Foreword

Welcome to the current issue, Hepato-Pancreato-Biliary (HPB) Surgery, of the Indian Journal of Surgery (IJOS) that has articles on various topics related to HPB surgery. Although, the main focus of IJOS remains on articles of interest to general surgeons, we now are receiving increasing number of articles related to HPB surgery/oncology including few on liver transplantation as well. Hence, our EIC decided to club together all the articles randomly received and peer reviewed on the subject by IJOS in to this special issue (SI). This SI thus has no invited articles and almost all articles included herein have already been published online previously. To synchronize the flow of articles I have just compiled them in to 3 sub-sections: namely, Liver, Pancreas, Gallbladder/Biliary Tree/Miscellaneous, breaking away from the traditional structure that follows the sequence of Review Article, Original Article, Surgical Techniques and Innovations, Case Report, Images in Surgery, and lastly Letter to Editor.

The Liver section contains 18 articles discussing different aspects of management of hepatocellular carcinoma (HCC) and liver transplantation, with majority contributions coming in from China. The first article is an interesting meta-analysis from China discussing ALPPS procedure vs. 2-stage hepatectomy and concludes that ALPPS does promote faster liver regeneration but at the cost of higher mortality. Minimally invasive liver resections (MILR) are now being increasing performed in high-volume centers and a meta-analysis again from China shows that short-term outcomes (operative time, R0 resection rates, transfusions, mortality) of laparoscopic right hepatectomy are similar to that of open right hepatectomy with shorter length of hospital stay (LOHS) and estimated blood loss. A strong critic of the said study, however, has been succinctly presented by authors from Pakistan in their Letter to Editor and is worth a read. Another Chinese study evaluates a prognostic scoring model using parameters like age, race, grade, summary stage, radiotherapy status, and AJCC stage and has revealed a significantly poorer survival of their high-risk group of HCC patients based on their scoring criteria. Recurrence of HCC after resection is the greatest fear. A meta-analysis from China reports cirrhosis, AFP > 400 ng/dl, perioperative blood transfusion, tumor diameter > 5 cm, multiple tumors, satellite nodules, vascular invasion, MVI, low differentiation, advanced TNM, and BCLC stage as risk factors affecting the recurrence-free survival of HCC after hepatectomy. The follow-up question that arises is what’s next after post-hepatectomy recurrence of HCC. We have another study from China on this very aspect wherein the authors discuss the outcomes of repeat resection vs. local ablative therapy vs. transarterial chemoembolization (TACE) in 272 patients analyzed.

There are 3 operative technique-related articles on liver transaction tools (CUSA vs. Water jet) and Pringle maneuver. The Indian study on 50 patients revealed, as expected, no significant differences in morbidity, mortality, or markers of hepatocyte injury with either CUSA or Water jet techniques used for liver resection. Pringle maneuver is widely used by surgeons during major and complex hepatectomies. A retrospective study from Japan analyzed the effect of Pringle maneuver on 831 patients and found no correlations between ischemia time and remnant liver regeneration at 7 days, and 1, 2, 5, and 12 months, postoperatively, in either the normal or diseased liver groups. The next in the list is a French study that neatly describes the technique of intracorporeal Pringle maneuver using a urinary catheter during MILR.

We have 3 articles on liver transplant in this SI. A meta-analysis from China discusses the importance of gut microbiome and probiotics supplementation in improving outcomes after transplants by reducing postoperative infection (UTI, intraabdominal infections but not pneumonia), duration of antibiotics, and LOHS. The highly variable anatomy of the region is well known and requires extreme caution and planning before embarking upon any complex surgery in the region. A study from Turkey explores the value of 3D MRCP as a non-invasive useful method to evaluate non-dilated bile ducts preoperatively in living donor liver transplantation. We have a study from India reporting their outcomes after auxiliary partial orthoptic liver transplant (APOLT) in acute liver failure in which 3 of their 6 patients died postoperatively, thereby stressing on its poor outcomes and the need to carefully select patients for this approach such as those with hepatitis A–related hyperacute liver failure.

Besides there are multiple images in surgery and a case report that make an interesting read such as on dreadful complication of hypercarbia during laparoscopic hepatectomy, recurrent HCC with middle hepatic vein tumor thrombus, HCC with hilar bile duct tumor thrombus mimicking hilar cholangiocarcinoma, and TACE in HCC that was supplied by a right renal artery trunk, among others.

