In the present study, the blood loss and the incidence of postoperative complications were significantly lower in the LG group than OG group in the elderly patients. The 5-year DSS rate in the LG group was better than that in the OG group because of the higher frequency of patients with advanced gastric cancer in the OG group. In comparison between the elderly and non-elderly LG groups, there were no significant differences in the pathological findings and short-term outcomes. Further, although the 5-year OS rate in the elderly group was worse than that in the non-elderly group, there was no significant difference between the two groups in 5-year DSS. These results showed that LG for elderly patients with gastric cancer is technically safe and less invasive than OG and is also oncologically safe, same as non-elderly patients.
For elderly patients undergoing LG, it is generally considered that special attention must be paid because of their reduced organ function and increased co-morbidities, such as cardiac, pulmonary, and renal diseases. However, some studies suggested that LG for elderly patients with gastric cancer offers several clinical advantages over OG, as in non-elderly patients. Honda et al. reported in the first and largest prospective cohort study conducted in Japan that LG shortened the length of the postoperative hospital stay more than did OG in elderly patients with gastric cancer . Tanaka et al. described that LG was safe and had some advantages such as lower complication rate and faster recovery than OG in propensity-matched patients aged over 80 years . In the present study investigating the advantages and disadvantages of LG compared to OG in the elderly, we also showed that short-term outcomes including blood loss and the incidence of postoperative complications were better in the LG group than those in the OG group. It is general knowledge that a reduction in intraoperative blood loss leads to a decrease in postoperative complications . Consequently, the length of hospital stay in LG group was also shorter than that in the OG group, which suggests that LG in elderly patients is not only safe but also less invasive. We believe that LG for elderly patients is a useful surgical procedure that can reduce postoperative complications.
Gastrectomy for elderly patients with gastric cancer is remarkably associated with a higher incidence of postoperative pneumonia, which can lead to lowering of the quality of life and postoperative death [21, 22]. Therefore, many surgeons are concerned that elderly patients have a limited capacity to tolerate gastrectomy. As well, more attention has been paid in recent years to preoperative evaluation of conditions such as sarcopenia and frailty in elderly patients [19, 23]. Kim and Kim used propensity score matching to investigate the outcomes of LG in very elderly gastric cancer patients whose age exceeded the average lifespan of the Korean population . They reported that only pulmonary complications were more frequent in this elderly group. In their meta-analysis, Pan et al. also showed that elderly patients with gastric cancer were associated with a higher rate of pulmonary complications following LG . We also investigated whether there were any postoperative complications peculiar to the elderly undergoing LG by comparison between the LG-E and LG-NE groups. The proportion of overall comorbidities was higher in the LG-E group than that in the LG-NE group. However, there were no significant differences in the incidences of postoperative complications directly attributable to poor functional capacity, such as postoperative pneumonia, between the two groups. Other authors showed similar results. Komori et al. reported that the short-term outcomes after gastrectomy without regard to approach were almost equal between non-elderly and elderly patients . Mikami et al. also showed that there were no differences in short-term outcomes including postoperative morbidity between elderly and non-elderly patients who underwent LG . Our results showed that the rate of postoperative complications in the elderly patients did not increase compared with that in the non-elderly patients, despite the higher incidence of comorbidities in the elderly patients. We believe that LG is more suitable for elderly patients with gastric cancer because LG helps to prevent postoperative pulmonary complications.
We also investigated whether LG would worsen the prognosis in the elderly. Our study showed that although the 5-year OS rate in the elderly group was worse than that in the non-elderly group, there was no significant difference in 5-year DSS rate between the two groups. There is little evidence on the long-term outcomes of LG compared to short-term outcomes in the elderly gastric cancer patients. Some studies reported that long-term outcomes of elderly patients in a laparoscopic group were similar to those for non-elderly patients [28, 29]. Shimada et al. showed that although 5-year OS was significant lower in the elderly group than in the non-elderly group, 5-year DSS was similar in the two groups, as with our results . Ushimaru et al. reported that although DSS was similar between the laparoscopic and open groups among young and elderly patients, the laparoscopic group was associated with more favorable OS than the open group only among the elderly patients because of the lower number of deaths from respiratory diseases . Some reports indicated that the incidence of postoperative complications was an important factor that influenced long-term outcomes [24, 32–34]. In the present study, the incidence of postoperative complications after LG was equal between the elderly and non-elderly patients. Therefore, we consider that LG without severe postoperative complications tends to lead to a good prognosis. To ensure favorable long-term outcomes in elderly patients after LG, surgeons need to carefully perform both the operation and perioperative intensive care to prevent postoperative complications.
There are some limitations in this study. First, this retrospective study was conducted in a single low-volume center. Second, there was selection bias in regard to the choice of the operation method in this study because OG tended to be selected for more advanced gastric cancer patients. It was difficult to apply case-matching due to the insufficient sample size in this study. Third, we could not evaluate postoperative delirium, nutritional status, and quality of life after gastrectomy because of the retrospective design. In the future, a larger-sized prospective cohort study will be necessary.
In conclusion, LG for elderly patients aged ≥ 80 years with gastric cancer was technically safer and less invasive than OG and provided acceptable oncologic outcomes compared with non-elderly patients. Our results suggest that LG can be an optimal surgical modality for elderly patients aged ≥ 80 years with gastric cancer. To confirm our findings, a multi-center prospective study with a larger sample size will be required in the future.