This systematic review and meta-analysis evaluated whether endoscopic submucosal dissection (ESD) offers different clinical efficacy and safety compared with surgical resection for patients aged 75 years and older with early gastric cancer (EGC). The primary aim was to compare long-term survival and recurrence outcomes between ESD and surgery in this older patient population.
The investigators conducted systematic searches of PubMed, Embase, the Cochrane Library, and CNKI from database inception through April 2026. Two researchers independently screened records and extracted data according to predefined inclusion and exclusion criteria. Study quality was assessed using the Newcastle-Ottawa Scale. Meta-analyses were performed using RevMan 5.4 and Stata 18.0; heterogeneity was quantified with I2.
Six studies met inclusion criteria and were included in the pooled analyses. Combined, these studies contributed data on 2,045 patients: 988 patients in the ESD group and 1,057 patients in the surgical control group. The review included published data summarized in English and Chinese abstracts as reported in the source.
Outcomes extracted and pooled across studies included the 5-year survival rate, gastric cancer recurrence rate, recurrence-related mortality rate, and tumor incidence rates stratified by mucosal layer involvement (mucosal vs submucosal). The authors applied standard meta-analytic techniques for pooling odds ratios (ORs) and reporting 95% confidence intervals (CIs) and P values.
The pooled 5-year survival rate favored the ESD group. Across the included studies the 5-year survival was 82.9% in the ESD group versus 77.4% in the surgery group. The pooled effect estimate was OR = 1.29 (95% CI 1.01–1.65), P = 0.040, with no observed heterogeneity (I2 = 0). This indicates a statistically significant higher odds of 5-year survival among patients treated with ESD in the pooled dataset.
Gastric cancer recurrence rate was higher after ESD compared with surgery in pooled analysis: 8.5% versus 4.3%, yielding OR = 2.39 (95% CI 1.37–4.14), P = 0.002, with low heterogeneity (I2 = 24%). In contrast, recurrence-related mortality was lower in the ESD group: 1.9% versus 4.9% in the surgery group. The pooled OR for recurrence-related mortality was 0.47 (95% CI 0.25–0.86), P = 0.020, with modest heterogeneity (I2 = 34%).
These pooled results indicate that while superficial recurrence events were more frequent after ESD, deaths related to recurrence were less frequent compared with surgical patients in the combined studies.
The meta-analysis included subgroup comparisons of tumor incidence by mucosal layer between treatment groups. The proportion of tumors confined to the mucosal layer was higher in the ESD group (78.8% vs 38.3%), with a pooled OR = 3.40 (95% CI 1.15–10.07), P = 0.030. Conversely, the proportion of submucosal tumors was lower in the ESD group (20.7% vs 61.4%), with pooled OR = 0.29 (95% CI 0.10–0.87), P = 0.030.
Heterogeneity for these subgroup comparisons was high (I2 = 95% for both mucosal and submucosal incidence analyses), indicating substantial variability across the included studies for layer-specific tumor distribution.
The authors assessed publication bias using funnel plots; the visual inspection suggested that study effect sizes were approximately symmetrically distributed around the pooled effect (log OR), forming an inverted funnel shape. Sensitivity analysis using a leave-one-out approach showed that pooled point estimates fluctuated only slightly around the original pooled effect size (reported pooled log OR = 1.05), indicating relative robustness of the primary pooled result to exclusion of individual studies.
Based on pooled data from six studies involving 2,045 patients aged 75 years and older, the authors concluded that ESD demonstrates superior clinical efficacy and safety compared with surgical treatment for EGC in this age group. Specifically, pooled analyses showed higher 5-year survival and lower recurrence-related mortality with ESD, but a higher overall gastric cancer recurrence rate. Subgroup data indicated that patients treated with ESD had a higher proportion of mucosal tumors and a lower proportion of submucosal tumors in the included series.
Note: All quantitative results, study counts, event rates, effect estimates, confidence intervals, heterogeneity statistics, and P values reported here are taken directly from the source abstract and are presented without additional interpretation beyond the source findings.