Hepato-Pancreato-Biliary surgery is the mainstay of therapy for primary and secondary tumors (providing the only chance for long-term survival. In the last few decades, we witnessed an impressive improvement in the short and long-term outcomes in this field. The multidisciplinary peri-operative management, innovations, and advancement in diagnostic and surgical technology, as well, as the progress in the experimental and clinical protocols of neoadjuvant and adjuvant treatments, have had a direct impact on the advancements in this field. This Special Issue will focus on the state of the art in the following: Surgical and diagnostical technological innovations; prognostic clinical, pathological, and molecular genomics that determine the management and outcome of Hepato-Pancreato-Biliary surgery due to primary or secondary tumors.

Carmel Medical Center

Frontiers in Surgery

Visceral Surgery

Hepato-Pancreato-Biliary Surgery: Innovations, Genomics, and Prognostic Management

Editorial on the Research Topic <a href="https://www.frontiersin.org/research-topics/52876/hepato-pancreato-biliary-surgery-innovations-genomics-and-prognostic-management">Hepato-pancreato-biliary surgery: innovations, genomics, and prognostic management</a>Hepato-Pancreato-Biliary surgery stands as the cornerstone of treatment for both primary and secondary tumors, offering a vital pathway to prolonged survival. Over the past few decades, remarkable strides have been made in enhancing the short and long-term outcomes within this domain. The collective efforts in multidisciplinary peri-operative care, coupled with advancements in diagnostic and surgical technologies, have significantly reshaped the landscape of Hepato-Pancreato-Biliary surgery.Cholecystectomy, has evolved over time. Initially performed as an open surgery involving a large incision, it has transitioned to minimally invasive laparoscopic techniques. Advanced technologies like robotic-assisted surgery have further refined the procedure. Laparoscopic cholecystectomy is considered the gold standard for gallbladder removal due to its minimally invasive nature, leading to faster recovery, reduced post-operative pain, and shorter hospital stays compared to open surgery. but it also can lead to severe complications like bile duct injury (BDI) (<a href="#B1">1</a>, <a href="#B2">2</a>).<a href="https://doi.org/10.3389/fsurg.2023.1280383">Vu et al.</a>, in their research found that the majority of BDIs are type (A) and diagnosed postoperatively. Endoscopic retrograde cholangiopancreatography (ERCP) was effective for the diagnosis and treatment of this type injuries.ERCP has evolved significantly since its introduction. Initially a diagnostic tool, it has developed into a therapeutic procedure for managing various pancreaticobiliary disorders. Advances include improved imaging technologies, better endoscopic instruments, and techniques like endoscopic ultrasound (EUS) and cholangioscopy, enhancing the precision and effectiveness of interventions.<a href="https://doi.org/10.3389/fsurg.2023.1206828">Uhe et al.</a>, in their case report showed that the diagnosis of entero-biliary fistula can be made by ERCP, which not only allow to visualize the fistula orifice and tract through the injection of contrast, but also allow definitive treatment with sphincterotomy and the implantation of a covered self-expandable metal stent in the common bile duct.Complications associated with ERCP encompass pancreatitis, hemorrhage, infection, perforation, and adverse reactions to sedatives or contrast agents. Factors such as advanced age, comorbidities, and procedural complexity can elevate the risk profile for these adverse events. <a href="https://doi.org/10.3389/fsurg.2023.1235833">Lee et al.</a>, reported the long-term sequalae of a rare case of a patient with a retained fractured end of the basket, used in ERCP, on the head of the pancreas, resulting in chronic pancreatitis with gross pancreatic atrophy, pancreatic duct dilatation, and early-onset diabetes mellitus.Duodenal diverticula (DD) is one of the most common digestive tract diverticula (<a href="#B3">3</a>), that might increase the complexity of the ERCP procedure. <a href="https://doi.org/10.3389/fsurg.2023.1267436">Ren et al.</a>, conducted a retrospective study to explore the clinical characteristics of patients with symptomatic DD and to generalize how to make appropriate treatment choices for this group of patients. They found that Patients with DD ≥1 cm or located periampullary were more likely to be symptomatic. The size of the DD and the combination of specific biliary comorbidities may have an impact on the choice of treatment modality. Although most patients with symptomatic DD can be treated conservatively only, surgical treatment is also a safe and effective approach when the appropriate procedure is chosen.However, when planning for surgical intervention, it&apos;s very crucial to be familiar with the standard human body anatomy and its variants. The anatomy of the hepato-pancreatico-biliary system is intricate, with structures such as the liver, pancreas, gallbladder, and bile ducts closely interconnected. This complexity presents challenges during surgical interventions, as any procedure in this area requires a precise understanding of the individual anatomy, as well as the interactions between these organs. Surgeons specializing in HPB surgery must navigate these structures with extreme care to minimize the risk of complications and ensure optimal patient outcomes.Prepancreatic postduodenal portal vein (PPPV) is a rare congenital variant of portal vein system, with only 16 cases reported in the literature, of them five underwent pancreaticoduodenectomy (PD) (<a href="#B4">4</a>). <a href="https://doi.org/10.3389/fmed.2023.1180759">Tang et al.</a>, in their case report concluded that PPPV is a rare portal vein anomaly that can be easily diagnosed by preoperative imaging. Awareness of PPPV may prevent injury or dissection of this variant vessel, which could result in fatal hemorrhage and liver ischemia. Preoperative diagnosis of PPPV is essential for surgical planning, including the selection of approach and site of dissection of the pancreatic neck, and the choice of resection/reconstruction or isolation depending on the PPPV morphology.In this Special Issue, we aimed to delve into the cutting-edge developments that define the current state of Hepato-Pancreato-Biliary surgery. Our focus encompasses the latest surgical and diagnostic technological breakthroughs in the field of Hepato-Pancreato-Biliary surgery. A field that still rapidly evolving.AM: Conceptualization, Writing &#x2013; original draft, Writing &#x2013; review &amp; editing.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Editorial: Hepato-pancreato-biliary surgery: innovations, genomics, and prognostic management

