Objectives: Malnutrition is a significant concern for patients with head and neck cancer (HNC) and is associated with poor outcomes. The Nutritional Risk Index (NRI) assesses malnourishment and has been shown to identify patients at risk for postoperative complications in different surgical fields. Our aim is to determine the utility of the NRI in predicting postoperative outcomes for patients undergoing head and neck cancer surgery using a national database.
Study Design: Retrospective database review
Methods: We queried the 2012-2018 National Surgical Quality Improvement Program (NSQIP) database for all patients undergoing oral cavity (OC), pharyngeal, or laryngeal cancer surgery. We excluded cases with missing height, weight, albumin levels, and patients undergoing free tissue transfer. The NRI score was calculated for each patient, and patients were subdivided into malnourished and nourished depending on their nutritional status. We conducted univariate and multivariate analyses.
Results: A total of 3,698 patients met inclusion criteria with 350 (9.5%) having NRI-defined malnutrition. Of these patients, 2,763 (74.7%) of cases received surgery for an OC malignancy while 596 (16.1%) and 546 (14.8%) had pharyngeal and laryngeal surgery, respectively. Patients were predominately less than 65 years (57.4%), male (63.2%), and white (76.9%). Malnourished patients with cancer of the OC, pharynx, and larynx had longer lengths of stay (8.0 vs. 3.2 days, 12.2 vs. 5.4, and 16.8 vs. 12.4, respectively; p<0.001 for all). Similarly, malnourished patients had longer operative times for OC (252.5 vs. 171.3 min; p<0.001), pharynx (370.06 vs. 267.2 min; p<0.001), and larynx (411.6; vs. 358.9 min; p=0.004) subsites. Accounting for demographic and comorbid conditions, multivariate regression analysis revealed no significant association between NRI-defined malnourishment and all complications (OR=1.37 [0.58-3.24], p=0.475), medical complications (OR=0.63 [0.19-2.15], p=0.459), or surgical complications (OR=2.37 [0.93-6.06], p=0.072) for the HNC cohort. On individual subsite analysis, we found similar trends for patients with OC surgery. However, for patients receiving pharyngeal surgery, we found a significant relationship for all (OR=2.25 [1.17-4.33], p=0.016) and surgical (OR=2.63 [1.28-5.39], p=0.008) complications. NRI-defined malnourishment also was significantly associated with all (OR=1.81 [1.09-3.00], p=0.022) and surgical (OR=2.09 [1.23-3.56], p=0.007) complications in laryngectomy patients.
Conclusion: Patients with NRI-defined malnourishment tend to have longer operative times and length of stays. We also find malnourished patients to be at an increased risk for all complications and surgical complications in pharyngeal and laryngeal but not in oral cavity cancer surgery. The NRI can be a useful clinical tool to help identify high risk patients in select cohorts.