Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
INTRODUCTION: Although infrequent, postoperative complications following microvascular free tissue transfer (MFFT) for head and neck cancer (HNC) such as acute myocardial infarction, cerebrovascular accident, pulmonary embolism, and pneumonia increase patient mortality and impose a significant burden on the healthcare system. Many previous studies have associated frailty, defined as a decrease in physiologic reserves and multisystem impairments beyond the normal aging process, with poor outcomes in HNC surgery using established indices such as the 5-factor modified Frailty Index (mFI-5).
Preoperative malnutrition is another common condition that is often underdiagnosed despite being present in over half of patients with HNC, representing a potentially important area for understanding and pre-emptive improvement. The Geriatric Nutritional Risk Index (GNRI) is a tool used to evaluate nutrition-related risk based on readily available variables including serum albumin, weight, and height. This study aimed to determine if nutrition-related risk, as defined by the GNRI, is associated with adverse outcomes following MFFT for HNC.
METHODS: The 2010-2022 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried for patients aged >65 years who underwent MFFT for HNC. Patients were stratified into three cohorts based on preoperative GNRI: no nutrition-related risk (GNRI >98), low nutrition-related risk (GNRI 92-98), and moderate to major nutrition-related risk (GNRI<92). After adjusting for potential confounders, multivariable logistic regression models were performed to assess the association between GNRI and postoperative outcomes. R Studio Version 2023.03.1 was used to conduct all statistical analyses.
RESULTS: Of 1,586 patients, 945 (59.6%) patients had a GNRI corresponding with no nutrition-related risk, 346 (21.8%) had low nutrition-related risk, and 295 (18.6%) had moderate to major nutrition-related risk. GNRI was unequally distributed across age groups (p=0.024), race, American Society of Anesthesiologists (ASA) physical classification, and BMI (p<0.001). Comorbidities associated with the moderate to major nutrition-related risk cohorts included smoking, disseminated cancer, contaminated wound, poor functional status, wound infection, weight loss, dialysis, and congestive heart failure. On multivariable regression, both low and moderate-major nutrition-related risk cohorts were associated with surgical, medical, and CDIV complications, along with non-home discharge, respectively (p<0.05).
CONCLUSION: Nutrition-related risk is associated with surgical, medical, and CDIV complications, and non-home discharge following MFFT for HNC. These findings align with existing literature identifying associations between GNRI and adverse postoperative outcomes across other subspecialties. Given that frailty, based on metrics such as the mFI-5, is a composite of comorbidities that may be difficult to alleviate, these results suggest the importance of nutritional status as a preoperative measure that can be pre-emptively identified and optimized to improve postsurgical outcomes. These findings encourage future studies to validate the utility of the GNRI and exploration into other metrics of nutritional status to help further optimize patient outcomes.