ObjectivesTo evaluate the clinical presentation, management, and outcomes of bile duct injuries (BDIs) after laparoscopic cholecystectomy (LC).</sec>MethodsThis is a case series of 28 patients with BDIs after LC treated at a tertiary hospital in Vietnam during the 2006-2021 period. The BDI's clinical presentations, Strasberg classification types, management methods, and outcomes were reported.</sec>ResultsBDIs were diagnosed intraoperatively in 3 (10.7%) patients and postoperatively in 25 (89.3%). The BDI types included Strasberg A (13, 46.4%), D (1, 3.6%), E1 (1, 3.6%), E2 (4, 14.3%), E3 (5, 17.9%), D + E2 (2, 7.1%), and nonclassified (2, 7.1%). Of the postoperative BDIs, the injury manifested as biliary obstruction (18, 72.0%), bile leak (5, 20.0%), and mixed scenarios (2, 8.0%). Regarding diagnostic methods, endoscopic retrograde cholangiopancreatography (ERCP) was more useful in bile leak scenarios, while multislice computed tomography, magnetic resonance cholangiopancreatography, and percutaneous transhepatic cholangiography were more useful in biliary obstruction scenarios. All 28 BDIs were successfully treated. ERCP with stenting was very effective in the majority of Strasberg A BDIs. For more complex BDI types, hepaticocutaneous jejunostomy was a safe and effective approach. The in-hospital morbidities included postoperative pneumonia (2, 10.7%) and biliary-enteric anastomosis leakage (1, 5.4%). There was no cholangitis or anastomotic stenosis during the follow-up after discharge (median 18 months).</sec>ConclusionsThe majority of BDIs are type A and diagnosed postoperatively. ERCP is effective for the majority of Strasberg A BDIs. For major and complex BDIs, hepaticocutaneous jejunostomy is a safe and effective approach.</sec>

