Published online Sep 27, 2026. doi: 10.4240/wjgs.120394
Revised: June 18, 2026
Accepted: August 10, 2026
Published online: September 27, 2026
Processing time: 153 Days and 23.9 Hours
Elderly individuals who undergo gastrointestinal or hepatobiliary surgery generally experience more postoperative complications than healthier, younger individuals do because of chronic illnesses, malnutrition, reduced functional capacity, and cognitive impairment. Comprehensive geriatric assessment (CGA) can identify treatable risk factors; however, few studies have investigated nurse-led CGA applications in elderly surgical populations.
To examine how CGA-guided nursing interventions affect postoperative complications and recovery in elderly patients undergoing gastrointestinal or hepatobiliary surgery.
This retrospective cohort study included data from 78 patients aged ≥ 60 years who underwent gastrointestinal or hepatobiliary surgery at Zhejiang Hospital (Zhejiang Province, China) between April 2025 and December 2025. Patients admitted concurrently during this period were allocated to two groups according to whether they had received CGA-guided nursing: CGA-guided (n = 40) or conventional control (n = 38) groups. CGA covered nutrition, activities of daily living, comorbidities, and cognition. Primary outcomes included complication rate and length of hospital stay (LOS).
The CGA group experienced fewer complications than the control group did (27.5% vs 55.3%; χ2 = 6.24, P = 0.013), including a shorter LOS (16.2 ± 4.2 days vs 20.8 ± 4.6 days; t = 4.58, P < 0.001). CGA-guided care was independently associated with a lower risk for compli
CGA-guided nursing care reduces postoperative complications and LOS in older surgical patients. Incorporating a systematic evaluation of elderly patients into perioperative nursing protocols is effective.
Core Tip: Comprehensive geriatric assistance-guided stratified nursing intervention reduced postoperative complications and shortened the length of hospital stay in elderly patients undergoing gastrointestinal or hepatobiliary surgeries. The effects remained significant after adjustment for other covariates. Hospitals should consider implementing the systematic integration of perioperative nursing for elderly individuals undergoing surgery.
- Citation: Dong ZX, Xie S, Xu J. Effects of comprehensive geriatric assessment-guided nursing interventions on postoperative complications/recovery in elderly patients undergoing gastrointestinal or hepatobiliary surgery. World J Gastrointest Surg 2026; 18(9): 120394
- URL: https://www.wjgnet.com/1948-9366/full/v18/i9/120394.htm
- DOI: https://dx.doi.org/10.4240/wjgs.120394
The global ageing population is transforming the landscape of surgical care. Contemporary surgical-population data indicate that adults aged ≥ 65 years now undergo approximately 35%-40% of all major operations performed in high-income health systems, a proportion that continues to rise with population ageing[1,2]. Among elderly patients, those who require abdominal surgery for gastric cancer, colorectal cancer, hepatocellular carcinoma, or benign hepatobiliary tumors experience more complications due to multiple diseases and poor physical function[3].
Several reasons may explain the vulnerability observed among elderly surgical patients. First, more than 65% of those aged > 65 years have multimorbidity[4], thus increasing the risk of surgical-site infection or cardiopulmonary complications, which can delay wound healing. Second, the prevalence of malnutrition among older hospitalized surgical patients is 30%-60%[5]. Third, functional impairment is associated with a longer length of hospital stay (LOS) and discharge to an institution in multiple surgical populations, as well as with increased mortality across patient populations[6].
Cognitive dysfunction increases perioperative complexity. Even subclinical cognitive impairment elevates the risk of postoperative delirium, which is reported in 15%-35% of older patients after major gastrointestinal surgery in recent multicenter cohorts[7,8]. Postoperative delirium prolongs the LOS, increases healthcare costs, accelerates functional decline, and increases short-term and long-term mortality. This cluster of deficits creates a frailty syndrome that cannot be adequately understood using routine organ-based preoperative work-up[9].
