Objective：To compare the long-term prognosis of endoscopic submucosal dissection（ESD）versus surgical treatment in patients with early Siewert type Ⅱ adenocarcinoma of the esophagogastric junction（AEGJ）. Methods：A retrospective analysis was conducted on 562 patients with early Siewert type Ⅱ AEGJ who underwent ESD or radical surgery at a single tertiary medical center between January 2010 and February 2021，including 393 cases treated with ESD and 169 cases treated with radical surgery. After balancing baseline characteristics using propensity score matching（PSM），the Kaplan-Meier analysis was used to compare long-term survival outcomes between ESD and surgical treatment. Results：The median follow-up time for all 562 patients was 57.7 months （range 6.2-147.0 months）. After PSM，two balanced cohorts of 163 patients each were generated. The 5-year overall survival（OS） rates showed no significant difference between the ESD and surgery groups（92.5% vs. 90.7%，P=0.734）. Similarly，no significant differences were observed in OS（P=0.95）or disease-specific survival（P=0.18）between the two groups. The analysis of adverse events showed no significant differences between the two groups in lymph node metastasis（6.7% vs. 7.4%，P=0.829），local recurrence（4.9% vs. 9.2%，P=0.130），postoperative stenosis（3.7% vs. 1.2%，P=0.152），or bleeding（1.2% vs. 0.6%，P=0.562）. However，the incidence of acid reflux symptoms was significantly higher in the surgery group（11.0% vs. 3.1%，P=0.005）. Conclusion：ESD and surgical treatment for early-stage Siewert type Ⅱ AEGJ demonstrate similar long-term survival outcomes，suggesting that ESD can be an effective alternative treatment for this patient population.