leakage.ConclusionThe nomogram showed good ability to predict anastomotic leakage in elderly patients with rectal cancer after surgery, and might be helpful in providing a reference point for selection of surgical procedures and perioperative treatment.

The aim of the present study was to examine the technical and oncological feasibility of laparoscopic surgery (LAP) in elderly patients with a history of abdominal surgery. We conducted a propensity score-matched case-control study of colorectal cancer (CRC) patients aged≥80years that were treated at 41 hospitals between 2003 and 2007. We included 601 patients who had a history of abdominal surgery and underwent curative and elective surgery for stage 0 to III CRC. After the matching procedure, 153 patients were included in each cohort. The surgical outcomes of LAP and open surgery (OS) were compared. P-values of<0.05 were considered statistically significant. LAP resulted in a significantly longer surgical time (220 vs. 170min, p<0.001), but significantly less intraoperative blood loss (39 vs. 100ml, p<0.001). A number of postoperative recovery-related parameters, including the length of the hospitalization period (12 vs. 14days, p=0.002), and the days to the resumption of fluid (2 vs. 3days, p<0.001) and solid food intake (4 vs. 5days, p<0.001), were significantly better in the LAP group. Moreover, the overall morbidity rate (43 vs. 66%, p=0.009) and the frequency of postoperative ileus (7 vs. 19%, p=0.023) were significantly lower in the LAP group, while the frequencies of other morbidities did not differ significantly between the groups. In the survival analyses, overall survival and disease-free survival did not differ between the two groups. In this population, LAP can be performed safely in elderly CRC patients with a history of abdominal surgery, and LAP resulted in a lower postoperative morbidity rate than OS.

To investigate the value of individual risk-adapted therapy in geriatric patients, we performed a consecutive analysis of 363 patients undergoing potentially curative surgery for gastric cancer. All patients underwent extensive preoperative workup to assess surgical risk. The following criteria were evaluated in 3 age groups (<60 years, 60-75 years, and >75 years): comorbidity, tumor characteristics, type of resection, postoperative morbidity and mortality, recurrence rate, overall survival, and disease-free survival. There was an increased rate of comorbidity in the higher age groups (51% vs 76% vs 83%; P<0.05). Cardiovascular and pulmonary diseases were most common. There was a decrease in the rate of both total gastrectomy (74%, 54%, 46%; P<0.05) and D2 lymphadenectomy (78%, 53%, 31%; P<0.05). The 30-day mortality in the 3 age groups was 0%, 1%, and 8%, respectively (P<0.05). There was only a slight difference in tumor recurrence rate (35%, 37%, and 27%; P=0.437), with no significant difference in 5-year cancer-related survival (61%, 53%, 61%; P=0.199). Patient selection and risk-adapted surgery in elderly patients can result in acceptable therapeutic results comparable to younger patients. Limited surgery in elderly gastric cancer patients with high comorbidity does not necessarily compromise oncological outcome.

