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Page 2 of 11 Wong et al. Hepatoma Res 2021;7:45 https://dx.doi.org/10.20517/2394-5079.2021.28

= 0.041), and a trend towards better overall survival compared with the open group. (78.4% vs. 64.8%; P = 0.110).

Conclusion: Laparoscopic liver resection is a safe approach for elderly patients with HCC with benefits from faster
recovery and better oncological outcomes.

Keywords: Hepatectomy, open hepatectomy, laparoscopic liver resection, open liver resection, elderly,
hepatocellular carcinoma, propensity score matching analysis

INTRODUCTION
With an aging population and increasing life expectancy, a growing incidence of hepatocellular carcinoma
(HCC) in elderly population is expected. Pre-existing comorbidities and a diminished physiological reserve
add additional concern for surgeons and anaesthetists on the planning of operations. Although open liver
resection is a feasible modality in the elderly, 5%-40% postoperative morbidity and up to 13% hospital
mortality were reported . Laparoscopic liver resection has gained momentum in worldwide centres. Its
[1,2]
benefits from earlier recovery, reduced blood loss and shortened hospital stay has been recognized in
previous consensus conference, and has now become the standard of practice for minor liver resection .
[3-7]
Previous studies have shown that minimally invasive liver resection appears to be a safe and feasible option
in elderly patients with malignant liver lesions [8-10] . Nonetheless, it remains unclear if similar results can be
[11]
attained in elderly HCC patients, in particular on oncological outcome . The aim of the study was to
review on the short-term and long-term outcomes of elderly patients undergoing laparoscopic
hepatectomies for HCC compared with conventional open approach. Propensity score matched analysis
was performed to reduce the heterogeneity arising from selection bias and to increase the level of evidence
in a nonrandomized observational study.

METHODS
From 1st January 2008 to 1st January 2019, a total of 911 hepatectomies were performed for HCC in the
Department of Surgery, Queen Mary Hospital, the University of Hong Kong. Of those patients, 320 patients
aged over 65 years old were included for analysis. Data on pre-operative characteristics, intraoperative
information and postoperative outcomes were reviewed. Patients were divided in two groups based on the
mode of resection, the laparoscopic and the open liver resection groups. Propensity score matching with the
nearest neighbouring method was conducted in 1:2 ratio between the laparoscopic and the open group
before comparison. After matching, 46 patients in the laparoscopic group and 92 patients in the open group
were included in this study.

Preoperative evaluation
For assessment of risk of operation and anaesthesia, a cardiopulmonary workup in the form of
electrocardiogram and spirometry was undertaken for elderly patients. For patients with a high index of
suspicion for occult cardiopulmonary disease, an echocardiogram and/or lung function test was performed.
Patients’ functional status and comorbid conditions were taken into account before surgery was offered.
Liver resection was not offered to patients with an American Society of Anesthesiologists score ≥ 3 or with
significant comorbidities such as ischaemic heart disease, congestive heart failure, recent stroke, and chronic
obstructive pulmonary disease.

Resectability of HCC was assessed by imaging in the form of contrast-enhanced computed tomography or
magnetic resonance imaging, and treatment plan were discussed in a multi-disciplinary meeting. Patients
with main portal vein invasion and/or distant metastasis were deemed unsuitable for resection, and were
referred to oncologist. Laparoscopic approach was considered for tumours as per chief surgeon’s discretion.