Endoscopic resection (ER) has been a standard treatment modality for early gastric cancer with ignorable risks of lymph node metastasis. As for EGCs within expanded indications, endoscopic submucosal dissection (ESD) has considerable advantages over endoscopic mucosal resection (EMR) regarding higher rate of en bloc resection, complete resection, but lower risk of local recurrence. Previous meta-analyses comparing ESD with surgery for EGC are scarce and not robust to reach definitive conclusions. We searched PubMed, Web of Science, EMBASE, Cochrane Library Databases and Google Scholar through July 2019 to identify studies evaluating ESD vs surgery for EGC. Newcastle-Ottawa Quality Assessment Scale was used to assess the quality of enrolled studies. Patient baseline characteristics, procedure-related and prognosis outcomes, and adverse event data were extracted and pooled for analyses by the Review Manager 5.3 software. Grading of Recommendations Assessment, Development and Evaluation guidelines (GRADE) were used to assess the quality of evidence. Trial Sequential Analysis (TSA) was conducted to weaken random error and enhance the reliability of evidence. Totally 18 retrospective studies, involving 5993 patients, were included. ESD benefits were 128.38 min shorter operation duration 95%CI: (−204.68, −52.09), P = 0.001, 7.13 days shorter hospital stay 95%CI: (−7.98, −6.28), P < 0.00001, lower risk of procedure-related death OR = 0.21, 95%CI: (0.07, 0.68), P = 0.009, lower risk of overall complication OR = 0.47, 95%CI: (0.34, 0.63), P < 0.00001. ESD was also associated with lower costs and better quality of life. However, ESD had lower rate of en bloc resection OR = 0.07, 95%CI: (0.03, 0.21), P < 0.00001, histologically complete resection OR = 0.07, 95%CI: (0.03, 0.14), P < 0.00001, curative resection OR = 0.06, 95%CI: (0.01, 0.27), P = 0.002, and higher rate of local recurrence OR = 5.42, 95%CI: (2.91, 10.11), P < 0.00001, metachronous cancer OR = 10.84, 95%CI: (6.43, 18.26), P < 0.00001, synchronous cancer OR = 6.59, 95%CI: (1.96, 22.1), P = 0.002. ESD also led to lower disease-free survival HR = 4.58, 95%CI: (2.79, 7.52), P < 0.00001 and recurrence-free survival HR = 1.99, 95%CI: (1.38, 2.87), P = 0.0002. No significant differences in overall survival (OS) and disease-specific survival (DSS) between ESD and surgery were observed. ESD offers a method of less expensive, less trauma, faster recovery and better quality of life compared to surgery for EGC. However, ESD is associated with higher risk of recurrence without compromising OS and DSS. Strict and careful surveillance after ESD is needed. Recurrent EGCs following ESD can usually be detected in early stage and successfully managed by repeated ESD. Accordingly, ESD technique provides an alternative to surgical resection for highly selected EGC patients. •The meta-analyses of the same topic are scarce and not robust to reach definitive conclusions.•ESD offers a method of less expensive, less trauma and faster recovery than surgery for EGC.•Due to higher risk of recurrence following ESD pathway, strict and careful surveillance is needed.•ESD technique provides an alternative to surgical resection for highly selected EGC patients.