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Page 6 of 8 David et al. Hepatoma Res 2018;4:2 I http://dx.doi.org/10.20517/2394-5079.2017.51

A B
1.0 1.0

0.8 0.8

Overall survival 0.6 LLR OLR Disease-free survival 0.6 OLR

0.4
0.4
P = 0.583
0.2 0.2 P = 0.947
LLR
0.0 0.0
0.0 25.0 50.0 75.0 100.0 125.0 0.0 25.0 50.0 75.0 100.0 125.0
Months Months
Figure 1. Overall survival andrecurrence-free survival for laparoscopic and open liver resection for intermediate stage BCLC-B
hepatocellular carcinoma. A: Overall survival. B: Recurrence-free survival for laparoscopic and open liver resection for intermediate stage
BCLC-B hepatocellular carcinoma. Solid line: open liver resection (blue line); dot line: lap liver resection (green line). The OS at 1, 3 and
5 years for LLR was 89.1%, 70.4% and 58.6%, respectively; and 76.2%, 55.9% and 43.5%, respectively for OLR (P = 0.583). The 1-, 3-
and 5-year DFS was 59.3%, 20.2% and 16.2% for the LLR group and 51.0%, 44.6% and 37.2% for OLR groups, respectively (P = 0.947).
LLR:laparoscopic liver resection; OLR: open liver resection; BCLC: Barcelona Clinic Liver Score

survival was higher in patients who received surgical resection compared to those who received non-surgical
therapy (50.9 vs. 22.1 months), with an overall 5-year survival of 63% in the resection group. This is in part
due to recent advances in surgical devices and techniques and improved perioperative care, with some high-
[12]
volume centers reporting surgical mortality rates as low as 0.8% .
However, because of the underlying liver disease concomitant with HCC, patients undergoing open liver
resection are still at a high risk of developing significant postoperative complications . LLR, since its
[2]
inception in 1993, is currently being considered as a feasible, safe and less invasive alternative to open
surgery in the case of malignant hepatic tumors . Particularly, the benefit of LLR is more pronounced
[13]
in this population of cirrhotic patients, despite initial studies that considered it a contraindication. The
minimally invasiveness of LLR may decrease the risk of peri-operative complications and mortality , as
[9]
evidenced by our present study wherein the LLR group was associated with a lower rate of post-operative
complications. In terms of mortality, there was no observed 90-day post-operative mortality in both the LLR
[13]
and OLR groups. Previous studies have shown longer operative times for laparoscopic surgery , and this is
also consistent with our study because most of the cases included were done during the early phase of LLR.

Adequacy of resection margin, which was initially a limitation for laparoscopic surgery due to the inability
of direct palpation of tumor, has been overcome by the use of intraoperative Doppler ultrasonography, and
has greatly facilitated the achievement of good oncologic outcomes. Indeed as shown in our present study,
tumor-free margins on pathological examination were similar between the LLR and OLR group, and this is
[13]
consistent with results of previous studies .
The high propensity of HCC for recurrence after resection is well-documented, with reported recurrence
rates ranging from 70% to 100%; among several factors, number of tumors was noted to be the most
significant predictor. Indeed, previous data have shown that the 5-year DFS rates after surgical resection for
[12]
multiple HCCs ranges from 0 to 26% . This is consistent with our present study, which revealed comparable
5-year DFS rates for both the LLR and OLR group at 16.2% and 37.2%, respectively, despite the presence
of multiple tumors for both treatment groups. Also, our study showed that liver resection was associated
with 5-year OS rates of almost 60% for the LLR group and 44% for the OLR group, despite the presence of
multiple, large tumors.