The association of geriatric nutritional risk and perioperative anesthesia–related adverse reactions in elderly patients with colorectal cancer—a prospective study
Highlight box
Key findings
• The presence of nutritional risks significantly increased the risk of anesthesia-related adverse reactions in patients with colorectal cancer (CRC).
What is known, and what is new?
• Patients with nutritional risks have more surgery-related complications and a worse postoperative prognosis than those without nutritional risks.
• The present study analyzed the association of the geriatric nutritional risk index with perioperative anesthesia-related adverse reactions in CRC patients.
What is the implication, and what should change now?
• Preoperative nutritional support for CRC patients should be increased to reduce the risks of the incidence of anesthesia-related adverse reactions during the perioperative period.
Introduction
Colorectal cancer (CRC) is the most common gastrointestinal cancer (1). Surgical removal of the tumors plays a crucial role in the treatment of CRC. However, the incidence of postoperative complications is high, significantly impacting patients’ recovery after surgery. One way to categorize post-operative complications after surgery for CRC is to distinguish between anesthesia-related complications and surgery-related complications. Anesthesia-related complications primarily include headaches, delirium, cognitive impairment, gastrointestinal reactions, hypotension, and tachycardia. The incidence of anesthesia-related complications is high and can lead to poor outcomes. At present, research has confirmed that factors such as age and long surgical time are influencing factors of anesthesia-related adverse reactions (2-4).
Based on the literature, we hypothesized that nutritional status may significantly affect the incidence of anesthesia-related adverse reactions in CRC patients. Bouillanne et al. proposed the Geriatric Nutritional Risk Index (GNRI) in 2005 (5). Chen et al. demonstrated that the GNRI was a strong independent risk factor associated with postoperative delirium in patients with gastric cancer (6). Xie et al. also confirmed that in elderly surgical patients a decrease in the GNRI is associated with an increased risk of postoperative delirium (7). Other studies also confirmed the value of GNRI in predicting the clinical outcomes (8-10).
However, few studies have analyzed the association between nutritional status and perioperative anesthesia-related adverse reactions in CRC patients. Thus, this study sought to analyze the relation between GNRI and perioperative anesthesia-related adverse reactions in a population of elderly patients who underwent surgery for CRC. We present this article in accordance with the STROBE reporting checklist (available at https://tcr.amegroups.com/article/view/10.21037/tcr-2025-1140/rc).
Methods
General information
From January 2023 to December 2024, the data of CRC patients admitted to the Second Affiliated Hospital of the Army Medical University (AMU) were prospectively collected and retrospectively reviewed. First, GNRI was calculated for each patient, and based on its value, the patients were divided into the nutritional risk group and the control group based on their GNRI (cut-off of 98). To be eligible for inclusion in the study, the patients had to meet the following inclusion criteria: (I) have received a diagnosis of CRC; (II) be aged ≥65 years old; and (III) have received radical surgery with curative intent at the Second Affiliated Hospital of the AMU. Patients were excluded from the study if they met any of the following exclusion criteria: (I) had CRC concomitant to other malignant tumors; (II) had a previous history of gastrectomy or colorectal resection; (III) urgent operation; (IV) had distant metastasis; (V) had coagulation dysfunction; and/or (VI) had recurrent CRC. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of the Second Affiliated Hospital of the AMU (No. 20250124), and all the patients signed the informed consent form.
Treatment
According to the CRC treatment guidelines established by the National Comprehensive Cancer Network, radical CRC surgery was performed and symptomatic supportive treatments like prophylactic anti-infection were administered as cephalosporin antibiotics 30 minutes before surgery and continued until 48 hours after surgery. Nutritional support was provided with enteral and parenteral nutrition, and water and electrolyte balance maintenance were provided after surgery. The following anesthetic methods were used during the operation: All surgeries were performed under general endotracheal anesthesia using standard monitors. Patients were induced with midazolam (0.02 mg/kg), sufentanil (0.4 µg/kg), propofol (1.5 mg/kg), dexamethasone (10 mg), and rocuronium (0.8 mg/kg). Maintenance anesthesia included sevoflurane, propofol, and remifentanil. The Narcotrend values were maintained between 40 and 50, and the decision regarding patient-controlled analgesia was made post-surgery based on the patient’s preferences.
Data collection
The primary outcomes of the study were anesthesia-related adverse reactions (including intraoperative and postoperative adverse reactions), intraoperative adverse reactions (including hypotension and tachycardia), and postoperative adverse reactions (including headache, delirium, cognitive impairment, and gastrointestinal reactions). The other observation indicators were age, gender, height, weight, serum albumin, presence of comorbid hypertension, hyperlipidemia, or diabetes, operation time, surgical method (laparoscopic surgery or open surgery), the use of patient-controlled analgesia for analgesia after surgery (yes/no), tumor diameter, tumor location, the degree of tumor cell differentiation, pathological type, lymph node metastasis and length of hospital stay.