Traditionally, perioperative nursing has followed standardized protocols designed for otherwise healthy adults without adjusting for the specific vulnerabilities of older patients[10]. Individuals with preserved function and minimal comorbidities require fundamentally different nursing care than those with nutritional risks, functional dependence, and cognitive vulnerabilities do. Failure to acknowledge this heterogeneity may help explain the persistently high compli
Comprehensive geriatric assessment (CGA) has evolved from a concept of geriatric medicine to a systematic, multidimensional evaluation of the overall needs of elderly individuals[12]. Multiple randomized controlled trials have shown that CGA-based interventions decrease mortality and institutionalization and improve functional recovery[13]. Recent systematic reviews and meta-analyses have reported that CGA can reduce complications and shorten the LOS in surgical patients[14,15]. However, most research has focused on assessment rather than the systematic delivery of targeted interventions[16]; as such, the application of nurse-led CGA-guided care remains underdeveloped[17].
The premise of CGA-guided nursing intervention is the systematic identification and modification of reversible risk factors. For nutritional risk, nurses can deliver structured, preoperative oral nutritional supplementation and proto
This retrospective cohort study was conducted at the Department of Geriatrics of Zhejiang Hospital (Zhejiang Province, China), a class 3 comprehensive hospital that admits seriously ill elderly patients with multisystem pathologies. The CGA-guided stratified nursing pathway was implemented in our department as a routine clinical quality-improvement initiative in April 2025 in accordance with standard local quality-improvement governance for perioperative care; it was not initiated as a research project. The present study involved a retrospective analysis of routinely collected medical-record data covering admissions from April 2025 through December 2025. The retrospective research protocol was reviewed and approved by the Institutional Ethics Committee of Zhejiang Hospital (Approval No. ZJHIRB-2025-166K) before any research data were extracted. The Institutional Ethics Committee waived the requirement for individual informed consent because the analysis was performed exclusively on de-identified retrospective data extracted from the hospital’s electronic medical record system and involved no direct contact with patients or additional risks.
Eligible patients included elderly adults who underwent gastrointestinal or hepatobiliary surgery during the study period. Inclusion criteria: Age ≥ 60 years at the time of surgery; surgery for gastric cancer, colorectal cancer, hepatocellular carcinoma, or benign hepatobiliary tumor; elective admission; and complete medical records. Exclusion criteria: Emergency surgery; advanced metastatic malignancy; incomplete medical records; or severe preexisting illness pre
The CGA protocol comprised four domains: Nutrition, scored using the Nutritional Risk Screening 2002 (NRS-2002) tool[22]; functional status, scored using the Barthel Index[23]; comorbidity burden, calculated using the Charlson Comor
Patients in the observation group received stratified nursing interventions according to the CGA results. The actionable core elements of each stratified intervention bundle were as follows.
Nutritional risk (NRS-2002 ≥ 3): Preoperative oral nutritional supplement 400 mL/day providing 600 kcal and ≥ 24 g protein for at least 5 days before surgery; nasogastric/nasojejunal enteral feeding initiated within 24 hours after surgery, beginning at 20 mL/hour and titrated to tolerance; target protein intake 1.2-1.5 g/kg/day; weekly weight, prealbumin, and grip-strength monitoring; dietitian review when oral nutritional supplement adherence fell below 75%.
Functional impairment (Barthel Index < 80): Structured out-of-bed mobilization within 24 hours after surgery (sit → stand → ambulate 5 m → progressive ambulation) for at least 30 minute/day under nursing supervision; daily Morse fall-risk reassessment; bedside resistance-band exercises three times daily; clear documentation of mobilization miles
High comorbidity burden (CCI ≥ 3): Twice-daily vital signs and SpO2 monitoring; daily infection screening using a standardized checklist (wound, urinary, respiratory, and line); pharmacist-led medication reconciliation within 24 hours of admission and again at discharge; explicit Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions/Screening Tool to Alert doctors to Right Treatment review of potentially inappropriate medications; expedited con
Cognitive impairment (MMSE < 24): Environmental adjustment (clock, calendar, family photograph at bedside, and hearing aids/glasses kept within reach); sleep-hygiene bundle (lights off from 22:00-06:00, ear-plugs and eye-mask offered, and clustered overnight care); validated postoperative pain assessment with the Pain Assessment in Advanced Dementia scale; reorientation by nursing staff every 4 hours while awake; benzodiazepine avoidance; family-led reori
Patients in the control group received conventional perioperative nursing care during the same period; surgical, anesthetic, and enhanced recovery after surgery protocols were identical in both groups. The operator, frequency, and monitoring metrics for each element of the bundle are listed in Supplementary Table 1.
