Gastric cancer remains one of the leading causes of cancer-related mortality worldwide, despite a declining incidence in recent decades due to improved screening and early detection strategies. Early gastric cancer (EGC), defined as carcinoma confined to the mucosa or submucosa regardless of lymph node status, accounts for an increasing proportion of newly diagnosed gastric cancers, particularly in East Asian countries such as Japan and Korea where endoscopic surveillance is well established. The management of EGC aims to achieve complete oncologic resection while minimizing postoperative morbidity and preserving quality of life. Traditionally, gastrectomy with lymph node dissection has been the standard curative treatment for EGC. However, laparoscopic gastrectomy (LG), introduced in the early 1990s, has gained widespread acceptance as a minimally invasive alternative to open surgery, offering advantages such as reduced postoperative pain, faster recovery, and shorter hospital stay without compromising oncologic outcomes in selected patients (1,2). Advances in laparoscopic instruments and techniques have further enhanced the feasibility and safety of LG even for complex gastric procedures. In parallel, endoscopic submucosal dissection (ESD) has emerged as a less invasive, organ-preserving technique that allows en bloc resection of early gastric lesions with precise histologic assessment and minimal damage to gastric function. ESD is now considered the standard treatment for intramucosal cancers without lymphovascular invasion and with negligible risk of nodal metastasis (3,4). Several studies have demonstrated excellent long-term outcomes for ESD in appropriately selected EGC patients, with survival rates comparable to those achieved with surgical resection (5,6). However, the optimal treatment strategy for EGC remains a subject of debate, particularly in cases that meet expanded criteria for endoscopic resection. While ESD offers superior postoperative quality of life and faster recovery, concerns remain regarding incomplete resection, local recurrence, and undetected lymph node metastasis compared to LG (7,8). Conversely, LG provides a more comprehensive oncologic resection at the expense of greater invasiveness and postoperative morbidity. Therefore, a comparative evaluation of laparoscopic gastrectomy versus endoscopic submucosal dissection is essential to determine their relative efficacy, safety, and long-term outcomes in patients with early gastric cancer.

Study Design and Setting This was a retrospective comparative cohort study conducted at a tertiary care academic hospital with a high volume of gastric cancer surgeries. Medical records of patients who underwent either laparoscopic gastrectomy (LG) or endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) between January 2015 and May 2022 were reviewed. Institutional Ethics Committee approval was obtained, and informed consent was secured from all participants. Patient Selection Patients were included if they met the following criteria: Histologically confirmed adenocarcinoma of the stomach, limited to the mucosa or submucosa (T1 stage) without evidence of distant metastasis. Underwent LG with D1/D1+ lymphadenectomy or ESD as definitive therapy. Had complete clinicopathological and follow-up data for a minimum of 12 months. Exclusion criteria included: Locally advanced or metastatic disease. Previous gastric surgery or synchronous malignancies. Conversion from laparoscopic to open surgery. Incomplete resection (R1/R2) or inadequate follow-up data. Preoperative Evaluation All patients underwent upper gastrointestinal endoscopy, endoscopic ultrasonography (EUS) for tumor depth evaluation, and contrast-enhanced CT of the abdomen and pelvis to exclude nodal or distant metastases. Routine laboratory tests were performed, including hematologic and biochemical parameters. Tumor characteristics (location, size, morphology) were classified according to the Japanese Classification of Gastric Carcinoma (JCGC) (9). Treatment Procedures Endoscopic Submucosal Dissection (ESD): ESD was carried out under conscious sedation or general anesthesia using a standard single-channel endoscope fitted with a transparent cap. After marking the lesion margins, a submucosal injection (glycerol with indigo carmine and epinephrine) was administered to elevate the mucosa. Circumferential incision