High-risk Elderly Patients Research Articles

Long-term outcomes of Allium ureteral stent as a treatment for ureteral obstruction

Ureteral obstruction is a prevalent urological condition associated with significant complications. The purpose of our study was to assess the safety and efficacy of a novel self-expanding, large caliber, biocompatible polymer-coated ureteral stent (Allium) for the treatment of ureteral obstructions. We conducted a retrospective analysis of data from patients who underwent Allium ureteral stent placement at our institute between November 2018 and May 2023. Demographic, clinical, and perioperative parameters were collected and analyzed. Logistic regression analyses were performed to identify preoperative factors predicting Allium stent migration. The study cohort comprised 30 patients who received a total of 40 successfully implanted Allium stents. No significant adverse events related to the insertion procedure were observed. During a median follow-up period of 29 months (range: 1–60 months), migration occurred in 11 (27.5%) stents while encrustation was noted in 8 (20%) stents. The median functional duration of the Allium stents was found to be 22 months (range:1–60 months), with an overall functioning rate at last follow-up being recorded as 59.5%. Multivariate analysis revealed that the glomerular filtration rate of the ipsilateral kidney was the sole risk factor predictive of Allium stent migration. With its minimal invasiveness and good tolerability, the Allium stent represents a safe and viable management option for treating ureteric obstructions; however, it should not be considered as definitive treatment but rather as an alternative option for patients unwilling or unsuitable for definitive treatment, particularly high-risk individuals or elderly patients exhibiting decreased ipsilateral glomerular filtration rates.

The Effect of Transurethral Holmium Laser Enucleation of the Prostate in the Treatment of High-Risk Elderly Patients with BPH and Its Influence on Quality of Life.

Transurethral holmium laser enucleation of the prostate (HoLEP) has a good therapeutic effect on benign prostatic hyperplasia (BPH). The purpose of this study was to investigate the clinical efficacy of HoLEP in the treatment of high-risk elderly patients with BPH and assess its impact on the inflammatory response, vascular endothelial function and quality of life (QoL). Patients at high risk of BPH who were hospitalised in Chengde Central Hospital from February 2021 to December 2022 were retrospectively selected as the study objects, and a total of 100 cases were included. The control group underwent transurethral resection of the prostate, and the observation group underwent HoLEP. Perioperative indexes, urodynamic indexes, QoL 6 months after surgery and incidence of postoperative complications were compared between the two groups. Moreover, serum levels of inflammatory factors and vascular endothelial factors were detected in two groups. We found no significant difference in general data between the two groups of patients (p > 0.05). The operation time, perioperative bleeding, bladder flushing time and hospitalisation time of the observation group were significantly shorter than those of the control group (p < 0.05). On the 7th day after surgery, the serum levels of tumour necrosis factor alpha, interleukin-1β, interleukin-6, vascular endothelial growth factor, basic fibroblast growth factor and endothelin-1 in the observation group were significantly lower than those in the control group (p < 0.05). Six months after surgery, the maximal urinary flow rate and QoL scores of the patients in the observation group were significantly higher than those of the control group (p < 0.05), and the residual urine volume and International Prostate Symptom Score of observation group were significantly lower than those of the control group (p < 0.05). The incidence of postoperative complications in the observation group was significantly lower than that in the control group (χ2 = 7.440, p = 0.006). HoLEP can effectively remove hyperplasia of the prostate and reduce the inflammatory response in the patient's body when treating BPH in high-risk elderly patients. It can also regulate the levels of vascular endothelial factors and effectively improve the patient's QoL.