Definitions
The GNRI was calculated using the following formula: GNRI = [1.489 × albumin (g/L)] + 41.7× (weight/ideal weight), where the ideal weight for males was calculated as follows: Ideal weight (male) = height − 100 − [(height − 150)/4]; and the ideal weight for females was calculated as follows: ideal weight (female) = height − 100 − [(height − 150)/2.5]. When the body weight exceeded the ideal weight, the body weight/ideal body weight was set as 1. A GNRI >98 indicated no nutritional risk, the cohort of patients with GNRI >98 was called in as “Control”, while a GNRI ≤98 indicated nutritional risk; thus, this cohort was termed the “Nutritional Risk Group. Delirium was defined as impaired consciousness with persistent or diminished ability to divert attention, the presence of altered cognitive function (including memory loss, disorientation, and language impairment), or the presence of perceptual impairment that could not be explained by dementia. The condition occurred over a short period of time (hours to days) with fluctuation throughout the day. Other features included sleep disturbances such as changes in sleep-wake cycle, changes in psychomotor activity, and neurobehavioral abnormalities.
The Mini-Mental State Examination Scale (MMSE) was used to evaluate the cognitive function of the patients, with a score <27 indicating the existence of cognitive dysfunction (11).
Intraoperative hypotension was defined as a mean arterial pressure below 65 mmHg, while intraoperative tachycardia was defined as a heart rate exceeding 100 beats per minute.
Statistical analysis
Sample size estimation: According to the requirements of multiple regression analysis, one independent variable corresponded to at least 10 samples, and it was expected to include 3–5 independent variables. The expected incidence of anesthesia-related adverse reactions is 40%, which means the minimum sample size was 125. For data analysis, the software SPSS version 26.0 (IBM, Chicago, USA) was utilized in this study. A P value of less than 0.05 was considered statistically significant (two-sided test). Normally distributed continuous data are presented as means ± standard deviations, and the independent samples t-test was employed to analyze differences between the two groups. Categorical data are expressed as counts of “Yes” or “No”, and the chi-square test was used to evaluate differences between the two groups. A multivariate logistic regression analysis was conducted to identify risk factors that were independently associated with nutritional risk and anesthesia-related adverse reactions during the perioperative timeframe in CRC patients.
Results
Patient inclusion flowchart
During the study period, a total of 349 CRC patients met the inclusion criteria. Of these, 27 were excluded for meeting exclusion criteria. Ultimately, 322 patients were included in the study (Figure 1). Based on GNRI, patients were divided into the nutritional risk group (n=142) and the control group (n=180).
There were significant differences between the two groups in terms of age, tumor diameter, and lymph node metastasis (P<0.05) (Table 1).
Table 1
| Variables | Nutritional risk group (n=142) | Control group (n=180) | t/χ2 value | P value |
|---|---|---|---|---|
| Age (years) | 76.28±6.32 | 73.67±5.19 | 2.609 | <0.001 |
| Male | 82 (57.75) | 99 (55.00) | 0.243 | 0.62 |
| Height (cm) | 171.37±8.16 | 170.76±8.81 | 0.638 | 0.52 |
| Weight (kg) | 66.31±11.74 | 68.02±10.86 | 1.357 | 0.18 |
| Albumin (g/L) | 32.49±4.41 | 45.53±4.68 | 25.478 | <0.001 |
| GNRI | 87.87±6.85 | 108.02±6.82 | 26.263 | <0.001 |
| Hypertension | 12 (8.45) | 14 (7.78) | 0.048 | 0.83 |
| Diabetes | 9 (6.34) | 9 (5.00) | 0.269 | 0.60 |
| Hyperlipidemia | 19 (13.38) | 18 (10.00) | 0.892 | 0.35 |
| Operation time (min) | 135.18±27.70 | 130.69±30.93 | 1.353 | 0.18 |
| Open surgery | 22 (15.49) | 22 (12.22) | 0.720 | 0.40 |
| Type of surgery | 1.105 | 0.58 | ||
| Right colectomy | 50(35.21) | 56(31.11) | ||
| Left colectomy | 32(22.54) | 49(27.22) | ||
| Rectectomy | 60 (42.25) | 75 (41.67) | ||
| Patient-controlled analgesia | 50 (35.21) | 58 (32.22) | 0.318 | 0.57 |
| Tumor size (cm) | 4.72±2.09 | 3.54±1.58 | 5.774 | <0.001 |
| Tumor location | 0.011 | 0.92 | ||
| Colon | 82 (57.75) | 105 (58.33) | ||
| Rectum | 60 (42.25) | 75 (41.67) | ||
| Tumor cell differentiation | 2.551 | 0.11 | ||
| Poor | 32 (22.54) | 28 (15.56) | ||
| Moderate-to-high differentiation | 110 (77.46) | 152 (84.44) | ||
| Pathological type | 1.033 | 0.31 | ||
| Adenocarcinoma | 131 (92.25) | 160 (88.89) | ||
| Other | 11 (7.75) | 20 (11.11) | ||
| Lymph node metastasis | 60 (42.25) | 36 (20.00) | 18.786 | <0.001 |
Data are presented as n (%) or mean ± standard deviation. GNRI, Geriatric Nutritional Risk Index.