The section on Pancreas has overall 19 different articles. A study from Italy presents a detailed update on intraductal papillary mucinous neoplasms (IPMN) with radiological images and a flow diagram. A retrospective study from Vietnam reports their outcomes on 89 patients with pancreatic ductal adenocarcinoma (PDAC) after resection and reiterates the importance of lymph node dissection which is pretty much now a standard part of pancreaticoduodenectomy (PD) for cancer. Post-operative pancreatic fistula (POPF) remains the most hazardous and at times a life-threatening complication after pancreatic resections. A multitude of preventive modalities and technical modifications have been tried to minimize its occurrence and different prediction models/nomograms have been studied to identify a high-risk gland and the patient. A single-institutional study from India validates one such useful score, Fistula Risk Score (FRS), as a reliable method for predicting the development of clinically relevant POPF after PD. Another common post-pancreatectomy complication is delayed gastric emptying (DGE). A study from an Indian center discusses their favorable outcomes on DGE following addition of Braun enteroenterostomy after Whipple PD with binding pancreaticogastrostomy. Addition of another anastomosis, Braun enteroenterostomy, after PD for reducing DGE is still controversial. Herein the authors do not mention any data on POPF, intraabdominal collections, and other complications in their patient cohort that are the main risk factors for DGE and also if ERAS protocol is followed in their unit. A sharp meta-analyses on the upcoming role of liquid biopsy in oncology and its significance, KRAS mutations in the peripheral blood, from China analyzes 28 studies and 2006 patients. The study revealed that KRAS mutations in peripheral blood of pancreatic cancer patients are associated with poor overall survival. Also included in this series are two articles from India giving interesting insights in acute pancreatitis scoring systems.

Authors from Thailand describe a novel technique of retracting stomach facilitating excellent exposure during laparoscopic distal pancreatectomy. The technique simply requires a nasogastric tube and a 2/0 polypropylene straight needle suture and calls attention of readers interested in the topic. There are articles and images on commonly encountered biliary and arterial anomalies in the region challenging the surgical expertise of a HPB surgeon and presentations/complications associated with pancreatic lesions. Letter to Editor includes an engrossing write up on “Robotic enucleation for cystic tumors of the pancreas,” wherein the author from Germany defends enucleation of certain cystic lesions of the pancreas as a pancreas saving procedure. While it may be true for definitely benign lesions, but in a borderline case such as the one discussed, BD (Branch duct)-IPMN > 2 cm vs. mucinous cystic neoplasm (MCN), one is left wondering if the procedure is justified?

The Gallbladder/Miscellaneous section (6 articles) has an excellent pooled analysis from China discussing hepatopancreatoduodenectomy (HPD) for locally advanced gallbladder cancer (GBC), something we are tempted to do in a fit patient with a still resectable GBC. The results suggest that HPD may be advisable only when a R0 resection can be achieved. The chief drawback of this article is that it included only case reports and case series over a long period of time (1990–2021) and studies on the upcoming role of neoadjuvant chemotherapy in advanced GBC were not included. An article from India presents their audited account on the causes of in-hospital and 90-day mortality after HPB and GI surgery in their unit. Authors from Thailand present an easy biliary drainage technique for intraoperatively diagnosed advanced perihilar bile duct tumor involving both hepatic ducts by combined intraoperative biliary stent with choledocho-duodenostomy with some excellent diagrammatic representations and operative photographs. Biliary cystadenoma and portal biliopathy capture rare entities in the images section.

This SI also has two editorials. I am really grateful to Dr. Savio George Barreto FRACS, PhD, for having agreed to pen down an editorial at a very short notice. He deserves special thanks more so because he has almost never regretted reviewing an article for IJOS, also serves IJOS as its Associate Editor, and is a gifted academic writer, too. His editorial discusses a relevant but less understood topic of young-onset pancreatobiliary adenocarcinoma which is a rising phenomenon being witnessed across the world. Lastly, my editorial largely addresses the upcoming role of artificial intelligence and its application in HPB surgery and the importance of patient rehabilitation in improving overall outcomes in HPB surgery/oncology.

As a concluding note, I would humbly like to draw your kind attention to the fact that case reports form a major chunk of all submissions made to the IJOS. Even this SI has systematic reviews and meta-analysis, reviews, original articles, and articles on surgical technique coming almost all from outside India, indicating perhaps that we should consider submitting more quality original articles to IJOS. Happy reading!!