and submucosal dissection were performed with an insulated-tip or dual knife. Hemostasis was maintained using hemostatic forceps. En bloc resection was achieved wherever possible. Resected specimens were pinned on boards, fixed in formalin, and examined histopathologically for margin and invasion depth. Laparoscopic Gastrectomy (LG): LG was performed under general anesthesia using a standard five-port technique. Depending on the tumor site, laparoscopic distal or total gastrectomy with D1 or D1+ lymphadenectomy was performed following the Japanese Gastric Cancer Treatment Guidelines (10). Reconstruction was achieved via Billroth I, Billroth II, or Roux-en-Y anastomosis. All resected specimens were examined for margin status and lymph node retrieval count. Outcome Parameters Primary outcomes included: Curative resection rate (R0) Operation time (minutes) Intraoperative blood loss (mL) Postoperative complications, graded using the Clavien-Dindo classification Length of postoperative hospital stay (days) Secondary outcomes were: Recurrence rates (local and distant) Disease-free survival (DFS) and overall survival (OS) at 3 years Quality of life (QOL), assessed using the EORTC QLQ-STO22 questionnaire at 6 and 12 months postoperatively. Histopathological Assessment Specimens were evaluated for tumor size, differentiation, depth of invasion, lymphovascular invasion, and resection margin status. Lymph node retrieval and metastasis were recorded for LG cases. For ESD, curative resection was defined according to Gotoda et al. criteria (11): en bloc resection, negative lateral and vertical margins, no lymphovascular invasion, and depth limited to the mucosa or superficial submucosa. Follow-up Protocol Patients were followed up every 3 months for the first 2 years, and every 6 months thereafter. Follow-up evaluations included clinical examination, serum tumor markers (CEA, CA19-9), endoscopic surveillance, and imaging (CT or MRI) to assess recurrence. Statistical Analysis All analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD) and compared using Student’s t-test or Mann–Whitney U test depending on data distribution. Categorical variables were analyzed using the Chi-square test or Fisher’s exact test. Kaplan–Meier survival curves with log-rank tests were used to compare survival outcomes. A p-value < 0.05 was considered statistically significant.

Patient Characteristics A total of 186 patients with early gastric cancer (EGC) were included in the study, comprising 96 patients who underwent endoscopic submucosal dissection (ESD) and 90 patients who underwent laparoscopic gastrectomy (LG). Baseline demographic and clinicopathologic characteristics were comparable between the two groups (Table 1). The mean age of patients was 63.8 ± 9.7 years in the ESD group and 62.4 ± 10.1 years in the LG group (p = 0.42). The male-to-female ratio was approximately 1.8:1. Mean tumor size was smaller in the ESD group (1.8 ± 0.6 cm) compared to the LG group (2.4 ± 0.9 cm, p < 0.001). Operative and Perioperative Outcomes The mean operative time was significantly shorter for the ESD group (82.6 ± 31.4 minutes) compared to the LG group (214.7 ± 52.9 minutes, p < 0.001). Similarly, intraoperative blood loss was substantially lower in the ESD group (18.5 ± 9.8 mL) than in the LG group (176.3 ± 94.2 mL, p < 0.001). No intraoperative mortality occurred in either group. he overall postoperative complication rate was significantly lower in the ESD group (5.2%) compared to the LG group (14.4%, p = 0.03). Major complications (Clavien-Dindo grade ≥ IIIa) occurred in 2 patients (2.1%) in the ESD group and 6 patients (6.6%) in the LG group, primarily due to anastomotic leakage or intra-abdominal abscess. The mean hospital stay was shorter following ESD (3.6 ± 1.8 days) than after LG (9.8 ± 3.5 days, p < 0.001). Histopathological Outcomes En bloc resection was achieved in all ESD cases, and curative (R0) resection was confirmed in 93 (96.8%) of ESD patients and 89 (98.9%) of LG patients (p = 0.62). Lymphovascular invasion (LVI) was detected in 4.1% of ESD and 7.8% of LG specimens (p = 0.28). In the LG group, the mean number of retrieved lymph nodes was 29.2 ± 8.6, with nodal metastasis detected in 4 (4.4%) patients. No nodal evaluation was done for ESD cases as per protocol. Recurrence and Survival Outcomes During a median follow-up of 41 months (range, 12–84 months), local