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Page 6 of 9 Yuu et al. Mini-invasive Surg 2019;3:6 I http://dx.doi.org/10.20517/2574-1225.2018.73

Table 4. Pathological data of the LDG group and ODG group
LDG group (n = 20) ODG group (n = 40) P value
Depth of invasion 0.156
pT1 0 0
pT2 8 6
pT3 2 3
pT4a 9 27
pT4b 1 4
Nodal catalog 0.215
pN0 8 11
pN1 3 9
pN2 5 3
pN3a 3 10
pN3b 1 7
Stage 0.62
IA 0 0
IB 4 3
IIA 1 4
IIB 6 8
IIIA 3 4
IIIB 1 4
IIIC 4 11
IV 1 6
Diameter of tumor (cm) 5.9 ± 2.2 6.1 ± 2.2 0.762
Number of lymph node removed 35.5 (14-65) 33.5 (5-96) 0.994
Number of positive lymph node metastasis 2 (0-12) 2.5 (0-47) 0.213

LDG: laparoscopic distal gastrectomy; ODG: open distal gastrectomy

LDG for advanced gastric cancer was shown to be more effective than open surgery in elderly patients, resulting
in reduced blood loss, faster first oral diet initiation, and shorter hospital stays. Conversely, the longer operative
time may lead to a higher rate of morbidity, including delirium, pneumonia, and cardiac failure. Acute cardiac
failure and pneumonia are the most common minor complications of distal gastrectomy for gastric cancer.
Some reports have suggested that the adverse cardiopulmonary effects of pneumoperitoneum occur only when
the intra-abdominal pressure is more than 15 mmHg, while low pressures do not affect cardiopulmonary
output [23-25] . Therefore, laparoscopic surgery may be safe even in high-risk patients. However, the operative
time was longer in the LDG group than in the ODG group, and longer operative times are associated with
[26]
postoperative delirium and pneumonia . Our results revealed no significant differences in postoperative
morbidities, suggesting that high-risk patients, including the elderly may be able to tolerate the prolonged
laparoscopic operative times. In accordance with previous reports, laparoscopic surgery led to a faster return to
[27]
a full diet and a shorter postoperative hospital stay in our study .

In fact, a shorter abdominal incision leads to less pain and, subsequently, earlier ambulation. Early
[28]
ambulation may prevent postoperative delirium as evidenced by the findings of Schweickert et al. , who
found a shorter duration of intensive care unit-associated delirium in patients who received physical and
occupational therapy. Since postoperative pain is one cause of delirium, less pain after surgery may help
[29]
prevent postoperative delirium . Therefore, it is more important to reduce pain after surgery than to
shorten operative time, especially in elderly patients. In addition, early ambulation prevents pneumonia
resulting from atelectasis. Based on these advantages, LDG may provide superior short-term outcomes in
elderly patients with advanced gastric cancer.

A 2011 report stated that the average life expectancy at 80 years in Japan had increased by 8.39 years in
[2]
men and 11.36 years in women. However, Endo et al. reported that the overall survival of gastric cancer
patients was longer in the operation group than in the best supportive care group. The oncologic results
of LDG in elderly patients have not been determined. In a study of the overall gastric cancer patient
[30]
population, Hu et al. reported that the cumulative 3-year overall survival rate after laparoscopy-assisted
gastrectomy for advanced gastric cancer was 75.3%; in our study, it was 50.1% and 41.7% in the LDG and