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Objective: To systematically evaluate the clinical efficacy and safety of endoscopic submucosal dissection (ESD) versus surgical resection for early gastric cancer (EGC) in patients aged 75 years and above. Methods: A systematic search was conducted in PubMed, Embase, Cochrane Library, and CNKI from the inception of the database to April 2026, to include relevant literature on ESD and surgery for aged 75 years and above patients with EGC. The experimental group consisted of patients aged≥75 years treated with ESD (ESD group), while the control group included those treated with surgery (surgery group). According to inclusion and exclusion criteria, two researchers independently performed literature screening, data extraction using the Newcastle-Ottawa Scale, and conducted meta-analysis using RevMan 5.4 and Stata 18.0 software to assess heterogeneity using I². Outcome measures included the 5-year survival rate, recurrence rate, recurrence-related mortality rate, and tumor incidence rates across different mucosal layers in both groups of patients. Funnel plots and leave-one-out analysis were adopted for publication bias analysis and sensitivity analysis. Results: A total of 6 studies involving 2 045 patients were included, with 988 in the ESD group and 1 057 in the control group. The 5-year survival rate (82.9% vs 77.4%, OR=1.29, 95%CI: 1.01-1.65, P=0.040, I²=0) and gastric cancer recurrence rate (8.5% vs 4.3%, OR=2.39, 95%CI: 1.37-4.14, P=0.002, I²=24%) were higher in the ESD group than those in the surgical group, whereas the recurrence-related mortality rate was lower in the ESD group (1.9% vs 4.9%, OR=0.47, 95%CI: 0.25-0.86, P=0.020, I²=34%). Subgroup analysis by tumor incidence rates across different mucosal layers showed that the proportion of mucosal tumors was higher in the ESD group than that in the surgical group (78.8% vs 38.3%, OR=3.40, 95%CI: 1.15-10.07, P=0.030, I²=95%), whereas the proportion of submucosal tumors was lower in the ESD group than in the surgical group (20.7% vs 61.4%, OR=0.29, 95%CI: 0.10-0.87, P=0.030, I²=95%). Funnel plot analysis showed that the studies were generally symmetrically distributed on both sides of the pooled effect size (log OR), forming an inverted funnel shape; sensitivity analysis demonstrated that the point estimates of individual studies fluctuated slightly around the original pooled effect size (log OR=1.05). Conclusion: For EGC patients aged 75 years and above, ESD demonstrates superior clinical efficacy and safety compared to surgical treatment.