Introduction Total gastrectomy (TG) is associated with comparable survival outcomes but poorer short-term postoperative outcomes than distal gastrectomy (DG) in the general population with gastric cancer. However, evidence regarding these outcomes in the older population with early gastric cancer remains limited. This study compared long-term treatment outcomes after TG and DG, including longitudinal nutritional indicators, in this cohort. Materials and methods Patients aged ≥75 years with pathologically confirmed stage I gastric cancer were included. Among the 534 enrolled patients, 450 underwent DG and 84 underwent TG. Propensity score matching was performed to minimize baseline differences between the two groups. Results After 1:1 matching, 84 patients were included in each treatment group. Surgical outcomes, including hospital days and readmission rates, did not show significant differences. The overall complication rate was higher in the TG group (34.5% vs. 25.0%), although not significantly. 5-year overall survival rates were 79.8% in the DG group and 69.9% in the TG group. Body weights and hemoglobin levels declined more significantly in the TG group over time. Conclusion TG showed a numerically lower 5-year overall survival than DG, and was accompanied by less favorable longitudinal nutritional outcomes, although postoperative complication rates did not differ significantly between the two groups. The oncological benefit of TG may be expected primarily in disease-specific rather than overall survival in this age group, where non-cancer mortality contributes substantially. These observations may suggest that, in older adults with early gastric cancer at relatively low oncological risk, surgical strategies that minimize functional loss without compromising oncological adequacy deserve further investigation. Our findings could indirectly support stomach-preserving approaches in selected older patients with early gastric cancer.
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