Treatment of endometrial cancer from 2000 to 2020 in Germany: a retrospective population based cohort study

PurposeEndometrial cancer (EC) is one of the most common malignancies among women in western countries. This study aimed to assess data on patient treatment in Germany throughout two decades to evaluate the development and effect of surgery, radiation, and chemotherapy.MethodsThis retrospective registry study included 34,349 EC patients diagnosed between 2000 and 2020. Patients were classified into five risk groups. Overall survival was analyzed by Kaplan–Meier method as well as univariable and multivariable Cox regression to evaluate risk factors and treatment options.ResultsOver the study period, minimal invasive surgery was used more often compared to open surgery and was associated with better overall survival. Patients with advanced EC were more likely to receive multimodal therapy.Patients with intermediate risk EC had a good prognosis upon surgery, which further improved when radiotherapy was added. High-risk patients showed poorer prognosis but clearly benefited from additional radiotherapy. Survival of elderly high-risk patients with a non-endometrioid histology was improved when chemotherapy was added to surgery and radiotherapy.ConclusionOur study includes a large analysis of data from German clinical cancer registries on the care of endometrial cancer during two decades. We observed an increase of minimal invasive surgery. There is evidence that minimal invasive surgery is not inferior to open surgery. Adjuvant radio- and chemotherapy further improves survival depending on risk group and age.

Perioperative Outcomes after Elective Laparoscopic Cholecystectomy in High Risk Patients

Background: The global population is aging, leading to an increased incidence of acute cholecystitis and associated complications in the elderly. While laparoscopic cholecystectomy is the gold standard for treating acute cholecystitis, its safety and outcomes in high-risk, elderly patients with comorbidities are not well-documented. Objective: To compare postoperative complications, hospital stay duration, and nursing care requirements between high-risk elderly patients undergoing tube cholecystostomy versus early elective laparoscopic cholecystectomy for acute cholecystitis. Methods: This cross-sectional comparative study was conducted at Combined Military Hospital Rawalpindi from July 2021 to January 2022. A total of 70 patients aged 40-80 years and classified as ASA 3 or 4 were included. Patients were divided into two groups: Group 1 (n=35) underwent tube cholecystostomy followed by interval cholecystectomy after six weeks; Group 2 (n=35) underwent early elective laparoscopic cholecystectomy within 72 hours of admission. Data on hospital stay, postoperative complications, and nursing care were collected and analyzed using SPSS version 25.0. Quantitative data were presented as mean ± standard deviation (SD), and qualitative data as frequency and percentage. Independent t-tests were applied, with a p-value of less than 0.05 considered statistically significant. Results: In Group 1, 91% of patients had a hospital stay of less than 5 days compared to 11% in Group 2 (p=0.000). Group 1 had 94% of patients nursed in the ward/HDU, while 94% of Group 2 required ICU care (p=0.000). Postoperative complications were significantly lower in Group 1, with 97% having no complications compared to 34% in Group 2 (p=0.000). Only 3% of Group 1 required multidisciplinary team management versus 66% in Group 2. Conclusion: Tube cholecystostomy is a safer and more effective initial management strategy for high-risk elderly patients with acute cholecystitis, leading to shorter hospital stays, less intensive postoperative care, and fewer complications compared to early elective laparoscopic cholecystectomy.

A Comparative Analysis of Erector Spinae Plane Block Versus Conscious Sedation in Managing Percutaneous Cholecystostomy Pain.

This study investigates the efficacy of erector spinae plane block (ESPB) for managing perioperative and postoperative pain in patients undergoing percutaneous cholecystostomy (PC) for acute cholecystitis, particularly in high-risk elderly patients with extensive comorbidities and limited functional status. In a retrospective single-center study, 58 high-risk patients scheduled for PC were assessed. ESPB was administered to 23 patients, while 22 received conscious sedation. Pain intensity was measured using the numeric rating scale before any analgesic or ESPB administration, during the procedure and at 1 and 12h post-procedure and secondary outcomes included adverse effects and additional analgesic requirements. The ESPB group experienced significant pain reduction during and post-procedure compared to the conscious sedation group (p = 0.002). Procedure times were shorter (p = 0.015), and postoperative tramadol was less frequently needed in the ESPB group (p = 0.007). The incidence of nausea was also lower in the ESPB group (p = 0.001). No ESPB-related complications were reported. ESPB significantly alleviates perioperative and postoperative pain in PC patients, reducing additional analgesic use and side effects. It holds promise as a key component of pain management for high-risk surgical patients. Level 3, Non-randomized controlled cohort/follow-up study.