To the Editor: By a randomized controlled trial, Xi et at[1] assessed the effects of edaravone on the development of postoperative delirium (POD) and perioperative neuro-cognitive disorders (PND) in elderly patients with hip replacement and showed that edaravone significantly decreased the incidence of POD within 7 days after surgery and the incidences of PND at 1 and 12 months after surgery. Given that both POD and PND are common complications after hip surgery in elderly patients and have been significantly associated with postoperative death, hospital-acquired complications, persistent cognitive impairments, poor postoperative functional recovery, prolonged duration of hospital stay, and increased healthcare costs,[2,3] their findings have potential implications. However, we noted several issues in the methodology and results of this study on which we would like to invite authors’ comments. First, the study objects were elderly surgical patients with a mean age >72 years. The authors only assessed preoperative cognitive function by the Montreal cognitive assessment score but did not determine whether patients suffered from preoperative neuropsychiatric comorbidities such as anxiety, delirium, depression, and sleep disorders. In fact, these comorbidities are common among elderly patients undergoing hip surgery and cannot be determined by the Montreal cognitive assessment score. It has been shown that these preoperative neuropsychiatric comorbidities are the most established predisposing factors of PND and POD after hip surgery in elderly patients.[2-5] Furthermore, the history of elderly patients’ preoperative medications was not included in the baseline data. The available evidence indicates that anticholinergic drugs and benzodiazepines are widely utilized in managing elderly patients and have been significantly associated with the development and severity of POD.[6] In addition, preoperative hemoglobin and albumin levels were also not provided in baseline data, though preoperative anemia and hypoalbuminemia have been significantly associated with an increased risk of POD in elderly surgical patients.[7] We are concerned that any imbalance in the above preoperative risk factors would have biased their findings. Second, in this study, the modified telephone interview for cognitive status was used to assess the cognitive function of all patients before and after surgery. Furthermore, the incidences of PND at 1 and 12 months after surgery were significantly lower in the edaravone group than in the control group. In the methods, however, the authors did not provide the diagnostic criteria of PND. In 2018, the International Nomenclature Consensus Working Group recommends that definitions of PND in a clinical study must meet the diagnostic criteria of neurocognitive disorders in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition.[8] Evidently, the use of decreased scores of modified telephone interview alone for cognitive status to diagnose PND in this study cannot achieve the requirements of new recommendations for the definition of PND. Thus, we question the incidence of PND reported in this study. Third, the duration of the hospital stay was shorter in the edaravone group than in the control group, but the authors did not provided the reasons for a prolonged hospital stay in the control group. Most importantly, it was also unclear whether the two groups were comparable with respect to early postoperative complications, such as infection, hemodynamic instability, arrhythmia, sleep disorders, accidental fall, anemia, and pneumonia, which are common after major surgery in elderly patients. It has been shown that these early postoperative complications can significantly increase the risk of POD and prolong the duration of hospital stay after hip surgery in elderly patients.[9] To differentiate the real effect of one factor on the primary endpoint in a randomized controlled trial, we argue that all other possible influencing factors must be standardized for the avoidance of potential bias. Finally, the authors described that primary endpoint were the incidence of POD within 7 days after surgery, the scores of the modified telephone interview for cognitive status, and the activities of daily life at 1 and 12 months after surgery. However, they used the incidence rate of decline in postoperative cognitive function scores to calculate the sample size. In fact, as a basic principle, in a randomized controlled trial, only an important observed parameter can be designed as the primary endpoint and sample size calculation must be performed on solely the primary endpoint. Furthermore, analysis of multiple secondary outcome parameters requires significance levels to be adjusted, for example, using a Bonferroni correction.[10] We believe that clarification of these statistical issues will improve the transparency of this study design. Conflicts of interest None.

The development of sensitive myocardial-specific cardiac biomarkers allows for detection of very small amounts of myocardial injury or necrosis. Myocardial injury (MI) as a prelude of the serious perioperative complication myocardial infarction, should be paid more attention, especially in elderly susceptible patients. Myocardial injury after abdominal surgery in elderly patients has not been described yet. The objectives of this study were to identify the incidence, predictors, characteristics and the impact of MI on outcome in elderly patients underwent abdominal surgery. Patients aged ≥ 65 who underwent abdominal surgery longer than 2h between January 2016 and March 2017 were reviewed. Patients with peak troponin I level of 0.04ng/ml or greater (abnormal laboratory threshold) within once-administration-period and without non-ischemia troponin elevation proof (e.g., sepsis) were assessed for characteristics and prognosis. Risk factors of MI were determined by multivariable regression. Among 285 patients with whole information, 36 patients (12.6%) suffered MI, only 2 patients (0.7%) fulfilled definition of myocardial infarction. With most of them occurred within first 7days after surgery. Multivariable analysis showed that coronary artery disease (CAD) history [odds ratio (OR) 2.817, P = 0.015], non-laparoscopic surgery (OR 5.181, P = 0.030), blood loss ≥ 800ml (OR 3.430, P = 0.008), non-venous maintain (OR 2.105, P = 0.047), and infection (OR 4.887, P = 0.008) as risk factors for MI. MI was associated with longer hospital stay (P = 0.006), more cardiac consultation (P = 0.011), higher infection(P = 0.016) and reoperation(P = 0.026) rate. MI is common in elderly patients who underwent abdominal surgery, while myocardial infarction is infrequent. They are both associated with risk factors and worse prognosis. MI deserves more attention especially in elderly patients. Troponin I measurement is a useful test after massive surgery, which can help risk-stratifying patients, effective preventing, prompt managing and predicting outcomes. Routine monitoring of cardiac biomarkers especially within 7days after abdominal surgery in elderly patients is recommended.

We performed a retrospective study to evaluate the feasibility and safety of extensive upper abdominal surgery (EUAS) in elderly (≥65 yr) patients with advanced ovarian cancer. Records of patients with advanced epithelial ovarian cancer who received surgery at our institution between January 2001 and June 2005 were reviewed. A total of 137 patients including 32 (20.9%) elderly patients were identified. Co-morbidities were present in 37.5% of the elderly patients. Optimal cytoreduction was feasible in 87.5% of the elderly while 95.2% of young patients were optimally debulked (P=0.237). Among 77 patients who received one or more EUAS procedures, 16 (20.8%) were elderly. Within the cohort, the complication profile was not significantly different between the young and the elderly, except for pleural effusion and pneumothorax (P=0.028). Elderly patients who received 2 or more EUAS procedures, when compared to those 1 or less EUAS procedure, had significantly longer operation times (P=0.009), greater blood loss (P=0.002) and more intraoperative transfusions (P=0.030). EUAS procedures are feasible in elderly patients with good general condition. However, cautious peri-operative care should be given to this group because of their vulnerability to pulmonary complications and multiple EUAS procedures.

