Hepatopancreaticoduodenectomy for biliary cancer: operative strategies determine near-zero operative mortality, but tumor biology determines an acceptable long-term outcome

We would like to congratulate Aoki et al. on their promising surgical and oncological outcomes of performing the complicated multi-organ curative resection for biliary cancer, so-called hepatopancreaticoduodenectomy (HPD) (1). HPD depicts one of the most challenging surgical procedures aiming to resect neoplasm occupying the zone around hepatoduodenal ligament in the en bloc fashion. The essence of HPD, when being applied to bile duct cancer, is to completely remove the extrahepatic bile ducts to the level of hepatic hilum (2). For locally advanced gallbladder neoplasm, HPD should also be a rational resection to the extent which could include either longitudinally to liver bed/duodenum, or laterally to hepatic hilum/extrahepatic bile duct. In 1990’s, HPD was mainly applied to patients with locally advanced gallbladder cancers (3,4). Similar to the early period of our 30-year experience (unpublished data), we performed HPD as a curative resection for patients with gallbladder cancer invasion to both the liver and the duodenum but the outcome and prognosis were unsatisfactory, when compared with those with bile duct cancer.