[Rethinking the surgical treatment of hepatobiliary malignancies in the immunotherapy era]

The rapid progress in cancer immunology and immunotherapy has transformed the paradigm of surgical treatment for hepatobiliary malignancies. Comprehensive treatment strategies based on immunotherapy have been applied for downstaging and conversion treatment, allowing more advanced-stage patients to undergo radical or curative surgery; it has also become a new approach for neoadjuvant and adjuvant therapy. The following points deserve attention: (1) The "dual nature" of surgical treatment：it can "cure" primary malignancies, but also induce perioperative immune suppression through various mechanisms and promote postoperative metastatic recurrence. Minimizing surgical stress is the theoretical basis and advantage of the minimally invasive concept in surgical oncology. (2) Targeting the "surgical immune suppression" is a novel way to combat postoperative metastatic recurrence: the combination of neoadjuvant and adjuvant immunotherapy is a new trend. (3) Traditional lymph node dissection may impair immune responses and immunotherapy outcomes; selective preservation of regional lymph nodes can be a promising approach. For certain subgroups of patients, preoperative therapy leading to complete remission (immunological ablation) raises the possibility of organ-sparing and de-escalation of surgery.