ASO Author Reflections - Impact of Social Vulnerability and Allostatic Load on Postoperative Outcomes

Sep 29, 2026

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Sociologically vulnerable neighborhoods and chronic socioeconomic stressors are linked to adverse postoperative results in hepatopancreatobiliary (HPB) cancers. The study examines how allostatic load (AL), representing cumulative physiologic wear across cardiovascular, metabolic, renal, and immune systems, influences outcomes after high-risk HPB surgery. Findings show stepwise increases in allostasis with greater social vulnerability and associations with higher rates of severe complications, failure to rescue, and 30-day mortality.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

PAST

Allostatic load and socially vulnerable neighborhoods

PRESENT

Study population characteristics

Associations with complications and mortality

FUTURE

Integrating AL into preoperative workflows

FUNDING and DISCLOSURES

OPEN ACCESS

Ann Surg Oncol (2026) 33:1091–1092 [https://doi.org/10.1245/s10434-025-18274-w](https://doi.org/10.1245/s10434-025-18274-w) ASO AUTHOR REFLECTIONS ASO Author Reflections: Impact of Social Vulnerability and Allostatic Load on Postoperative Outcomes Mujtaba Khalil, MD1, and Timothy M. Pawlik, MD, PhD, MPH, MTS, MBA2 1Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI; 2Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH PAST Hepatopancreatobiliary (HPB) cancers remain among the most complex malignancies to treat surgically, with high postoperative morbidity and mortality. 1 For patients living in socially vulnerable neighborhoods, the challenges extend beyond the operating room.2, 3 Chronic exposure to socioeconomic stressors such as financial hardship, limited healthcare access, and unstable living conditions can alter the body’s regulatory systems, a process captured by the concept of allostatic load (AL) .4 AL reflects cumulative physiologic wear and tear across cardiovascular, metabolic, renal, and immune systems.4 While prior work has linked AL to poor outcomes in chronic medical conditions, its influence on patients undergoing high-risk HPB surgery has been ill-defined.4, 5 PRESENT Among 34,253 individuals, the mean patient age was 71 years (interquartile range 63–78), approximately half of the patients were male (n = 18,045, 52.7%), and 29,246 (85.4%) patients had a high Charlson Comorbidity Index score (CCI >2). The most common cancer site was the pancreas (n = 21,402, 62.5%), followed by the liver (n = 8451, This article refers to: Khalil M, Woldesenbet S, King J, et al. Impact of Social Vulnerability and Allostatic Load on Postoperative Outcomes. Ann Surg Oncol. Epub 20 Aug 2025. [https://doi.org/10.1245/s10434-025-18144-5](https://doi.org/10.1245/s10434-025-18144-5) . © The Author(s) 2025 First Received: 12 August 2025 Accepted: 13 August 2025 Published online: 27 August 2025 T. M. Pawlik, MD, PhD, MPH, MTS, MBAe-mail: [tim.pawlik@osumc.edu](tim.pawlik@osumc.edu) 24.7%) and biliary tract (n = 4400, 12.8%) . Overall, 13.8%(n = 4717) of patients had high AL. On multivariable analysis, the risk of allostasis increased stepwise with higher social vulnerability (reference: low; medium: odds ratio [OR] 1.11, 95% confidence interval [CI] 1.04–1.19; high: OR 1.17, 95% CI 1.11–1.17) . Moreover, high AL was associated with a 44% increased risk of Clavien–Dindo grade IV complications (OR 1.44, 95% CI 1.36–1.54) and an 85% increased risk of failure to rescue (OR 1. 85, 95% CI 1.60–2.13) . In addition, the risk of 30-day mortality was approximately twofold higher with elevated AL (OR 1.92, 95% CI 1.70–2. 19) . FUTURE The current study highlights the need to recognize and address biologic consequences of long-term social disadvantage in patients with cancer.5 AL, derived from routinely collected clinical data, could be integrated into preoperative workflows to identify patients who may benefit from targeted interventions ranging from prehabilitation and metabolic optimization to enhanced perioperative surveillance and tailored discharge planning.4 Future studies should explore whether modifying AL before surgery can improve recovery and survival, and how combining patient-level physiologic data with hospital-level quality measures might further reduce disparities in HPB cancer care.4, 5 FUNDING No sources of funding were used to assist in the preparation of this study. DISCLOSURES Mujtaba Khalil and Timothy M. Pawlik have no conflicts of interest to declare that may be relevant to the contents of this study. OPEN ACCESS This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the

FAQs

What is allostatic load (AL) in this study?

AL is described as the cumulative physiologic wear and tear across cardiovascular, metabolic, renal, and immune systems resulting from chronic exposure to socioeconomic stressors.

How does social vulnerability relate to allostatic load?

Risk of allostasis increased stepwise with higher social vulnerability categories, with odds ratios reported for medium and high compared with low.

What postoperative outcomes were associated with higher allostatic load?

High AL was associated with increased risk of Clavien–Dindo grade IV complications, failure to rescue, and roughly twofold higher 30-day mortality.

Sep 29, 2026

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