Neoadjuvant therapy followed by radical surgery is standard for locally advanced rectal cancer (LARC). However, compared to younger patients, elderly patients often had multiple commodities and may refuse surgery due to being medically unfit or the high risk of operative mortality. This study aims to explore the effects of surgery on short- and long-term mortality in elderly LARC patients using a nationwide cancer registry. The cohort included 6211 patients aged over 65, with 2556 matched through propensity scoring for comparison between surgery (N = 1704) and non-surgery (N = 852) groups. The Cox proportional hazard model compared mortality between these groups. Our results showed that the elderly LARC patients who underwent surgery were more likely to be younger (65-75 years), have clinically-positive lymph nodes, and no comorbidities. Surgery was associated with significantly lower 3-month, 6-month, and 5-year mortality rates, with a greater absolute survival benefit (adjusted hazard ratio [aHR], 4.78; 95% CI, 2.71-8.43; aHR, 4.50; 95% CI, 3.07-6.58 and aHR, 3.81; 95% CI, 3.21-4.51). In stratified analysis, surgery remains provide significantly survival benefit according different age, gender and clinical classification. Furthermore, among non-surgical patients, those receiving chemoradiation had better survival outcomes compared to those receiving radiation, chemotherapy, or no treatment (all P < 0.001). This study highlights the survival advantage of surgery in elderly LARC patients and offers valuable guidance for clinical decision-making.

The incidence of pituitary adenoma (PA) increases with age. Transsphenoidal surgery (TSS) in elderly patients is often considered to have greater risk compared to the younger population. The aim of this study is to compare surgical results, evolution and postoperative complications between elderly and young patients undergoing TSS. Retrospective review of patients undergoing TSS between 2011 and 2018 in our institution. Patients were divided into two cohorts: elderly (≥65 years) and non-elderly (<65 years). Characteristics and outcomes of both groups were compared at diagnosis, before surgery and for an average of 5.9 years of postoperative follow-up. One hundred and twenty-five patients were included, 53 patients were ≥65 years (42%). The elderly patients were more likely to have non-functioning PA (NFPA) (90.5% vs. 45.8%, p: <0.01), a higher proportion of macroadenomas (92.4% vs. 77.8%, p = 0.029) and greater extrasellar extension (88.7% vs. 68.1%, p = 0.007). The elderly group also had more compressive symptoms (54.7% vs. 34.7%, p = 0.035) and hypopituitarism (66% vs. 47.2%, p = 0.029). Overall, surgical and endocrinological outcomes between the two groups were similar. Inpatient mortality in the elderly group was 1.8%. Regarding long-term outcomes, elderly patients had more postoperative hypopituitarism (67.9% vs. 45.8%, p = 0.03) with no differences in permanent diabetes insipidus, less residual tumours (24.5% vs. 40.3%, p = 0.019) and a higher rate of remission after surgery (71.7% vs. 52.8%, p = 0.034). When only NFPA cases were compared, the only significant difference was a higher frequency of macroadenomas in the elderly group. Our results support the safety and efficacy of TSS in elderly patients with PA. Age should not be considered an exclusion criterion for TSS given that successful results can be achieved if an experienced pituitary team is available.

Laparoscopic Colorectal Surgery in Elderly Patients: A Matched Case-Control Study in 178 Patients

Background:The incidence of coronary artery bypass grafting surgery (CABG) in elderly patients has been increasing. There are contradictory reports on the early outcome of elderly coronary artery patients as compared with their young counterparts. We designed this retrospective study to address this issue.Methods:We retrospectively analyzed the results of 1489 on–pump CABG cases performed at our hospital during a 4.5-year period. Perioperative data such as demographic, medical, clinical, operative, and postoperative variables were collected and compared between patients 70 years old or younger (Group A, n = 1164) and patients above 70 years of age (Group B, n = 325). Statistical analysis was performed using the t-test for the continuous and the X2 tests for the categorical variables. Significant variables according to the univariate analysis (X2 and t-test) were further analyzed using multivariate logistic regression analysis.Results:The variables of weight (P value < 0.001), preoperative PO2 (P value = 0.005), ejection fraction > 30% (P value = 0.001), body surface area (P value = 0.003), and hypercholesterolemia (P value = 0.007) were higher in Group A, whereas preoperative myocardial infarction (P value < 0.001), postoperative low cardiac output syndrome (P value = 0.019), emergent surgery (P value = 0.003), inotropic drug use (P value < 0.001), preoperative heparin use (P value < 0.001), re-exploration for bleeding (P value = 0.015), hospital stay (P value < 0.001), low ejection fraction (≤ 30%) (P value = 0.001), preoperative creatinine > 1.5 mg/dl (P value < 0.001), chronic obstructive pulmonary disease (P value < 0.001), intra-aortic balloon pump use (P value < 0.001), infection (P value < 0.001), pulmonary complications (P value < 0.001), atrial fibrillation (P value < 0.001), postoperative renal complications (P value < 0.001), and death (P value = 0.012) were more frequent in Group B.Conclusion:CABG in the elderly patients had certain surgical risks such as chronic obstructive pulmonary disease, preoperative myocardial infarction, emergent surgery, and death. Also, postoperative complications such as pulmonary complications, inotropic drug use, intra-aortic balloon pump use, and infection were more frequent in the elderly than in the younger patients.