Risk factors for nutritional risk in CRC patients
Age, tumor diameter, and lymph node metastasis were independent risk factors for nutritional risk in CRC patients with relative risks of 1.089 (95% CI: 1.043–1.137, P<0.001), 1.463 (95% CI: 1.273–1.682, P<0.001), and 3.074 (95% CI: 1.790–5.278, P<0.001), respectively (Table 2).
Table 2
| Variables | B value | Standard error | Wald value | P value | Relative risk (95% CI) |
|---|---|---|---|---|---|
| Age | 0.085 | 0.022 | 14.863 | <0.001 | 1.089 (1.043–1.137) |
| Tumor size | 0.381 | 0.071 | 28.646 | <0.001 | 1.463 (1.273–1.682) |
| Lymph node metastasis | 1.123 | 0.276 | 16.567 | <0.001 | 3.074 (1.790–5.278) |
| Constant | −8.533 | 1.740 | 24.055 | <0.001 | – |
CI, confidence interval.
Analysis of anesthesia-related adverse reactions and hospital stay between the two groups
The incidence of anesthesia-related adverse reactions was significantly higher in the nutritional risk group compared to the control group (38.73% vs. 17.22%, P<0.001). Additionally, the length of hospital stay was significantly longer in the nutritional risk group (17.46±2.61 vs. 16.12±2.53 days, P<0.001) (Table 3).
Table 3
| Variables | Nutritional risk group (n=142) | Control group (n=180) | t/χ2 value | P value |
|---|---|---|---|---|
| Anesthesia-related adverse reactions | 55 (38.73) | 31 (17.22) | 18.763 | <0.001 |
| Intraoperative hypotension | 8 (5.63) | 3 (1.67) | 2.679 | 0.10 |
| Intraoperative tachycardia | 18 (12.68) | 6 (3.33) | 10.045 | 0.002 |
| Postoperative headache | 12 (8.45) | 6 (3.33) | 3.939 | 0.047 |
| Postoperative delirium | 12 (8.45) | 5 (2.78) | 5.108 | 0.02 |
| Cognitive impairment | 8 (5.63) | 7 (3.89) | 0.544 | 0.46 |
| Gastrointestinal reaction | 18 (12.68) | 11 (6.11) | 4.175 | 0.04 |
| Hospital duration (d) | 17.46±2.61 | 16.12±2.53 | 4.653 | <0.001 |
Data are presented as n (%) or mean ± standard deviation. In the nutritional risk group, 21 patients suffered from both types of anesthesia-related adverse reactions, while in the control group, 7 patients suffered from both types of anesthesia-related adverse reactions.
Risk factors for perioperative anesthesia-related adverse reactions in CRC patients
Independent risk factors for perioperative anesthesia-related adverse reactions in patients with CRC included age, the GNRI, operation time, type of surgery (open surgery), and use of patient-controlled analgesia. The relative risks for these factors were as follows: for age 1.131 (95% CI: 1.074–1.190), for not having GNRI 0.970 (95% CI: 0.947–0.994), for operation time 1.022 (95% CI: 1.011–1.032), for open surgery 4.375 (95% CI: 1.994–9.596), and for using patient-controlled analgesia 1.867 (95% CI: 1.049–3.324), respectively (Table 4).
Table 4
| Variables | B value | Standard error | Wald value | P value | Relative risk (95% CI) |
|---|---|---|---|---|---|
| Age | 0.123 | 0.026 | 22.287 | <0.001 | 1.131 (1.074–1.190) |
| Control-GNRI | −0.030 | 0.012 | 6.157 | 0.01 | 0.970 (0.947–0.994) |
| Operation time | 0.021 | 0.005 | 16.187 | <0.001 | 1.022 (1.011–1.032) |
| Open surgery | 1.476 | 0.401 | 13.561 | <0.001 | 4.375 (1.994–9.596) |
| Patient-controlled analgesia | 0.624 | 0.294 | 4.503 | 0.03 | 1.867 (1.049–3.324) |
CI, confidence interval; GNRI, Geriatric Nutritional Risk Index.
Discussion
The present study on nutritional risk factors for anesthesia-related adverse events found a significant association between GNRI and the main outcome. Patients with a low GNRI had a significantly higher risk of anesthesia-related adverse reactions (38.73% vs. 17.22%, P<0.001). The observed increase in adverse reactions included intraoperative tachycardia, postoperative delirium, postoperative headache, nausea, and vomiting.
