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Page 4 of 11 Wong et al. Hepatoma Res 2021;7:45 https://dx.doi.org/10.20517/2394-5079.2021.28

in 1:2 ratio accordingly. Survival outcomes in the 2 groups were then compared. Statistical significance was
denoted by P < 0.05. The computer software SPSS/PC+ (SPSS, Chicago, IL) was used for all statistical
calculations.

RESULTS
A total of 911 hepatectomies were performed for the management of HCC, and among them 320 patients
aged over 65 years old were identified. Seventy-nine patients (25%) underwent pure laparoscopic
hepatectomies and 241 patients (75%) underwent open procedure. After comparing confounding factors
between the two groups, significant differences in pre-operative aspartate transaminase, albumin, and
magnitude of hepatectomy were identified between the groups. Propensity score matching was performed
based on the variables above. Forty-six patients in the laparoscopic group and 92 patients in the open group
were included in the study after propensity score matching. Three patients in the open group had initial
laparoscopic approach before converting to open hepatectomy due to dense adhesions. There were no
significant differences with regard to age, gender, Child grading of liver function, hepatitis status, and
premorbid comorbidities. Almost all patients included in the study had cirrhosis with no differences
between the groups. Cardiovascular disease was the most common comorbid condition in both groups. A
comparison of baseline characteristics between the 2 groups can be viewed in Table 1.

Operative data and surgical outcomes between the groups were shown in Table 2. The magnitude and type
of resection were similar between the groups. The laparoscopic group showed a shorter operative time
(laparoscopic: 196 min vs. open: 274 min; P < 0.001), less blood loss (laparoscopic: 0.1 L vs. open: 0.5 L; P <
0.001), and shorter hospital stay (laparoscopic: 5 days vs. open: 8 days; P < 0.001). There were no significant
differences in blood transfusion requirement and postoperative complications. Postoperative ICU was
required for 13 patients in the laparoscopic group and 41 patients in the open group. There was no
difference in the median length of ICU stay. No hospital mortality was observed in both groups.

Regarding postoperative complications, there were 5 events in the laparoscopic group and 22 events in the
open group. One patient in the open group had biliary leakage requiring endoscopic
cholangiopancreatography (ERCP) and stenting. Two patients with open resection developed significant
ascites postoperatively requiring paracentesis to relieve abdominal distension. Postoperative pulmonary
embolism was noted in 2 patients in the open group who were treated conservatively with intravenous
heparin infusion. In contrast, all complications in the laparoscopic group were of Clavien-Dindo type I to II
which did not require surgical intervention. None of the patients included in the study developed cardiac or
liver failure.

A comparison between pathological characteristics between 2 groups were demonstrated in Table 3. The
groups had no significant differences in tumour number, tumour-node-metastasis staging, or Edmonson
grading. A smaller tumour size was observed in the laparoscopic group (3.3 cm in laparoscopic group vs.
4 cm in open group; P = 0.003). On final pathological examination, all patients in the laparoscopic group
had R0 resection. This was also achieved in all but 1 patient in the open group.

The median follow-up period for the study population was 51.4 months. The disease-free survival curve and
overall survival curve were demonstrated in Figure 1 and Figure 2, respectively. The median overall survival
was 85.1 months in the laparoscopic group and 75.4 months in the open group. The 1-, 3-, and 5-year
overall survival rates were 97.8%, 88.9%, and 74.7%, respectively, in the laparoscopic group, and 93.2%,
76.8%, and 64.1%, respectively, in the open group (P = 0.22). The median disease-free survival were more
than 95 months in the laparoscopic group and 48.1 months in the open group. The 1-, 3- and 5-year