Abstract: AIM To compare the efficacy and safety of endoscopic submucosal dissection (ESD) and surgery in the treatment of early gastric cancer and high-grade intraepithelial neoplasia in elderly patients.METHODS One hundred and five patients aged over 60 years with early gastric cancer or high-grade intraepithelial neoplasia were enrolled from March 2011 to September 2016.They were divided into either an ESD group or a surgical group according to the treatment method used.For patients whose lesions were located in the mucosa and who cannot tolerate surgery,or whose lesions were beyond the mucosal layer but who refused surgical procedures,they were treated by ESD.For patients whose lesions were beyond the mucosal layer but who refused ESD treatment,they were treated surgically.RESULTS There were 104 cases of successful operation,and one patient died in the surgical group.Both groups were effective.Compared with the surgical operation group,the patients in the ESD group had higher age,more complications,but the operation was well tolerated,the safety was high,the operation time was short and the patient was more acceptable.The time,age,and complication of the two groups were statistically significant (P < 0.05).Postoperative pathology showed that tumor infiltration was deeper in the surgical group than in the ESD group.CONCLUSION ESD is effective and safe in the treatment of early gastric cancer and high-grade intraepithelial neoplasia in elderly patients,especially for those who are intolerant of surgical procedures.