recurrence occurred in 5 (5.2%) patients after ESD and 1 (1.1%) after LG (p = 0.11). No distant metastasis was observed in the ESD group, while two LG patients (2.2%) developed hepatic recurrence at 30 and 34 months, respectively. The 3-year disease-free survival (DFS) was 94.7% in the ESD group and 96.5% in the LG group (p = 0.54). The 3-year overall survival (OS) was 97.8% in both groups (p = 0.89). Quality of Life Outcomes At 6 and 12 months postoperatively, the EORTC QLQ-STO22 scores indicated significantly better eating comfort, physical function, and body image in the ESD group (mean score 83.2 ± 8.5) compared to the LG group (71.4 ± 11.3, p < 0.001). Symptoms related to reflux, early satiety, and dumping were more frequently reported after LG. Table 1. Baseline and perioperative characteristics of patients Parameter ESD Group (n = 96) LG Group (n = 90) p-value Age (years, mean ± SD) 63.8 ± 9.7 62.4 ± 10.1 0.42 Male:Female ratio 63:33 58:32 0.89 Tumor size (cm) 1.8 ± 0.6 2.4 ± 0.9 <0.001 Operative time (min) 82.6 ± 31.4 214.7 ± 52.9 <0.001 Blood loss (mL) 18.5 ± 9.8 176.3 ± 94.2 <0.001 Hospital stay (days) 3.6 ± 1.8 9.8 ± 3.5 <0.001 Postoperative complications (%) 5.2 14.4 0.03 R0 resection (%) 96.8 98.9 0.62 Lymphovascular invasion (%) 4.1 7.8 0.28 Local recurrence (%) 5.2 1.1 0.11 3-year DFS (%) 94.7 96.5 0.54 3-year OS (%) 97.8 97.8 0.89

This study demonstrates that both laparoscopic gastrectomy (LG) and endoscopic submucosal dissection (ESD) are effective curative treatments for early gastric cancer (EGC), achieving high R0 resection rates and excellent long-term survival. However, ESD provided superior perioperative outcomes, including shorter operative time, lower blood loss, and faster postoperative recovery, supporting its role as a minimally invasive, organ-preserving treatment modality (13,14). ESD’s oncologic adequacy in carefully selected patients has been well established. Several Asian studies have shown that when lesions fulfill absolute or expanded indications, lymph node metastasis is rare, and curative endoscopic resection is feasible with favorable outcomes. Our findings are consistent with these reports, demonstrating excellent en bloc and curative resection rates with minimal recurrence. While LG remains a valuable option, especially for lesions exceeding endoscopic criteria or with submucosal invasion, its invasiveness and longer hospital stay make it less favorable for smaller, well-differentiated EGC. Recent multicenter trials have confirmed that LG achieves oncologic results comparable to open gastrectomy while reducing postoperative morbidity and improving recovery profiles (15). Post-treatment quality of life (QOL) is an essential consideration, as survival rates for EGC are generally high. In our study, patients treated with ESD reported significantly better QOL scores. This advantage is consistent with prior research, which demonstrated that endoscopic therapy preserves gastric anatomy and function, allowing faster nutritional and physical recovery compared to surgical resection (16,17). Nonetheless, patient selection for ESD must be meticulous. Incomplete resection and local recurrence, although rare, can occur in ulcerated or undifferentiated lesions, emphasizing the importance of strict adherence to established selection criteria and expert procedural performance (18). For such non-curative resections, LG provides an appropriate salvage approach. Overall, this study reinforces the concept of a treatment-stratified approach for EGC: ESD should be the first-line therapy for lesions within the absolute or expanded endoscopic criteria. LG remains essential for cases at higher risk of lymph node metastasis or non-curative ESD. Future prospective, multicenter studies are required to refine the long-term oncologic equivalence, cost-effectiveness, and QOL outcomes of these two minimally invasive modalities.

In this study, both ESD and LG offer excellent outcomes for early gastric cancer. ESD demonstrates clear advantages in operative safety, recovery, and postoperative quality of life, with survival outcomes comparable to laparoscopic gastrectomy when appropriately indicated. Therefore, ESD should be considered the preferred first-line treatment for patients meeting endoscopic curative criteria, reserving LG for cases with higher risk of nodal involvement or non-curative endoscopic resection.

