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Brolese et al. Hepatoma Res 2020;6:34 I http://dx.doi.org/10.20517/2394-5079.2020.15 Page 13 of 15

different countries of studies. We incorporated heterogeneity by performing random effect model meta-
analyses. On the contrary, the small numbers of the studies included did not allow us to further explore
heterogeneity with subgroup analyses and meta-regression.

Moreover, due to the limited number of the studies included in the quantitative analyses, we were unable to
properly verify if publication bias was present. Finally, we observed that our systematic review pooled papers
with different study populations. Indeed, two reports included a small number of patients [19,20] ; however, on
the other hand, two main studies analyzed very large populations [21,23] .

To conclude, the scientific literature shows the presence of other systematic reviews on this topic. However,
all these secondary studies are characterized by different study selection criteria, outcomes, and populations.
Consequently, we believe that our paper could add value to the HCC surgical literature, especially because it
assessed a very large number of key outcomes.

In conclusion, this study provides an overview of the last ten years about the comparison between MILR
and OLR for HCC treatment in elderly patients. Meta-analyses confirmed the advantages of MILR, both
laparoscopic and robotic, in terms of perioperative outcomes, where it may promote the extension of liver
resection to HCC patients with borderline liver function. Specifically, our results showed shorter LOS, less
intraoperative blood loss and lower morbidity rate in MILR. Moreover, major resections were significantly
more common in the OLR group compared to the MILR group. There were no significant differences in
survival and recurrence outcomes between the two groups.

According to our results, MILR, which minimizes surgical trauma, must be considered as an important
treatment option with significant quality of life benefits in the elderly, showing hopefully one of its best
advantages in this fragile population. Efforts should be made to avoid as much as possible OLR in this
population. However, randomized controlled trials or well-designed large prospective comparative studies
would be necessary to definitely support the superiority of MILR in elderly patients with HCC.

DECLARATIONS
Authors’ contributions
Study conception and design of the work: Brolese A, Ciarleglio FA
Literature search, acquisition, selection and reading: Brolese A, Rigoni M, Vitale A, de Pretis G, Avancini
I, Pravadelli C, Frisinghelli M, Rozzanigo U, Luppi G, Dionisi F, Marcucci S, Viel G, Beltempo P, Prezzi C,
Frisini M, Brolese M, Nollo G, Ciarleglio FA
Screening of the papers and data extraction from the selected studies: Rigoni M, Ciarleglio FA
Data analysis and statistical evaluation: Rigoni M, Nollo G
Interpretation of data for the work: Brolese A, Rigoni M, Vitale A, Nollo G, Ciarleglio FA
Drafting the work or revising it critically for important intellectual content: Brolese A, Rigoni M, Ciarleglio FA
Final approval of the version to be published: Brolese A, Rigoni M, Nollo G, Ciarleglio FA

Availability of data and materials
The datasets generated and/or analyzed during the current study are awailable in the cited current literature
or websites (PubMed and Cochrane).

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.