Impact of Social Vulnerability and Allostatic Load on Postoperative Outcomes - Original Article - Global Health Services Research

Sep 29, 2026

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Background investigates the link between allostatic load and social vulnerability and how they influence postoperative outcomes after hepatopancreatobiliary cancer surgery. Methods identify patients undergoing HPB surgery from the Epic Cosmos database; allostatic load is derived from 10 biomarkers across cardiovascular, metabolic, renal, and immune systems, then assessed using multivariable regression for outcomes and failure to rescue. Results show stepwise increased risk of allostasis with higher social vulnerability and associations with grade IV complications, failure to rescue, and 30-day mortality. Conclusion links socioeconomic stressors in vulnerable areas to long-term physiologic damage leading to worse surgical outcomes.

LanguageEnglish

CategoryResearch & Report

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Pages8

Reading Time20 min

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Abstract

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Methods

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Ann Surg Oncol (2026) 33:1068–1075 [https://doi.org/10.1245/s10434-025-18144-5](https://doi.org/10.1245/s10434-025-18144-5) ORIGINAL ARTICLE – GLOBAL HEALTH SERVICES RESEARCH Impact of Social Vulnerability and Allostatic Load on Postoperative Outcomes Mujtaba Khalil, MD, Selamawit Woldesenbet, PhD, Jasmine King, MA, Shreya Shaw, BS, Zayed Rashid, MD, Abdullah Altaf, MD, Shahzaib Zindani, MD, Samilia Obeng‑Gyasi, MD, and Timothy M. Pawlik, MD, PhD, MPH, MTS, MBA Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH ABSTRACT Background. We sought to investigate the association between allostatic load (AL), social vulnerability, and postoperative outcomes following hepatopancreatobiliary (HPB) cancer surgery. Methods. Individuals who underwent HPB surgery were identified using the Epic Cosmos database. AL was calculated based on 10 biomarkers across four physiological systems: cardiovascular, metabolic, renal, and immune. Multivariable regression models were used to examine the association between AL, postoperative outcomes, and failure to rescue (FTR) . Results. Among 34,253 individuals, mean patient age was 71 years (interquartile range 63–78) . Approximately half of patients were male (n = 18,045, 52.7%) and had a high Charlson Comorbidity Index (CCI) score (CCI >2; n = 29,246, 85.4%) . The most common cancer site was the pancreas (n = 21,402, 62.5%), followed by the liver (n = 8451, 24.7%) and the 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 ofFTR (OR 1.85, 95% © The Author(s) 2025 First Received: 12 June 2025 Accepted: 4 August 2025 Published online: 20 August 2025 T. M. Pawlik, MD, PhD, MPH, MTS, MBAe-mail: [tim.pawlik@osumc.edu](tim.pawlik@osumc.edu) 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) . Conclusion. Individuals residing in socially vulnerable areas experience socioeconomic stressors that contribute to long-term physiological damage, resulting in worse outcomes following surgery. Keywords Allostatic load · Surgical outcomes · Social vulnerability · Hepatopancreatobiliary surgery Hepatopancreatobiliary (HPB) cancer incidence and mortality have steadily increased over the past few decades. 1 Individuals from minoritized groups and socially vulnerable neighborhoods experience a higher risk of HPB cancer and poorer surgical outcomes.2,3 Of note, social vulnerabilities such as poverty, limited transportation, and food insecurity hinder access to care and contribute to these disparities.3–5 Long-term exposure to these challenges may also disrupt psychological and physiological systems, potentially affecting recovery after treatment.6,7 One framework for understanding the physiological impacts of social vulnerability on health is through calculating allostatic load (AL) .8 Allostasis refers to the cumulative effects of long-term stress exposure on the human body.8 When stress arises, the body recalibrates its adaptive mechanisms to maintain balance.8 If the demands exceed an individual’s capacity to adapt, allostatic overload may occur, disrupting metabolic, immune, cardiac, and hematologic functions.8 McEwen and Stellar first introduced the concept of allostasis, using individual biomarkers to calculate a score that could predict wear and tear in the body.9 These biomarkers include anthropometric, inflammatory, metabolic, and cardiovascular measurements.9 AL has been recognized asa significant predictor of vario

FAQs

What was the study’s primary objective?

To determine the association between social vulnerability, allostatic load, and postoperative outcomes among patients undergoing hepatopancreatobiliary cancer surgery.

How was allostatic load calculated in the study?

Allostatic load was calculated using 10 biomarkers across four physiological systems: cardiovascular, metabolic, renal, and immune.

What postoperative outcomes were associated with higher allostatic load?

High allostatic load 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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