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Yuu et al. Mini-invasive Surg 2019;3:6 I http://dx.doi.org/10.20517/2574-1225.2018.73 Page 7 of 9

ODG groups, respectively, which is lower than the overall rate. This may be because elderly patients have
concurrent ailments that affect prognosis and survival. Indeed, in the present study, 49 patients (81.7%) had
preoperative comorbid diseases. Concurrent disease was the cause of death in 2 patients in the LDG group
and in 4 patients in the ODG group. Since elderly patients are expected to have a shorter residual life span,
quality of life should also be considered when choosing a surgical procedure [31,32] .

The elderly patients in the ODG group were more likely to require inpatient rehabilitation due to their
diminished mobility and more persistent postoperative wound pain, which seriously hamper the recovery
[33]
of activities of daily living . Prolonged hospitalization after surgery can lead to worse quality of life in
elderly patients. Several reports have demonstrated that laparoscopic surgery leads to a faster return to a
full diet and a shorter postoperative hospital stay, as shown in our own study. These data indicate that LDG
may be superior to conventional open surgery in terms of the length of the hospital stay, even for advanced
gastric cancer.

Our overall rate of postoperative complications was higher than that in previous studies on the overall
[30]
gastric cancer patient population. Hu et al. reported a postoperative complication rate of 10.2% in 1,184
patients with advanced gastric cancer. The most common major complication in the LDG group was
[34]
pancreatic fistula, which tends to reflect surgical inexperience and a learning curve . Pancreatic fistulas
occurred in 3 patients undergoing LDG in 2010, the year we started performing D2 lymphadenectomy.
As experience accumulates, the incidence rate of major pancreatic fistulas may decrease. Although the
mortality rate was not significantly different between the 2 groups, 4 deaths occurred in the ODG group,
suggesting that radical gastrectomy may sometimes be excessively stressful for elderly patients, especially
those with advanced gastric cancer. Surgery should be performed more meticulously and quickly than
usual in elderly patients. The choice of surgical procedure in elderly patients with short life expectancies
[35]
must guarantee disease control as well as acceptable short- and long-term survival and quality of life .
Our study had some limitations inherent to retrospective and non-randomized studies, where selection
and observer biases with regard to the operative approach adopted are possible. Furthermore, our study
was limited by the small number of cases. Surgeons may have encouraged earlier discharge of the patients
in the LDG group. A high-volume, prospective, and randomized study is needed to confirm our findings.

According to the Japanese gastric cancer treatment guidelines, laparoscopic surgery is one of the most
reliable treatments for early gastric cancer. It is important to determine whether elderly patients with
advanced gastric cancer can benefit from laparoscopic surgery. Our results demonstrated that LDG for
advanced gastric cancer in patients older than 75 years was associated with lesser intraoperative blood loss
and shorter hospital stays than ODG, with no differences in survival. Patient age alone should not rule out
the feasibility of either LDG or ODG.

DECLARATIONS
Acknowledgments
We are grateful to the study participants and their caregivers. The authors thank participating surgeons
from the Bell Land General Hospital. We would like to thank Editage (www.editage.jp) for English
language editing.

Authors’ contributions
Designed the study and acquisition, analysis, and interpretation of the data: Yuu K
Collected the data: Yuu K, Tsuchihashi K, Toyoda S, Kawasaki M
Supervised this study: Kameyama M