Each at-risk domain contributed one point to a 0-4 total risk score (NRS-2002 ≥ 3, Barthel Index < 80, CCI ≥ 3, and MMSE < 24). Patients were grouped as low risk (0-1), moderate risk (2), or high risk (3-4).
The primary outcomes were postoperative complications and LOS. Postoperative complications were graded using the Clavien-Dindo classification; grade ≥ II was the primary complication endpoint[26]. LOS was defined as the number of calendar days from surgery to discharge. Secondary outcomes were postoperative infection, postoperative delirium, 30-day hospital readmission, and intensive care unit transfer.
Continuous data are expressed as mean ± SD and count data as n (%). Comparison of means between independent samples was performed using the independent-samples t-test, and those between counts using the χ2d test. Multivariate logistic regression analysis was performed to identify independent predictors of postoperative complications, which were reported as adjusted odds ratios (ORs) with 95% confidence intervals (CIs). Multivariate linear regression was performed for the LOS. The Hosmer-Lemeshow test was used to assess logistic-regression fit, and R2 reported for linear regression. Multicollinearity was evaluated using the variance inflation factor. All statistical tests were two-tailed, and statistical significance set at P < 0.05. Statistical analyses were performed using SPSS version 26.0 (IBM Corporation, Armonk, NY, United States).
Data from the 78 patients were divided into two groups: Control (n = 38) and observation (n = 40) groups. Demographic and baseline clinical characteristics of the patients are summarized in Table 1. The mean age of the cohort was 71.1 ± 6.0 years. No significant between-group differences were observed in age (control 71.8 ± 6.2 years vs observation 70.5 ± 5.8 years; t = 0.96, P = 0.342), sex distribution (male 65.8% vs female 60.0%; χ2 = 0.28, P = 0.594), or any CGA-domain score (all P > 0.05). The age distribution of the participants is illustrated in Figure 1.
| Variable | Control (n = 38) | Observation (n = 40) | P value |
| Age (years) | 71.8 ± 6.2 | 70.5 ± 5.8 | 0.342 |
| Male | 25 (65.8) | 24 (60.0) | 0.594 |
| NRS-2002 score | 2.8 ± 1.7 | 2.6 ± 1.5 | 0.573 |
| Barthel Index | 72.5 ± 14.8 | 74.2 ± 15.1 | 0.613 |
| CCI score | 2.4 ± 1.4 | 2.5 ± 1.3 | 0.738 |
| MMSE score | 24.1 ± 3.8 | 24.5 ± 3.6 | 0.627 |
| Surgery type | 0.996 | ||
| Gastric cancer | 12 (31.6) | 13 (32.5) | |
| Colorectal cancer | 15 (39.5) | 16 (40.0) | |
| Hepatocellular carcinoma | 7 (18.4) | 7 (17.5) | |
| Benign hepatobiliary | 4 (10.5) | 4 (10.0) |
The primary outcomes are reported in Tables 2 and 3 (Figure 2). The CGA group experienced significantly fewer postoperative complications than the control group did (27.5% vs 55.3%; χ2 = 6.24, P = 0.013), representing an absolute risk reduction of 27.8% points. The LOS was also significantly shorter in the CGA group than in the control group (16.2 ± 4.2 days vs 20.8 ± 4.6 days; t = 4.58, P < 0.001), corresponding to a mean LOS reduction of 4.6 days.