Objectives: To evaluate the clinical presentation, management, and outcomes of bile duct injuries (BDIs) after laparoscopic cholecystectomy (LC).Methods: This is a case series of 28 patients with BDIs after LC treated at a tertiary hospital in Vietnam during the 2006-2021 period. The BDI's clinical presentations, Strasberg classification types, management methods, and outcomes were reported.Results: BDIs were diagnosed intraoperatively in 3 (10.7%) patients and postoperatively in 25 (89.3%). The BDI types included Strasberg A (13, 46.4%), D (1, 3.6%), E1 (1, 3.6%), E2 (4, 14.3%), E3 (5, 17.9%), D + E2 (2, 7.1%), and nonclassified (2, 7.1%). Of the postoperative BDIs, the injury manifested as biliary obstruction (18, 72.0%), bile leak (5, 20.0%), and mixed scenarios (2, 8.0%). Regarding diagnostic methods, endoscopic retrograde cholangiopancreatography (ERCP) was more useful in bile leak scenarios, while multislice computed tomography, magnetic resonance cholangiopancreatography, and percutaneous transhepatic cholangiography were more useful in biliary obstruction scenarios. All 28 BDIs were successfully treated. ERCP with stenting was very effective in the majority of Strasberg A BDIs. For more complex BDI types, hepaticocutaneous jejunostomy was a safe and effective approach. The in-hospital morbidities included postoperative pneumonia (2, 10.7%) and biliary-enteric anastomosis leakage (1, 5.4%). There was no cholangitis or anastomotic stenosis during the follow-up after discharge (median 18 months).Conclusions: The majority of BDIs are type A and diagnosed postoperatively. ERCP is effective for the majority of Strasberg A BDIs. For major and complex BDIs, hepaticocutaneous jejunostomy is a safe and effective approach.

Clinical presentation, management and outcomes of bile duct injuries after laparoscopic cholecystectomy: a 15-year single-center experience in Vietnam

AimsTo explore the clinical characteristics of patients with symptomatic duodenal diverticula and to generalize how to make appropriate treatment choices for this group of patients.</sec>Materials and methodsFrom January 2010 to September 2020, a total of 647 patients with duodenal diverticula (DD) were included in this study. 345 of them with relevant symptoms were divided into the symptomatic group and the other 302 patients were in the asymptomatic group.</sec>ResultsAmong all patients, most DD were located in the periampullary area, <1 cm in size, and single in number. The distribution of DD localized in the 2nd portion/periampullary (P = 0.002/P < 0.001) and with a 1 cm size cut-off value (P = 0.003) was significantly different between the symptomatic and asymptomatic groups. Multivariate Logistics analysis further suggests that diverticular size (<1 cm, 1–3 cm) and combined biliary comorbidities (bile duct stones and gallstones, primary bile duct stones, cholangitis without bile duct stones) may be factors influencing the choice of treatment modality. Of all patients undergoing surgical treatment, a total of 7 cases developed various postoperative complications, and no one died.</sec>ConclusionsPatients with DD ≥1 cm or located in the periampullary were more likely to be symptomatic. The specific size of the DD and the combination of specific biliary comorbidities may have an impact on the choice of treatment modality.</sec>

Aims: To explore the clinical characteristics of patients with symptomatic duodenal diverticula and to generalize how to make appropriate treatment choices for this group of patients.Materials and methods: From January 2010 to September 2020, a total of 647 patients with duodenal diverticula (DD) were included in this study. 345 of them with relevant symptoms were divided into the symptomatic group and the other 302 patients were in the asymptomatic group.Results: Among all patients, most DD were located in the periampullary area, &lt;1 cm in size, and single in number. The distribution of DD localized in the 2nd portion/periampullary (P = 0.002/P &lt; 0.001) and with a 1 cm size cut-off value (P = 0.003) was significantly different between the symptomatic and asymptomatic groups. Multivariate Logistics analysis further suggests that diverticular size (&lt;1 cm, 1–3 cm) and combined biliary comorbidities (bile duct stones and gallstones, primary bile duct stones, cholangitis without bile duct stones) may be factors influencing the choice of treatment modality. Of all patients undergoing surgical treatment, a total of 7 cases developed various postoperative complications, and no one died.Conclusions: Patients with DD ≥1 cm or located in the periampullary were more likely to be symptomatic. The specific size of the DD and the combination of specific biliary comorbidities may have an impact on the choice of treatment modality.