The predictive role of carotid artery flow time for anesthesia-induced hypotension in high-risk elderly patients.

Hypotension induced by general anesthesia is associated with postoperative complications, increased mortality, and morbidity, particularly elderly patients. The aim of this study was to investigate the effectiveness of corrected carotid artery flow time (FTc) for predicting hypotension following anesthesia induction in patients over 65 years old.After faculty ethical committee approval and written informed consent, 138 patients (65 years and older, ASA physical status I-III) who scheduled for elective surgery were included in this study. In the pre-operative anesthesia unit, the carotid artery FTc value was measured by ultrasound and hemodynamic values were recorded. Following anesthesia induction with propofol, hemodynamic data were recorded at 1-minute intervals for 3min. Measurements were terminated prior to endotracheal intubation, as direct laryngoscopy and endotracheal intubation could cause sympathetic stimulation and hemodynamic changes.Hypotension occurred in 52 patients (37.7%). The preoperative FTc value of the patients who developed hypotension was statistically lower (312.5 ms) than the patients who did not (345.0 ms) (p < 0.001). The area under the ROC curve for carotid artery FTc was 0.93 (95% CI for AUC:0.89-0.97; p < 0.001) with an optimal cut-off of value for predicting post-anesthesia hypotension 333 ms, a sensitivity of 90.4% and a specificity of 84.9%. As a result of the multiple logistic regression model, carotid artery FTc emerged as the sole independent risk factor for hypotension following anesthesia induction.Preoperative carotid artery FTc measurement is a simple, bedside, noninvasive, and reliable method for predicting anesthesia-induced hypotension in elderly patients.

The impact of preoperative nutritional status on postoperative outcomes: an insight from Geriatric Nutritional Risk Index in elderly pancreaticoduodenectomy patients

BackgroundMalnutrition is not uncommon among the elderly undergoing pancreatoduodenectomy (PD) and is related to increased complications. Previous studies have shown that the Geriatric Nutritional Risk Index (GNRI) predicts outcomes in various populations. Nevertheless, the research exploring the correlation between GNRI and postoperative outcomes in PD is scarce. This study aimed to investigate the preoperative malnutrition, as measured by GNRI, on outcomes in elderly patients undergoing PD.Materials and MethodsThis retrospective analysis enrolled 144 elderly patients underwent PD for periampullary tumors from November 2016 to December 2021. Patients were stratified based on the GNRI value: high/moderate nutrition risk (GNRI ≤ 92, N = 54), low nutrition risk (92 < GNRI ≤ 98, N = 35), and no nutrition risk (GNRI > 98, N = 55). Perioperative outcomes and postoperative surgical complications were compared between these groups. Univariate and multivariate analyses were performed on major postoperative complications and prolonged postoperative length of stay (PLOS).ResultsPatients in the high/moderate risk group were significantly older, with lower BMI (P = 0.012), higher mortality rate (11.1%, P = 0.024), longer PLOS (P < 0.001), and higher incidence of over grade IIIB complications (37.0%, P = 0.001), Univariate and multivariate analyses showed the high/moderate risk GNRI group (OR 3.61, P = 0.032), increased age (OR 1.11, P = 0.014) and operative time over 8 h (OR 3.04, P = 0.027) were significantly associated with increased major postoperative complications. The high/moderate risk GNRI group was also a significant predictor for prolonged PLOS (OR 3.91, P = 0.002).ConclusionsPreoperative GNRI has the potential to be a predictive tool for identifying high-risk elderly patients and monitoring nutritional status preoperatively to improve postoperative surgical outcomes following PD.

Clinical Midterm Results of Surgical Aortic Valve Replacement with Sutureless Valves.