CRC is more common in middle-aged and elderly individuals, and older patients with CRC face a heightened risk of nutritional deficiencies before surgery for several reasons: (I) CRC cells continue to divide and consume the body’s energy, leading to weight loss; (II) metabolic disorders in CRC patients can cause a loss of appetite; (III) gastrointestinal dysfunction in CRC patients can lead to difficulties in digestion; (IV) chronic blood loss due to gastrointestinal bleeding in CRC patients can result in malnutrition; and (V) preoperative chemotherapy and gastrointestinal obstruction can further increase nutritional risks.
In the current study, the GNRI was utilized to assess the nutritional status of the patients. The results indicated that 44.10% (142 out of 322) of the patients were at nutritional risk. These findings are consistent with a previous study, which has also shown a high prevalence of nutritional risk among patients with CRC (12).
We also documented that age, tumor size, and lymph node metastasis are independent factors affecting nutritional risk (P<0.05). As people age, their ability to digest and absorb nutrients decreases. Additionally, the likelihood of developing various chronic diseases rises with age, which can further increase the risk of malnutrition (7,13,14).
The larger the tumor diameter and the presence of lymph node metastasis, the more likely it is for the patient to develop gastrointestinal dysfunction and cachexia. Additionally, gastrointestinal dysfunction may increase the risk of malnutrition (15-18).
Perioperative nutrition, although often assessed preoperatively, does not typically lead to appropriate interventions such as prehabilitation periods, primarily due to concerns about delaying surgery. Malnutrition is accompanied by circulatory system dysfunction and metabolic dysfunction, which are more likely to lead to postoperative anesthesia-related adverse reactions. The GNRI is an indicator used to assess the nutritional status of the elderly and is mainly calculated based on sex, albumin, body, and weight. At present, the GNRI has become an important research index for surgery. In a previous study, the GNRI was found to be associated with postoperative delirium and prolonged hospital stays in patients undergoing noncardiac surgery (19). Another study confirmed that a reduction in the GNRI was associated with longer hospital stays for non-cardiac surgery in older adults and had high value in predicting anesthesia-related adverse reaction events such as postoperative delirium (20). Another study achieved similar results (21), supporting the present study.
QT Prolongation is a known risk factor for tachycardia and a previous study suggested that a reduced GNRI was associated with QT prolongation (22). In addition, another study showed the GNRI can be used as an independent predictor of arrhythmias after treatment in patients with atrial fibrillation (23). Finally, our findings showed that patients with nutritional risk had an increased incidence of postoperative headache and gastrointestinal reactions. Patients with malnutrition lack vitamin B2, magnesium, and vitamin D, which could cause nervous system dysfunction leading to headache and nausea (24-28), and ultimately a delay in postoperative recovery.
Preoperative physiologic status optimization and preparation for the surgery has been extensively studied in various fields of surgery, including colorectal procedures for CRC. The wide variety of treatments and interventions to improve patients’ functional reserves includes smoking cessation, optimization of comorbid conditions, such as diabetes, hypertension, nutritional supplementation, physical endurance trainings, and breathing exercises, etc. Prehabilitation strategies should be incorporated into the perioperative assessment of patients undergoing CRC surgery to enhance their functional reserve and reduce postoperative adverse events. Our study reinforces the association between high nutritional risk and anesthesia-related postoperative complications, which could be mitigated through structured prehabilitation programs. This highlights the need for integrating such programs into routine clinical practice for CRC patients.
Limitations
This study has several limitations. Notably, it is retrospective in nature; therefore, some newly emerging questions and parameters to answer them are not readily available. Based on the relatively small sample size of the patients, subgroups of patients, or subparameters, are not analyzable from a statistical point of view. Third, although data were prospectively collected, the analysis was retrospective, limiting the ability to control for unmeasured confounders. Fourth, this study was a single center clinical research, and the limitations of sample sources limited the external applicability of the research results.
Conclusions
Our study highlights a correlation between nutritional index and anesthesia-related adverse events after surgery for CRC. These single-center data suggest the need for broader investigation on the topic to support future interventions aimed at reducing perioperative malnutrition in patients undergoing surgery for CRC.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tcr.amegroups.com/article/view/10.21037/tcr-2025-1140/rc
Data Sharing Statement: Available at https://tcr.amegroups.com/article/view/10.21037/tcr-2025-1140/dss
Peer Review File: Available at https://tcr.amegroups.com/article/view/10.21037/tcr-2025-1140/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tcr.amegroups.com/article/view/10.21037/tcr-2025-1140/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of the Second Affiliated Hospital of the AMU (No. 20250124), and all the patients signed the informed consent form.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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