From feasibility to biological recovery: Reframing enhanced recovery pathways for elderly gastric cancer patients

Table 1 Operational framework for integrating psychophysiological, nutritional, and metabolic axes within enhanced recovery after surgery pathways in elderly surgical patients

Trigger	Definition/threshold	Rationale/mechanistic link	Prompted action (MDT-governed)	Governance/notes
Autonomic-sleep dysregulation (≤ 72 hours post-op)	HRV ↓ ≥ 20% from baseline and sleep efficiency < 80%	Autonomic imbalance → sympathetic predominance → catabolic & inflammatory surge	Review analgesia/sedation timing. Activate sleep-protection bundle (timed light, noise reduction, melatonin). Screen for early delirium/uncontrolled pain (geriatric input as needed)	Process prompt; not therapeutic. Requires prospective validation
Reduced mobility trajectory (POD 2-5)	Step-count ↓ ≥ 30% from prior day or below ward target ≥ 48 hours	Impaired recovery reserve → pulmonary and thrombotic risk	Escalate physiotherapy/mobilization. Reassess nutrition (protein ≥ 1.2 g/kg). Check orthostatic vitals	Needs wearable or nurse-logged data; align with ERAS mobility KPIs
Metabolic stress signature (any time)	Resting nocturnal HR ↑ ≥ 10 bpm for ≥ 2 nights plus appetite decline	Hypermetabolic state; low-grade inflammation; energy deficit	Rule out infection/pain. Review fluid/glucose management. Consider early immunonutrition based on PINI trend	MDT review trigger; actions supervised jointly by surgical, geriatric, and nutrition teams
Inflammatory-nutritional deviation (POD 3-7)	PINI > 1 or PNI < 40 or CRP > 50 mg/L persistent ≥ 48 hours	Sustained inflammation & malnutrition predict delayed recovery	Initiate targeted nutrition (ω-3, arginine, nucleotides). Evaluate infection source. Recheck markers in 48 hours	Exploratory markers; standardization needed for multicenter use
Behavioral-psychological distress (pre- or early post-op)	HADS-A ≥ 8 or PHQ-9 ≥ 10	Psychological stress → HPA activation → IL-6 ↑ → impaired healing	Initiate CBT/narrative-based support. Arrange mental-health professional review. Consider IL-6 monitoring if available	Optional; integrate with perioperative mental-health resources under psychology/geriatric oversight

These thresholds and responses are hypothesis-driven process prompts, not validated outcome predictors. All interventions should operate within institutional audit and feedback frameworks until prospective validation is achieved. Multidisciplinary governance involves surgeons, geriatricians, anesthesiologists, dietitians, psychologists, and physiotherapists, each contributing to domain-specific assessment and intervention. ERAS: Enhanced recovery after surgery; HR: Heart rate; HRV: Heart-rate variability; POD: Postoperative day; PINI: Prognostic Inflammatory and Nutritional Index; PNI: Prognostic Nutritional Index; HADS: Hospital Anxiety and Depression Scale; PHQ-9: Patient Health Questionnaire-9; MDT: Multidisciplinary team; HPA: Hypothalamic-pituitary-adrenal; CRP: C-reactive protein; IL-6: Interleukin-6; KPIs: Key performance indicators.