Sutureless aortic valves may enable shorter procedure times, which benefits patients with elevated surgical risk. We describe the outcomes of patients with aortic stenosis who underwent aortic valve replacement (AVR) using the sutureless Perceval aortic bioprosthesis. Data from a retrospective cohort were obtained from a clinical database. The study enrolled patients with symptomatic severe aortic stenosis who underwent surgical AVR with a sutureless bioprosthesis between August 2015 and December 2020. In total, 113 patients were included (mean age, 75.3±8.4 years; 57.5% women; median Society of Thoracic Surgeons score, 9.7%; mean follow-up period, 51.19±20.6 months). Of these patients, 41 were octogenarians (36.2%) and 3 were nonagenarians (2.6%). Transthoracic echocardiography was employed to assess changes in ejection fraction (EF), left ventricular mass index (LVMI), and mean pressure gradient (MPG). The in-hospital mortality rate was 2.6%, and 13 patients developed new-onset atrial fibrillation. A permanent pacemaker was implanted in 3 patients (2.6%). The median intensive care unit stay was 1 day (interquartile range [IQR], 1-2 days), and the median hospital stay was 12 days (IQR, 9.5-15 days). The overall survival rate at 5 years was 95.9%. LVMI and MPG were reduced postoperatively, while EF increased over the follow-up period. No structural valve deterioration was observed, and no meaningful paravalvular leakage developed during follow-up. The use of a sutureless valve in the aortic position is safe and feasible, even for high-risk elderly patients requiring surgical AVR. LVMI and MPG decreased postoperatively, while EF increased over the follow-up period.

Risk factors and clinical significance of subcutaneous emphysema after robot-assisted laparoscopic rectal surgery: a single-center experience.

Subcutaneous emphysema (SE) is a complication of laparoscopic surgery, potentially resulting in severe respiratory failure. No reports to date have focused on SE during robot-assisted (RA) rectal surgery. We aimed to reveal the risk factors and clinical significance of SE after RA/laparoscopic rectal surgery. We retrospectively reviewed 221 consecutive patients who underwent RA/laparoscopic rectal surgery. The occurrence of SE was evaluated on postoperative radiographs. Laparoscopic surgery was performed in 120 patients and RA in 101. SE developed in 55 (24.9%) patients. Logistic regression analysis identified RA surgery (odds ratio [OR]: 4.89, 95% confidence interval [CI] 2.13-11.22, p < 0.001), higher age (OR: 1.06, 95% CI 1.03-1.11, p < 0.001), lower body mass index (BMI) (OR: 0.79, 95% CI 0.67-0.93, p = 0.004), thinner subcutaneous layer (OR: 0.88, 95% CI 0.79-0.98, p = 0.02), and lateral lymph node dissection (OR: 9.43, 95% CI 2.44-36.42, p < 0.001) as risk factors for SE. Maximum end-tidal CO2 was significantly higher in the SE than the non-SE cohort (p < 0.001). There was no difference in postoperative complication rate or length of hospital stay. Lower BMI (OR: 0.79, 95% CI 0.62-0.97, p = 0.02) and thinner subcutaneous layer (OR: 0.84, 95% CI 0.71-0.97, p = 0.01) were predictive factors in the RA cohort. SE occurs more frequently in RA compared with laparoscopic surgery. SE has a modest impact on short-term outcomes, but may occasionally cause severe problems. The indication of RA surgery should be considered carefully in high-risk elderly patients.

The role of periprocedural hemodynamic variables during carotid stenting for the mid-term general mortality in advanced age patients.

Carotid stenting may produce significant bradycardia and/or hypotension. This may have negative short- and long-term effects for the elderly high-risk patients. Their cerebral hemodynamics is with exhausted adaptive capacity because of the multiple cardiovascular risk factors, advanced age, and significant stenosis.

