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David et al. Hepatoma Res 2018;4:2 I http://dx.doi.org/10.20517/2394-5079.2017.51 Page 3 of 8

was preferred for larger tumors or where tumor was in proximity to major vascular structures, requiring
formal anatomical resection, otherwise non-anatomical resection was performed when adequate margins
could be achieved. Standard vascular staping devices were used for both OLR and LLR when required, and
combination of ultrasonic dissection using cavitron ultrasonic surgical aspirator and harmonic scalpel was
used for parenchymal transection. Glissonian approach and individual approach were used to isolate and
resect the hilar structures.

Clinical outcomes
Patient demographics, including age, gender, body mass index (BMI), previous abdominal surgery,
RFA ortranscatheter arterial chemoembolization (TACE), and Child-Turcott-Pugh classification were
recorded. Peri-operative outcomes included intraoperative and post-operative complication rate, severity
of complications based on Clavien-Dindo classification, type of hepatic resection, resection margin
status, estimated blood loss, length of stay, total operative time (incision to closure time), and amount of
transfusion. Histological analysis of resected HCC specimens was also assessed, including the Edmondson
histological grade, PT staging, microvascular invasion, tumor number, and maximal tumor diameter.

Follow-up, survival and recurrence
After resection, patients were followed up 1 month after surgery, then every 3 months in the first 2 post-
operative years and then at 6-month intervals for post-operative years 3 to 5, using serum a-feto-protein
(AFP), with multi-phase contrast enhanced CT or magnetic resonance imagin (MRI), or Gadoxetate disodium
(Gd-EOB-DTPA) enhanced MRI of the liver.

The OS was calculated from the day of surgery until the day of death or last contact. The recurrence-free
survival of patients who recurred was defined as the time from the day of surgery to the day of imaging
study that confirmed tumor recurrence.

Statistical analysis
Descriptive statistics were reported as a mean with standard deviation for continuous variables, and as
a number and percentage for discrete variables. OS and recurrence-free survival were calculated by the
Kaplan-Meier method and differences were compared by the log-rank test. Statistical significance was
defined as P < 0.05. Statistical analysis was carried out using SPSS software (version 20; SPSS, Chicago, IL,
USA).

RESULTS
Clinicopathologic characteristics of patients with BCLC stage B according to treatment group
Demographics and peri-operative outcomes according to treatment group are shown in Table 1. Six out of
28 patients required conversion from a laparoscopic to open resection. There was no statistical difference
between these groups in terms of age, gender, BMI, history of previous abdominal surgery, biochemistry
profiles (albumin, bilirubin, prothrombin, AST and ALT levels, platelet), and preoperative AFP levels.

Majority of resections in the LLR group were minor resections (75.0% vs. 38.1%, P = 0.009). The LLR group
had longer mean operation time (350 vs. 339 min, P = 0.066) and higher estimated blood loss (1707 vs. 1055 mL,
P = 0.039). However, LLR group was able to achieve R0 resection in all resections, compared to 81.0% in the
OLR group.

Histological findings
There were a greater proportion of cirrhotic patients in the LLR and OLR groups (67.9% vs. 42.9%,
respectively, P = 0.080) [Table 2]. Although the OLR group had significantly greater mean tumor diameter
(P = 0.048), there was no significant difference between the number of tumors removed in both treatment
groups (P = 0.074). There was also no statistically significant difference of resection margin, presence of
microvascular invasion and Edmondson-Steiner grading between LLR and OLR groups (P = 0.649, 0.740 and