Evaluation and management of symptomatic duodenal diverticula: a single-center retrospective analysis of 647 patients

IntroductionPrepancreatic postduodenal portal vein (PPPV) is a rare congenital variation, with only 17 cases reported in the literature and five of them undergoing pancreaticoduodenectomy (PD). Of these, four were L-shaped PPPV with a thin wall that was difficult to isolate, while only one normal-shaped PPPV was reported previously. For patients undergoing PD, recognizing this variation is important to prevent PPPV injury, which could lead to liver ischemia or intraoperative hemorrhage. We here present a case of normal-shaped PPPV who underwent PD.</sec>Case presentationA 68-year-old woman underwent PD for bile duct carcinoma at our hospital. Preoperative enhanced CT revealed that the portal vein was located anterior to the pancreas and posterior to the duodenum, and the L-shaped splenic vein was longitudinally located posterior to the pancreatic neck. During surgery, there was a loose tissue area between the PPPV and the pancreatic head, and the PPPV could be isolated safely. The morphology of PPPV was similar to normal portal vein. Due to the presence of the PPPV, a superior mesenteric artery (SMA)-first approach from the anterior was at high risk of vascular injury, and the pancreatic neck could not be dissected at the dorsal face of PV. Therefore, the SMA was revealed by the classic right posterior approach after transection of the pancreatic neck on the dorsal surface of L-shaped spleen vein, and the specimen was successfully resected without significant intraoperative bleeding. The patient was discharged 18 days after surgery without complications. The final pathology was bile duct carcinoma with R0 resection.</sec>ConclusionPPPV is a rare variant that can be diagnosed by preoperative imaging. In PD procedure, knowledge of PPPV helps in surgical decision-making, approach selection and avoid major bleeding due to PPPV injury. The origin of normal-shaped and L-shaped PPPV might be different. Normal-shaped PPPV can be safely isolated in this case.</sec>

Introduction: Prepancreatic postduodenal portal vein (PPPV) is a rare congenital variation, with only 17 cases reported in the literature and five of them undergoing pancreaticoduodenectomy (PD). Of these, four were L-shaped PPPV with a thin wall that was difficult to isolate, while only one normal-shaped PPPV was reported previously. For patients undergoing PD, recognizing this variation is important to prevent PPPV injury, which could lead to liver ischemia or intraoperative hemorrhage. We here present a case of normal-shaped PPPV who underwent PD.Case presentation: A 68-year-old woman underwent PD for bile duct carcinoma at our hospital. Preoperative enhanced CT revealed that the portal vein was located anterior to the pancreas and posterior to the duodenum, and the L-shaped splenic vein was longitudinally located posterior to the pancreatic neck. During surgery, there was a loose tissue area between the PPPV and the pancreatic head, and the PPPV could be isolated safely. The morphology of PPPV was similar to normal portal vein. Due to the presence of the PPPV, a superior mesenteric artery (SMA)-first approach from the anterior was at high risk of vascular injury, and the pancreatic neck could not be dissected at the dorsal face of PV. Therefore, the SMA was revealed by the classic right posterior approach after transection of the pancreatic neck on the dorsal surface of L-shaped spleen vein, and the specimen was successfully resected without significant intraoperative bleeding. The patient was discharged 18 days after surgery without complications. The final pathology was bile duct carcinoma with R0 resection.Conclusion: PPPV is a rare variant that can be diagnosed by preoperative imaging. In PD procedure, knowledge of PPPV helps in surgical decision-making, approach selection and avoid major bleeding due to PPPV injury. The origin of normal-shaped and L-shaped PPPV might be different. Normal-shaped PPPV can be safely isolated in this case.