First Phase of Integrated Care Initiative PAIK in Estonia: Lessons Learned

Background: Patients with chronic conditions often experience fragmented care and suboptimal health outcomes. Therefore, initiatives to improve the care-continuum of high-risk patients have emerged in Estonia. PAIK project was the first which tried to integrate social-services sector, specialist care and primary healthcare to co-ordinate the care for high-risk elderly patients with social health determinants. Although we measured improved perception of quality of care and level of integration, pragmatic analysis with matched controls failed to improve health outcomes and reduce costs.&#x0D; Aim: To analyse and describe lessons learned from PAIK initiative and if intervention or implementation failure explains the negative results of the project.&#x0D; Method: A qualitative analysis using focused interviews and expert opinion was used.&#x0D; Results: Firstly, the PAIK project was more a pragmatic service design and feasibility exercise than a full-fledged study designed to demonstrate better health outcomes. It was started without power analysis and analytical components were added later. No control arm was used and having social health determinants as inclusion criteria prevented retrospectively finding an unbiased propensity matched control group. Analysis showed that majority of the patients included, belonged to a very high-risk stratum (top 1%), where care-management is less effective. Also we found that not all components of the intervention were aligned with reducing hospitalisations and ER-visits.&#x0D; Another factor was that the healthcare sector lacked any prior experience with integrated care practice implementation and scaling, so the lack of existing workforce resulted in training activities continuing well into the duration of the project. Mid-study there was a change in clinical leadership, which also resulted in target population adjustment and process redesign.&#x0D; Thirdly we failed to identify and recruit champions from the primary care and social services sides, therefore engagement of these sectors was modest and the service was dominantly specialist care focused. The Covid pandemia also coincided causing resource conflicts in the sector both on hospital and primary care side. &#x0D; Despite these above mentioned shortcomings, we consider the study generally a success, as we feel that focusing on social health determinants is important in such services and was very welcomed by both the social service providers and GP nurses. Also due to our project the role of care managers was defined in Estonia and educational programs implemented. Also, a functional care-management software module was developed and tested during the service. Finally our experience has been seen as valuable and has attracted specialist in several other counties to invest in integrated care efforts and there is greater readiness to change.&#x0D; Conclusions: Despite the PAIK intervention in Viljandi being well received by the patients and showed better patient reported outcomes, it failed to convincingly reduce health resource utilisation and hospitalisations. Both components of intervention failure and implementation failure are probably responsible. Experience from the project however might improve the success of future initiatives and be part of the foundation for care-delivery model innovation in Estonia.&#x0D;

Pre-treatment optimisation with pulmonary rehabilitation of elderly lung cancer patients with frailty for surgery

ObjectiveFrailty develops as a result of age-related decline in many physiological systems and is associated with increased vulnerability to adverse outcomes following thoracic surgery. We prospectively tested our hypothesis that pre-operative pulmonary rehabilitation (Prehab) improves frailty, as suggested by a frailty index > 3 (FI > 3) and fitness, and thereby reduces the risk of post-surgical complications and death in vulnerable elderly lung cancer patients.Methods221 surgical patients, 80 with FI > 3 vs. 141 patients with FI < 3, following Prehab proceeded to surgery. Their Frailty index (FI), dyspnoea scores, performance status (PS), level of activity (LOA) and six-minute walk test (6MWT) prior to and following Prehab were determined. The post-operative length of hospital stay (LOHS), complications, mortality and mid-term survival at 1100 days were compared. Similarly, outcomes for elderly patient ≥ 70 years with FI > 3 (≥ 70,FI > 3) were compared with younger patients < 70 years with FI ≤ 3 (< 70,FI ≤ 3).ResultsPatients with FI > 3 were significantly older, had lower 6MWT and higher thoracoscores hence, 82.5% of patients with FI > 3 vs. 33.3% (p = 0.02) with FI ≤ 3 were considered high risk for surgery and postoperative adverse events. With Prehab there was significant improvement in the FI, dyspnoea scores, PS, LOA and 6MWT. Following surgery, there were no differences in major complication rates (8.8% vs. 9.2% p = ns); LOHS median (IQR) [7 (6.8) vs. 8 (5.5) days]; mortality at 30-days (3.7% vs. 0.7%, p = ns); 90-days (6.3% vs. 2.8%, p = ns) and 1-year survival (81.1% vs. 83.7% p = ns). Survival at 1100 days was (63.2% vs. 71.1%, p = 0.19). Likewise, 87.7% elderly ≥ 70,FI > 3 patients were considered high-risk for surgery and postoperative adverse events vs. 35.1% younger patients < 70,FI ≤ 3 (p = 0.0001). Following Prehab and surgery, there were no significant differences in complications, LOHS, mortality at 365 days between the two groups. Survival at 1100 days for ≥ 70,FI > 3 was 55.2% vs. 79.96% for < 70,FI ≤ 3; (p = 0,01).ConclusionOur study suggests that Prehab optimises vulnerable high-risk elderly lung cancer patients with frailty allowing them to undergo surgery with outcomes of post-surgical complications, LOHS and mortality at 365 days no different to patients with no frailty. However, mid-term survival was lower for elderly patients with frailty.