| Outcome | Control (n = 38) | Observation (n = 40) | P value |
| Complication rate (Clavien-Dindo ≥ II) | 21 (55.3) | 11 (27.5) | 0.013a |
| Length of stay, days | 20.8 ± 4.6 | 16.2 ± 4.2 | < 0.001b |
| Postoperative infection | 12 (31.6) | 10 (25.0) | 0.519 |
| Postoperative delirium | 8 (21.1) | 5 (12.5) | 0.310 |
| 30-day readmission | 7 (18.4) | 2 (5.0) | 0.076 |
| ICU transfer | 7 (18.4) | 4 (10.0) | 0.290 |
| CD grade | Control (n = 38) | Observation (n = 40) | Total |
| No complication | 17 (44.7) | 29 (72.5) | 46 |
| Grade II | 14 (36.8) | 4 (10.0) | 18 |
| Grade IIIa | 4 (10.5) | 4 (10.0) | 8 |
| Grade IIIb | 2 (5.3) | 2 (5.0) | 4 |
| Grade IV | 1 (2.6) | 1 (2.5) | 2 |
| Grade V (death) | 0 (0) | 0 (0) | 0 |
| Total ≥ grade II | 21 (55.3) | 11 (27.5) | 32 |
The secondary outcomes are summarized in Tables 2 and 3 (Figure 3A). The infection rate was similar between groups (CGA 25.0% vs control 31.6%; χ2 = 0.42, P = 0.519). The absolute postoperative delirium rate was 12.5% in the CGA group vs 21.1% in the control group (χ2 = 1.03, P = 0.310), and the respective 30-day readmission rate 5.0% vs 18.4% (χ2 = 3.15, P = 0.076); these between-group differences did not reach the conventional threshold for statistical significance. The intensive care unit transfer rate was 10.0% in the CGA group vs 18.4% in the control group (χ2 = 1.12, P = 0.290). Complication severity according to the Clavien-Dindo classification system is shown in Figure 3B.
Results of the multivariate logistic regression analysis of postoperative complications are shown in Table 4 and Figure 4A. CGA-guided care was independently associated with a reduction in complications after adjusting for baseline covariates (adjusted OR = 0.35, 95%CI: 0.14-0.87; P = 0.024); a high comorbidity burden was also an important predictor (CCI ≥ 3, adjusted OR = 2.56, 95%CI: 1.02-6.43; P = 0.045). Age, nutritional risk (NRS-2002 ≥ 3), functional status (Barthel Index < 80), and cognitive impairment (MMSE < 24) did not reach statistical significance as independent predictors. The Hosmer-Lemeshow test indicated good model fit (χ2 = 4.86, P = 0.772). All variance inflation factor values were < 2.5.
The multivariate linear regression results for LOS are summarized in Table 5. CGA-guided care was independently associated with a shorter LOS (adjusted β = -3.68, 95%CI: -5.72 to -1.64; P = 0.001). Other significant predictors included the presence of complications (adjusted β = 5.45, 95%CI: 3.28-7.62; P < 0.001), high comorbidity burden (adjusted β = 1.98, 95%CI: 0.42-3.54; P = 0.014), and age (adjusted β = 0.11 per year, 95%CI: 0.01-0.21; P = 0.032). The model explained 51.2% of the variance in LOS (R2 = 0.512). A correlation matrix of the study variables is shown in Figure 4B.
The intervention effect by risk stratum is shown in Figure 5. Among low-risk patients (score 0-1; n = 20), the complication rates were 50.0% (control group; n = 8) vs 16.7% (observation group; n = 12). Among moderate-risk patients (score 2; n = 32), the complication rates were 50.0% (control group; n = 16) vs 25.0% (observation group; n = 16). Among high-risk patients (score 3-4; n = 26), the complication rates were 64.3% (control group; n = 14) vs 41.7% (observation group; n = 12). The LOS showed the same pattern across risk levels.
The present study showed that CGA-guided stratified nursing interventions reduced postoperative complication rates in elderly patients undergoing gastrointestinal or hepatobiliary surgery (27.5% vs 55.3%) and shortened the LOS (16.2 days vs 20.8 days). These findings remained statistically significant after multivariate adjustment (adjusted OR = 0.35 for complications; adjusted β = -3.68 days for LOS), supporting an independent protective effect of CGA-guided nursing care.
The complication rate of 55.3% recorded for the control group is consistent with that reported among elderly patients after major abdominal surgery. Jakobson et al[27] reported that an overall complication rate after gastrointestinal, hepatobiliary, or pancreatic surgery of 33.5%, exceeding 44% in the high-risk subgroup. The higher rate observed in our study is likely due to the higher proportion of patients ≥ 60 years and inclusion of Clavien-Dindo grade II events. With CGA-guided care, the complication rate decreased to 27.5%, similar to the rates reported in younger surgical populations.
