Evolving patterns of hepato-pancreato-biliary surgery in the immunotherapy era.

Introduction: Immunotherapy has revolutionized cancer treatment with remarkable outcomes, expanding treatment options and enabling new surgical opportunities for patients with previously unresectable disease. This descriptive study examines the impact of immunotherapy on the volume and nature of hepato-pancreato-biliary (HPB) surgeries in a large referral center and reviews the current literature. Methods: Analysis included consecutive surgeries performed in a referral HPB unit between January 1, 2020, and June 1, 2025. Patients undergoing HPB surgery following immunotherapy-based treatment, in clinical scenarios historically infrequently considered for surgery, were identified. Surgical volume trends, indications, perioperative outcomes, and oncologic follow-up were assessed. Results: Of 1,306 surgeries, 22 (1.6%) were performed in patients who received immunotherapy-based treatment prior to surgical consideration. The proportion of these patients increased from 0.71% in 2020 to over 4% in 2025. Surgical indications were divided into three main patterns; patients who were downstaged to resectability, those in whom the primary disease was controlled by immunotherapy and developed new resectable cancer, and those in whom surgery was used as an adjunct to immunotherapy. Notably, the proportion of complex procedures increased over the study period, reflecting growing surgical experience and confidence in the durability of immunotherapy responses. Discussion: Immunotherapy is reshaping the role of HPB surgery by expanding the spectrum of clinical scenarios in which surgical intervention may be considered. These findings highlight the evolving integration of surgery within multidisciplinary cancer care in the immunotherapy era and the need for refined patient selection and clearer operative indications.