To investigate the effect of parecoxib sodium preemptive analgesia on pain and stress response after surgery in elderly hip fracture patients. The clinical data of 70 elderly patients with hip fracture treated in our hospital from October 2017 to October 2019 were prospectively analyzed. According to different analgesic patterns, 35 cases were randomly divided into experimental group, aged 65 to 86(78.5±9.1) years, 21 males and 14 females, including 18 femoral neck fractures and 17 femoral intertrochanteric fractures. There were 35 cases in control group, aged 66 to 88 (80.6±8.1) years, 18 males, and 17 females, including 20 cases of femoral neck fractures and 15 cases of intertrochantericfractures. The visual analogue scale (VAS) at 4 h, 12 h, 24 h, 48 h, and 72 h after surgery, the incidence of delirium and stress indicators of malondialdehyde (MDA), superoxide dismutase (SOD), cortisol (COR), and epinephrise (E) postoperatively in the two groups were observed. At 4 h, 12 h, 24 h, 48 h after surgery, the VAS score of experimental group was lower than that of the control group, and the difference was statistically significant (P<0.05). There was no statistical difference between the two groups at 72 h postoperatively (P>0.05). Within 72 h after surgery, the dosage of indomethacin suppository (0.1 g/suppository) in experimental group was 0.3 g, and that in control group was 1.2 g, the dosage of experimental group was less than that of control group. Within 7 days after operation, delirium occurred in 2 cases(5.7%) in experimental group and 8 cases (22.8%) in control group, the incidence of delirium in experimental group was significantly lower than that in the control group (χ2=4.2, P= 0.040). Two days after surgery, the serum SOD content of the two groups of patients increased, and the levels of MDA, E, and COR decreased; and the serum MDA, E, and COR levels of experimental group were lower than control group, and the SOD content was higher than control group;the differences were statistically significant (χ2<0.05). The advanced analgesic application of parecoxib sodium can significantly reduce the postoperative stress response of elderly hip fracture patients, enhance the postoperative analgesic effect, reduce the incidence of postoperative delirium, and improve the quality of rehabilitation of patients.

It remains controversial whether open or laparoscopic surgery should be indicated for elderly patients with colorectal cancer and a poor performance status. In those patients aged 80 years or older with Eastern Cooperative Oncology Group performance status score of 2 or greater who received elective surgery for stage 0 to stage III colorectal adenocarcinoma and had no concomitant malignancies and who were enrolled in a multicenter case-control study entitled "Retrospective study of laparoscopic colorectal surgery for elderly patients" that was conducted in Japan between 2003 and 2007, background characteristics and short-term and long-term outcomes for open surgery and laparoscopic surgery were compared. Of the 398 patients included, 295 underwent open surgery and 103 underwent laparoscopic surgery. There were no significant differences in the baseline characteristics between open surgery and laparoscopic surgery patients, except for previous abdominal surgery and TNM stage. The median operation duration was shorter with open surgery (open surgery, 153 min; laparoscopic surgery, 202 min; P < 0.001), and less blood loss occurred with laparoscopic surgery (median open surgery, 109 g; median laparoscopic surgery, 30 g; P < 0.001). An operation duration of 180 min or more (odds ratio, 1.97; 95 % confidence interval, 1.17-3.37; P = 0.011) and selection of laparoscopic surgery (odds ratio, 0.41; 95 % confidence interval, 0.22-0.75; P = 0.003) were statistically significant in the multivariate analysis for postoperative morbidity. Moreover, laparoscopic surgery did not result in an inferior overall survival rate compared with open surgery (log-rank test P = 0.289, 0.278, 0.346, 0.199, for all-stage, stage 0-I, stage II, and stage III disease, respectively). Laparoscopic surgery in elderly colorectal cancer patients with a poor performance status is safe and not inferior to open surgery in terms of overall survival.