Our findings on nutritional risk are consistent with existing evidence. Sun et al[28] reported in a systematic review and meta-analysis that an NRS-2002 score indicating nutritional risk is associated with a three-fold higher likelihood of postoperative complications (pooled OR = 3.13, 95%CI: 2.51-3.90) and 5.58-day longer LOS. In our multivariate model, NRS-2002 ≥ 3, Barthel Index < 80, and MMSE < 24 were not independent predictors of postoperative complications. A low Barthel Index has been reported as a predictor of postoperative complications in elderly patients undergoing abdominal surgery[29]. We did not interpret these P-values as evidence of a trend; with 78 patients and 32 events, the study had limited statistical power to detect modest independent effects in any of these domains, and these findings should thus be interpreted as inconclusive rather than directional.
A high comorbidity burden, as defined by the CCI, was an independent predictor of complications in our cohort (adjusted OR = 2.56; P = 0.045), consistent with previous studies. Laor et al[30] reported that a higher CCI was associated with a higher risk of death in older surgical patients, and Fabbian et al[31] reported that the risk of death increased by approximately 13% per one-point increase in the CCI.
The absolute postoperative delirium rate was lower in the CGA group than in the control group (12.5% vs 21.1%); however, this between-group difference did not reach the conventional threshold for statistical significance and was thus interpreted as inconclusive. Postoperative delirium after gastrointestinal surgery affects 15%-35% of patients aged > 65 years and is associated with a prolonged LOS and increased mortality[32,33]. Multicomponent, non-pharmacological delirium interventions can reduce the incidence of delirium by approximately 40%[34]. Whether CGA-guided nursing achieves a comparable absolute reduction in delirium can only be established in an adequately powered prospective study.
The absolute difference in 30-day readmission rate (5.0% vs 18.4%) did not reach the conventional threshold for statistical significance (P = 0.076); given the sample size of 78 patients, the study had insufficient statistical power to confirm a between-group difference of clinical interest, and this finding thus requires confirmation in an adequately powered study.
Importantly, no significant baseline differences were observed between the two groups in terms of age, sex, nutrition, function, comorbidity burden, or cognition. This baseline balance strengthens internal validity and reduces the likelihood of selection bias, although it cannot fully replace randomization.
The present study has several limitations. First, this was a single-center retrospective study, which limits the generalizability of our findings. Second, as only 78 patients were included, we had limited statistical power to detect modest effects in nonsignificant CGA domains. Third, the relatively short study period may not have captured long-term outcomes. Fourth, without randomization, residual confounding by indication and allocation mechanism cannot be excluded; although both patient groups were drawn concurrently from the same ward and managed by the same surgical and nursing teams, allocation to CGA-guided care depended on availability of the CGA-trained nursing team and patient/family acceptance. Fifth, the nonblinded design introduced potential observer bias in the outcome assessment. Despite these limitations, the present study provides preliminary support for the feasibility of CGA-guided nursing interventions in elderly surgical patients.
Future research should include prospective randomized controlled trials with larger sample sizes to confirm our findings. Systematic identification of older adults at elevated risk of harm after elective surgery may help target CGA-guided nursing to those most likely to benefit[35]. Cost-effectiveness analyses would help inform health-policy decisions, and component analyses of the intervention bundle would help identify which elements of CGA-guided care contribute the most to improved outcomes. Moreover, implementation research would help inform the sustainable integration of CGA-guided nursing into routine perioperative care.
CGA-guided stratified nursing intervention reduced postoperative complications (27.5% vs 55.3%; P = 0.013) and shortened the LOS (16.2 days vs 20.8 days; P < 0.001) in elderly patients undergoing gastrointestinal or hepatobiliary surgery. The effects remained significant after adjustment for other covariates (complication-adjusted OR = 0.35; P = 0.024, LOS-adjusted β = -3.68 days; P = 0.001). Hospitals should consider the systematic integration of CGA-guided perioperative nursing for elderly surgical patients. Further prospective randomized trials and cost-effectiveness analyses are warranted.
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