PP47 Experience And Its Implication For Reassessment Of The Transcatheter Aortic Valve Implantation Using Real World Data

IntroductionSouth Korea has introduced conditionality to coverage decisions for certain difficult or high-risk procedures. The transcatheter aortic valve implantation (TAVI) was included in the coverage with evidence development (CED) in 2014. This study reviewed the results of reassessment for the TAVI using real world data (RWD) and suggested its implications.MethodsHealthcare providers authorized to use the promising technologies are required to collect the RWD for suitability evaluation, safety monitoring, and cost-effectiveness, differing from the general reassessment process. In 2021, 45 healthcare providers collected clinical information for TAVI patients. Their registries were linked with the national health insurance claims, which provided data on 19 items to assess safety and effectiveness such as overall mortality, reoperation rates, hospital readmission rates, and degree of functional improvement.ResultsAccording to the Society of Thoracic Surgeons’ predicted risk of mortality (STS), 988 TAVI patients were classified into three groups; high (STS &gt;8 percent, n=347), intermediate (STS 4-8 percent, n=272), and low (STS &lt;4 percent, n=369); We compared main outcomes and estimated survival probabilities between subgroups. Within 30 days, the overall mortality rates were 4.9 percent (high), 2.6 percent (intermediate), and 1.4 percent (low); major bleeding rates were 7.6 percent (high), 6.2 percent (intermediate),and 1.4 percent (low); incidence of new atrial fibrillation were 6.8 percent (high), 4.2 percent (intermediate), and 3.2 percent (low). Based on the quantitative results using RWD and systematic review for the safety and effectiveness, TAVI is reported to have essential benefits for high-risk group and elderly patients (&gt;80 years). Whereas, intermediate and low-risk groups have out-of-pocket payment rates of 50 percent and 80 percent, respectively.ConclusionsThe reassessment system through RWD accumulation enabled the evidence-based evaluation for the TAVI. Based on the transition to CED for essential benefits, a systematic framework such as RWD collection from treatment commencement should be introduced to broaden RWD use for benefit management of medical technologies with uncertain levels of evidence. Therefore, this ensures overall quality of care and effective coverage in health.

Osteoporosis and Vertebral Column.

Osteoporosis is an age-related metabolic disease which has a significant impact on bone health and overall quality of life. It is gaining importance as a major medical consideration with the rapid increase in geriatric population globally. It increases the risk of vertebral fractures, progressive spinal deformities and neurological complications, contributing significantly to morbidity and mortality. Increase in life expectancy and advancement of medical technology has led to an increase in the proportion of geriatric patients undergoing orthopaedic procedures. It is becoming vital to adequately evaluate, investigate and treat osteoporosis before planning spinal surgery, especially spinal fusions and instrumentation. Historically, osteoporosis was considered a contraindication to spine surgery adding to the burden of Disability Adjusted Life Years (DALYs) and mortality. Conversely, osteoporotic patients who underwent spine surgery were not adequately optimized, leading to an increase in failure and complication rates. Better understanding of the pathophysiology of osteoporosis and the biomechanics of an osteoporotic spine with knowledge of current standards of treatment of osteoporosis facilitate the timely and adequate management of this disease. Advances in surgical and anaesthetic techniques facilitate successful surgeries on high-risk elderly and osteoporotic patients with multiple comorbidities allowing for a significantly high predictability for long-term positive outcomes.This article discusses the biomechanics of the osteoporotic spine, the diagnosis and management of osteoporotic patients with spinal disease, and the new treatments, recommendations, surgical indications, strategies and advances in instrumentation in patients with osteoporosis who require spinal surgery. In this article, the authors aim to provide a generalized overview for better understanding of the pathophysiological processes underlying osteoporosis in the vertebral column. This review provides a comprehensive set of guidelines for overall health and management of spine patients with pathologies, either caused by or compounded with osteoporosis. An overview of current techniques, strategies and technologies designed to address the challenges associated with spine surgery in osteoporotic patients is also outlined. Content for this article has been sourced from routinely cited articles available via PubMed, from National Institute of Health consensus development conference, from the recommendations by World Health Organization technical report series, from previous articles by the authors and from the protocols established by the authors in their clinical practice based on experience and detailed case reviews.

