Beyond Frailty in Pancreatic Surgery: Toward a Pancreas-Specific Surgical Vulnerability Framework

Frailty is an important determinant of postoperative outcomes after pancreatic surgery. However, available assessment instruments are heterogeneous and may inadequately capture the interaction between patient vulnerability, nutritional status, body composition, and procedure-specific risk. This systematic review evaluated frailty assessment tools in pancreatic surgery and proposed a conceptual pancreas-specific framework for surgical vulnerability assessment.

A systematic review was conducted according to PRISMA 2020 guidelines. PubMed/MEDLINE, Embase, Scopus, Web of Science, and Google Scholar were searched for studies published between January 2016 and April 2026 evaluating frailty in adult patients undergoing pancreatic resection. Findings were primarily synthesized narratively because of substantial methodological heterogeneity. An exploratory subgroup meta-analysis was restricted to studies using the Modified Frailty Index that reported adjusted effect estimates for major morbidity or short-term mortality.

Twenty studies involving more than 150,000 patients were included. The Modified Frailty Index was the most frequently used instrument, followed by the Hospital Frailty Risk Score. Frailty was generally associated with increased postoperative morbidity, major complications, mortality, prolonged hospitalization, non-home discharge, and functional decline, although the extent of confounding control varied across studies. Several associations persisted in adjusted analyses, whereas other findings were supported only by unadjusted comparisons. In an exploratory subgroup meta-analysis restricted to adjusted estimates from Modified Frailty Index studies, greater mFI-defined frailty burden was associated with major morbidity (pooled OR 1.60, 95% CI 1.27-2.01; I² = 53%) and short-term mortality (pooled OR 1.31, 95% CI 1.16-1.48; I² = 0%), although these findings remain hypothesis-generating because of substantial methodological heterogeneity. However, most tools primarily reflect comorbidity burden and incompletely capture nutritional status, sarcopenia, obesity, and pancreas-specific operative risk. Current evidence suggests that surgical vulnerability in pancreatic resection results from the interaction between patient-related, nutritional-, body-composition, and procedure-related factors rather than frailty alone.

Frailty is clinically relevant to postoperative risk assessment in pancreatic surgery and should be incorporated into preoperative evaluation. Existing tools, however, inadequately capture the multidimensional nature of surgical vulnerability. We therefore propose the PANFRAIL framework, a conceptual, hypothesis-generating model integrating frailty, nutritional status, body composition, procedure-related complexity, and pancreas-specific risk to guide future development of pancreatic surgery-specific risk assessment strategies.