Preoperative staging and risk analysis in esophageal carcinoma

In esophageal cancer surgery a preoperative risk analysis of the patient and staging of the tumor are necessary to reduce postoperative mortality and to identify those patients who will benefit from primary surgery. A risk analysis includes the recording of cardiac, pulmonary, renal, hepatic and cerebral functions, and defines the functional limits of the various systems. Preoperatively it is most important to assess whether the primary tumor is completely resectable or not, because only patients undergoing complete tumor resection benefit from surgery with respect to the long-term prognosis. It is necessary to undertake a classification on the basis of tumor localization and local infiltration, which today can most reliably be evaluated by endoscopic ultrasonography. Advanced tumors above the bifurcation are associated with early infiltration of the tracheobronchial system, and should therefore receive preoperative treatment with combined radiotherapy and chemotherapy. Below the bifurcation, only T4-tumors invading neighboring structures should receive this pretreatment, whereas all others can be resected primarily.