Two-Year-Survival Rate of High-Risk Elderly Patients With Severe Aortic Stenosis Treated With Perfusion-Balloon Valvuloplasty Without Rapid Pacing

Two-Year-Survival Rate of High-Risk Elderly Patients With Severe Aortic Stenosis Treated With Perfusion-Balloon Valvuloplasty Without Rapid Pacing

Nonocclusive Balloon Aortic Valvuloplasty in High-Risk Elderly Patients With Severe Aortic Stenosis

Nonocclusive Balloon Aortic Valvuloplasty in High-Risk Elderly Patients With Severe Aortic Stenosis

BMI trajectories, associations with outcomes and predictors in elderly gastric cancer patients undergoing radical gastrectomy: a prospective longitudinal observation study.

Elderly gastric cancer patients undergoing radical gastrectomy are prone to experience unexpected weight loss. Preoperative weight risk prediction may be a promising way to prevent weight loss and improve prognosis. The objectives of this study were to explore the BMI trajectory of elderly gastric cancer patients one year after surgery, evaluate theirs the association with outcomes, and explore their related predictors, so as to provide evidence for weight management and prognosis improvement. 412 gastric cancer patients were included and recorded BMI at 6 time points. The trajectories of BMI were analyzed by growth mixture modeling, and the associations of BMI trajectories with outcomes as well as their predictors were investigated by regression models. We identified 3 classes of BMI trajectories: the "slow-decreasing BMI", "rapid-decreasing BMI" and "maintaining BMI". Compared with class1, patients in class 2 were more likely to have a higher frequency of readmission within 1-year(β = 0.59, 95%CI: 0.29, 0.89, P < 0.001) and a higher rate of mortality within 1-year(β = 24.74, 95%CI: 9.60, 63.74, P < 0.001) ; patients in class 3 were more likely to have a higher quality of life (β=-10.46, 95%CI: -17.70, -3.22, P = 0.005) and fewer readmission times within one year (β=-0.43, 95%CI: -0.77, -0.09, P = 0.015). Predictors of decreasing BMI trajectories were TNM stage, comorbidity, anxiety, family cohesion and social support(P < 0.05). Our findings can provide a basis for screening high-risk elderly gastric cancer patients with poor prognosis, implementing risk stratification, formulating accurate weight management programs and improving prognosis. The results of our study can provide gastric cancer survivors with preoperativerisk screening based on predictive factors so that nutritional support and weight management can be implementedin a timely manner to improve prognosis.

Differences of clinical features and outcomes between male and female elderly patients in gastric cancer

Although the average life span differs between males and females, little is known about differences in clinical features and short and long-term outcomes between elderly male and female gastric cancer patients. This study was designed to clarify these issues to identify the possibility for sex-based treatment strategies in elderly gastric cancer patients. This study included 295 consecutive elderly gastric cancer patients (75 years or older) who underwent curative gastrectomy between 1997 and 2016. We defined postoperative complications as Clavien–Dindo classification grade II or higher. Comorbidities were present in 67% of all patients. Males tended to have more comorbidities than females (P = 0.077). Male patients had significantly more upper gastric cancers (P = 0.001), a higher incidence of postoperative complications (P = 0.045), and poorer prognoses than females (P = 0.003). Multivariate analysis revealed that being male was an independent risk factor for postoperative complications (Odds ratio 2.5, P = 0.045) and a poor prognostic factor (Hazard ratio 1.81, P = 0.008). Patients who underwent limited surgery without postoperative complications tended to have a better prognosis than patients receiving standard surgery with postoperative complications (3-year overall survival: 78% vs. 55%, P = 0.156). Male was an independent risk factor for postoperative complications and an independent poor prognostic factor in elderly gastric cancer patients. To avoid postoperative complications, the limited surgery might be justified for high-risk elderly male patients.

