Long-term muscle-sparing benefits of proximal gastrectomy in elderly patients with upper-third early gastric cancer: A propensity score-matched analysis

BACKGROUND: As the global population ages, surgical strategies must shift from focusing solely on cancer control to prioritizing functional longevity. Laparoscopic proximal gastrectomy (LPG) has emerged as a potential organ-preserving alternative to laparoscopic total gastrectomy (LTG) for early upper-third gastric cancer (GC). However, the comparative efficacy of LPG versus LTG in elderly patients remains uncertain, as this population is more vulnerable to surgical stress due to age-related multimorbidity and frailty. METHODS: We conducted a retrospective analysis of patients aged ≥65 years who underwent either LPG with double-tract reconstruction (LPG-DTR) or LTG for upper-third cT1-2N0M0 GC between January 2018 and December 2021. Propensity score matching (PSM) was used to mitigate selection bias, generating comparable cohorts (n = 51 per group). Comparative analyses focused on perioperative outcomes and longitudinal nutritional parameters, quantified by percentage body weight loss (BWL) and skeletal muscle index (SMI) over 3 postoperative years. RESULTS: LPG-DTR and LTG demonstrated similar surgical outcomes, including operative time, blood loss, and hospitalization, with comparable early and late complication rates. Over the 3-year follow-up, LPG-DTR exhibited significantly superior skeletal muscle preservation compared to LTG, as evidenced by smaller declines in the SMI at Year 2 (-5.89 % vs. -9.54 %, P = 0.011) and Year 3 (-7.23 % vs. -10.69 %, P = 0.039). Additionally, the LPG-DTR group had less pronounced body weight loss at the 2 year (-4.71 % vs. -9.55 %, P = 0.031) and 3 year (-5.63 % vs. -10.2 %, P = 0.011) postoperatively. The risk of severe skeletal muscle loss increased over time, particularly in patients older than 75 (OR 2.05, P = 0.025), those who underwent LTG (OR 1.89, P = 0.031), and males (OR 3.73, P = 0.006). Both groups had similar 3-year overall survival rates (86.3 % vs. 88.2 %, P = 0.777), with age >75 (HR 2.946, P = 0.012) and preoperative sarcopenia (HR 1.795, P = 0.039) being independent predictors of poorer survival. CONCLUSION: These findings suggest that LPG-DTR is as safe as LTG, offering superior preservation of skeletal muscle mass and nutritional status without compromising oncological outcomes. LPG-DTR may provide a function-preserving alternative for treating elderly patients with upper-third early GC.