1.Kitano S, Iso Y, Moriyama M, Sugimachi K. Laparoscopy-assisted Billroth I gastrectomy. Surg Laparosc Endosc. 1994;4(2):146–8. 2.Huscher CG, Mingoli A, Sgarzini G, Sansonetti A, Lirici MM, Ponzano C, et al. Laparoscopic versus open subtotal gastrectomy for distal gastric cancer: five-year results of a randomized prospective trial. Ann Surg. 2005;241(2):232–7. 3.Gotoda T, Yanagisawa A, Sasako M, Ono H, Nakanishi Y, Shimoda T, et al. Incidence of lymph node metastasis from early gastric cancer: estimation with a large number of cases at two large centers. Gastric Cancer. 2000;3(4):219–25. 4.Oda I, Saito D, Tada M, Iishi H, Tanabe S, Oyama T, et al. A multicenter retrospective study of endoscopic resection for early gastric cancer. Gastrointest Endosc. 2005;61(4):AB124. 5.Choi KS, Jung HY, Choi KD, Lee GH, Song HJ, Kim DH, et al. Long-term outcomes of endoscopic submucosal dissection for early gastric cancer: a Korean multicenter study. Gastrointest Endosc. 2011;73(5):911–20. 6.Isomoto H, Shikuwa S, Yamaguchi N, Fukuda E, Ikeda K, Nishiyama H, et al. Endoscopic submucosal dissection for early gastric cancer: a large-scale feasibility study. Gut. 2009;58(3):331–6. 7.Kim HH, Hyung WJ, Cho GS, Kim MC, Han SU, Kim W, et al. Morbidity and mortality of laparoscopic gastrectomy versus open gastrectomy for gastric cancer: an interim report—a phase III multicenter, prospective, randomized Trial (KLASS Trial). Ann Surg. 2010;251(3):417–20. 8.Hirasawa T, Gotoda T, Miyata S, Kato Y, Shimoda T, Taniguchi H, et al. Incidence of lymph node metastasis and the feasibility of endoscopic resection for undifferentiated-type early gastric cancer. Gastric Cancer. 2009;12(3):148–52. 9.Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma: 3rd English edition. Gastric Cancer. 2011;14(2):101–12. 10.Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2021 (5th edition). Gastric Cancer. 2022;25(1):1–25. 11.Gotoda T, Yanagisawa A, Sasako M, Ono H, Nakanishi Y, Shimoda T, et al. Incidence of lymph node metastasis from early gastric cancer: estimation with a large number of cases at two large centers. Gastric Cancer. 2000;3(4):219–25. 12.Hatta W, Gotoda T, Oyama T, Kawata N, Takahashi A, Yoshifuku Y, et al. Is radical surgery necessary after non-curative endoscopic submucosal dissection for early gastric cancer? Gastroenterology. 2017;152(4):924–35. 13.Park CH, Kim EH, Chung H, Park JC, Shin SK, Lee SK, et al. Comparison of laparoscopic and endoscopic treatment for early gastric cancer: a propensity score–matched analysis. Gastric Cancer. 2014;17(2):323–32. 14.Lee JH, Kim JG, Jung HK, Kim JH, Jeong WK, Jeon TJ, et al. Clinical practice guidelines for gastric cancer in Korea: an evidence-based approach. J Gastric Cancer. 2014;14(2):87–104. 15.Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2018 (5th edition). Gastric Cancer. 2021;24(1):1–21. 16.Nakamura K, Uedo N, Takeuchi Y, Ishihara R, Higashino K, Inoue T, et al. Long-term quality of life after endoscopic submucosal dissection for early gastric cancer: a multicenter prospective study. Endoscopy. 2018;50(7):641–9. 17.Ono H, Yao K, Fujishiro M, Oda I, Nimura S, Yahagi N, et al. Guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for early gastric cancer. Dig Endosc. 2016;28(1):3–15. 18.Song KY, Park CH, Kang HC, Kim JJ, Park SM, Kim W. Is laparoscopic surgery better than open surgery for early gastric cancer? Surg Endosc. 2008;22(6):1604–9.