Pancreaticoduodenectomy performed for a patient with prepancreatic postduodenal portal vein: a case report and literature review

BackgroundEndoscopic retrograde cholangiopancreatography is a common procedure performed for choledocholithiasis and gallstone pancreatitis. Although a relatively low risk procedure, it is not without its complications. Cases of impacted Dormia baskets during stone retrieval have been reported, but these are usually retrieved surgically during the same setting.</sec>Case summaryA 40-year-old man presented to our hospital with an episode of epigastric pain and discomfort. He has a prior background of recurrent episodes of pancreatitis of which he underwent prior endoscopic therapy in his home country. Initial investigations revealed a metallic object seen on abdominal x-ray, computer tomographic scan of the abdomen and pelvis, and magnetic resonance imaging of the pancreas. Further evaluation was done with endoscopy, which revealed a retained stone extraction basket from a previous endoscopic retrograde pancreatography, resulting in recurrent episodes of acute chronic pancreatitis. Although the retained foreign body was removed, he subsequently developed further complications of portal vein thrombosis as a result of recurrent acute chronic pancreatitis, which required anticoagulation.</sec>ConclusionThis case highlights the importance of retrieving any foreign body from the pancreas, especially on the head, to prevent the development of further complications.</sec>

Background: Endoscopic retrograde cholangiopancreatography is a common procedure performed for choledocholithiasis and gallstone pancreatitis. Although a relatively low risk procedure, it is not without its complications. Cases of impacted Dormia baskets during stone retrieval have been reported, but these are usually retrieved surgically during the same setting.Case summary: A 40-year-old man presented to our hospital with an episode of epigastric pain and discomfort. He has a prior background of recurrent episodes of pancreatitis of which he underwent prior endoscopic therapy in his home country. Initial investigations revealed a metallic object seen on abdominal x-ray, computer tomographic scan of the abdomen and pelvis, and magnetic resonance imaging of the pancreas. Further evaluation was done with endoscopy, which revealed a retained stone extraction basket from a previous endoscopic retrograde pancreatography, resulting in recurrent episodes of acute chronic pancreatitis. Although the retained foreign body was removed, he subsequently developed further complications of portal vein thrombosis as a result of recurrent acute chronic pancreatitis, which required anticoagulation.Conclusion: This case highlights the importance of retrieving any foreign body from the pancreas, especially on the head, to prevent the development of further complications.

Retained stone retrieval basket causing chronic pancreatitis: a case report

Peptic ulcer disease (PUD) is a very common condition, with an annual incidence ranging from 0.1% to 0.3% and a lifetime prevalence ranging from 5% to 10%. If not treated, it can lead to severe complications such as gastro-intestinal bleeding, perforation, or entero-biliary fistula. Entero-biliary fistulas and especially choledocho-duodenal fistula (CDF) are a rare, but relevant and important diagnosis, which can lead to several complications such as gastric outlet obstruction, bleeding, perforation, or recurrent cholangitis. In this article, we present the case of an 85-year-old woman with PUD complicated with gastro-intestinal bleeding and a CDF. We also performed a review of the literature to search for pre-existing cases with this atypical clinical presentation. The aim was to raise awareness among surgeons and clinicians by offering a summary of different types of entero-biliary and especially CDF, existing diagnostic investigations, and management.

Peptic ulcer disease (PUD) is a very common condition, with an annual incidence ranging from 0.1% to 0.3% and a lifetime prevalence ranging from 5% to 10%. If not treated, it can lead to severe complications such as gastro-intestinal bleeding, perforation, or entero-biliary fistula. Entero-biliary fistulas and especially choledocho-duodenal fistula (CDF) are a rare, but relevant and important diagnosis, which can lead to several complications such as gastric outlet obstruction, bleeding, perforation, or recurrent cholangitis. In this article, we present the case of an 85-year-old woman with PUD complicated with gastro-intestinal bleeding and a CDF. We also performed a review of the literature to search for pre-existing cases with this atypical clinical presentation. The aim was to raise awareness among surgeons and clinicians by offering a summary of different types of entero-biliary and especially CDF, existing diagnostic investigations, and management.