Purpose <p>Gastrectomy for gastric cancer (GC) can impair gastrointestinal function, leading to malabsorption, bone loss, and vertebral fractures (VFs), especially in older adults. Pylorus-preserving gastrectomy (PPG) may attenuate these metabolic complications. This study compared long-term bone outcomes after laparoscopic distal gastrectomy with Billroth-I reconstruction (LDGBI) versus laparoscopic PPG (LPPG).</p> Methods <p>We retrospectively analyzed 75 patients aged ≥75 years with clinical T1N0M0 GC who underwent LDGBI (n = 50) or LPPG (n = 25) between 2005 and 2019. Bone mineral density (BMD) was measured using CT-based Hounsfield units at L1, and VFs were evaluated 1, 3, and 5 years postoperatively. Analysis of covariance and logistic regression were performed.</p> Results <p>BMD loss was significantly greater after LDGBI at 3 years (10 vs. 5 HU, P = 0.038) and 5 years (16 vs. 6 HU, P = 0.036). VF incidence was higher in the LDGBI group at 3 years (14.0% vs. 0%, P = 0.014) and 5 years (28.0% vs. 8.0%, P = 0.034). LDGBI was independently associated with greater 5-year BMD reduction (coefficient 7.83, 95% CI 0.22–15.44, P = 0.044). Logistic regression showed no significant association with VFs (OR 3.57, 95% CI 0.71–17.88, P = 0.12).</p> Conclusion <p>LPPG was associated with reduced long-term BMD loss in older GC patients and may better preserve postoperative bone health.</p> Graphical abstract <p></p>