Large common bile duct stones in high-risk elderly patients: Immediate endoscopic stone removal or elective stone removal? A single-center retrospective study

Background and objectiveFor high-risk elderly patients with chronic diseases, endoscopic stone removal for large common bile duct stones is associated with a high risk of adverse events and incomplete stone removal. The aim of this study was to investigate whether the treatment strategy of short-term biliary plastic stent placement followed by elective endoscopic stone removal is more effective and safer than immediate endoscopic stone removal.MethodsThe data of 262 high-risk elderly patients who received endoscopic retrograde cholangiopancreatography (ERCP) for large common bile duct (CBD) stones from 2017 to 2022 were retrospectively analyzed. The patients were divided into group A (immediate stone removal) and group B (stent drainage + elective stone removal). The baseline data of the 2 groups were matched 1:1 by propensity score matching. The stone clearance rate, ERCP procedure time, total hospital stay, and procedure-related adverse events were compared between the matched groups. In group B, stone size before and after stent placement, hospital stay, procedure time and adverse events of two ERCPs were compared.ResultsA total of 57 pairs of patients were successfully matched between the 2 groups. The stone clearance rate in group B was higher than that in group A (89.5% vs. 75.3, P = 0.049). The total hospital stay in group B was longer than that in group A (11.86 ± 3.912 d vs. 19.14 ± 3.176 d, P<0.001). The total adverse event rate in group A was higher than that in group B (29.8% vs. 12.3%, P = 0.005). The incidence of cholangitis/cholecystitis after ERCP was significantly higher in group A than in group B (7.0% vs. 0.9% P = 0.029). There was no significant difference in the incidence of post-ERCP pancreatitis, bleeding, pneumonia, and cardio-cerebrovascular events between the 2 groups. There were no perforation cases in either group. After plastic biliary stent placement in group B, the stone size was significantly smaller than before stent placement (1.59 ± 0.544 cm vs. 1.95 ± 0.543 cm, P < 0.001), and there was no significant difference in the total adverse event incidence between the two ERCP procedures (18.8% vs. 10.9%, P = 0.214).ConclusionFor high-risk elderly patients with large CBD stones, the treatment strategy involving temporary placement of plastic stent and elective endoscopic stone removal is safer and more effective than immediate stone removal.

PENG block associated with dexmedetomidine sedation for intramedullary femoral fixation in high-risk elderly patients: a case series and review of the literature.

Hip fracture is a major cause of hospitalization among the elderly population. The standard surgical treatment involves early repair to reduce mortality and morbidity. One type of treatment in the case of intertrochanteric and subtrochanteric fractures is intramedullary nailing, as it decreases soft tissue damage and permits early weight bearing. The most common anesthesia technique combines spinal anesthesia with a peripheral block. In cases where spinal anesthesia is contraindicated, general anesthesia is preferred. However, both techniques can lead to significant complications, especially in patients with multiple comorbidities. Pain management after hip surgery, particularly in elderly and frail individuals, poses a challenge. The pericapsular nerve group block (PENG) targets the innervation of the anterior portion of the hip joint and is increasingly used for pain management related to hip surgery. This paper presents a case series of three elderly patients who underwent pericapsular nerve group block (PENG) block combined with dexmedetomidine sedation for intramedullary femoral fixation. The PENG block can be effectively used as the sole anesthetic technique for managing elderly patients undergoing intramedullary femoral fixation while on antiplatelet drugs. This procedure effectively controlled pain during both the surgical and postoperative periods. The addition of dexmedetomidine for sedation enables comfortable and safe procedures, minimizing the risk of perioperative neurocognitive dysfunctions and without adverse effects on cardiorespiratory function.