Objective To compare the surgical safety and postoperative quality of life between laparoscopic pylorus-preserving gastrectomy (LPPG) and laparoscopic distal gastrectomy (LDG) following endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) in the middle of stomach. Methods A single-center retrospective cohort study was conducted on the clinical and follow-up data of 48 patients who underwent additional surgery after ESD for EGC in the middle of stomach at the Department of Gastric and Hernia Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, between January 2016 and February 2024. Patients were divided into two groups based on the surgical procedure: LPPG (n=9) and LDG (n=39). Clinicopathological characteristics, short-term postoperative outcomes, 2-year survival, and postoperative quality of life scores were compared between the two groups. Results R0 resection was achieved in all patients in both groups. Patients in the LPPG group were significantly younger than those in the LDG group (P=0.038). No statistically significant differences were observed between the two groups in operative time, intraoperative blood loss, number of lymph nodes dissected (median 25 in both groups), time to first flatus or defecation, or length of hospital stay (all P>0.05). The proximal and distal resection margins were significantly shorter in the LPPG group than in the LDG group (P=0.001 and P=0.041, respectively). The incidence of short-term (≤30 d) postoperative complications was 22.2% (2/9) in the LPPG group and 2.6% (1/39) in the LDG group. At 6 months postoperatively, serum albumin levels were numerically higher in the LPPG group than in the LDG group (45.4 g/L vs. 43.2 g/L, Hedges’ g=0.78), but the difference did not reach statistical significance (P=0.065). Hemoglobin levels did not differ significantly between the two groups at either 6 months or 2 years postoperatively (P>0.05). The overall incidence of long-term complications did not differ significantly between the two groups (11.1% vs. 17.9%, P>0.05), although the complication spectra differed. At 2 years postoperatively, life quality scores were comparable between the two groups (all P>0.05); the LPPG group had a significantly higher constipation subscale score than the LDG group (P=0.047). No tumor recurrence, lymph node metastasis, or distant metastasis was observed in either group during the 2-year follow-up. Conclusion Both LPPG and LDG can achieve satisfactory oncological outcomes as salvage surgery after ESD for early gastric cancer in the middle stomach. LPPG shows better nutritional preservation without increasing long-term complications or overall QOL loss, but it has higher short-term complication rates and more constipation, thus being more suitable for carefully selected patients requiring function preservation.