**3. Evaluation of physiological reserve**

Traditionally, open approaches have been used to resect esophageal cancer, performed by transhiatal, transthoracic, or combined approach. Esophagectomy is a complex challenge for the surgeon, dealing with wide areas of the neck, mediastinum, and abdomen. Open esophagectomy is considered to be one of the most traumatic oncologic procedures performed in gastrointestinal surgery because of the extent of resection and dissection required [3]. It entails a significant risk of morbidity (at least a half of patients develop complications) and mortality, that ranges from 6–7% in high-volume centers to 20–28% in low-volume centers. Orringer et al. [4] reported a large series of 1085 patients who underwent open esophagectomy by transhiatal approach, which has served as a standard to compare postoperative outcomes: hospital mortality rate of 4%; 53% of patients were discharged by 10th postoperative day; and an anastomotic leak rate of 13%. The most frequently reported complications of open approach have been pneumonia (21%), respiratory failure (16%), prolonged ventilatory sup-

port more than 48 h (22%), according to the report published by Bailey et al. [5].

ducted by videolaparoscopy with no mortality and minimal blood loss.

**2. Patient selection**

36 Esophageal Abnormalities

situation.

In an attempt to avoid extensive tissue aggression and reduce the high morbidity and mortality, the minimal invasive approach has been introduced in the field of gastroesophageal surgery [6]. Cuschieri et al. [7] and DePaula et al. [8] were the first to apply a laparoscopic approach to patients with esophageal cancer. Cuschieri et al. performed six subtotal endoscopic esophagectomies through a right thoracoscopic approach with a mean duration of stay in the ICU of 19 h (range 16–26 h) and a median hospital stay of 11 days (8–18 days). DePaula et al. reported a small series of 12 patients who underwent transhiatal esophagectomy con-

Thanks to the improvements in technology and instrumentation, as well as the surgeons' training in advanced minimally invasive procedures, the practice of this technique has been extended since the 1990s. There are several single institution series reports [7–10] (retrospective and prospective) comparing Minimally Invasive Esophagectomy (MIE) versus open surgery [11, 12], and recent meta-analyses [13, 14] that have confirmed the safety and feasibility of the procedure and the advantages of minimally invasive surgery. These reports show that MIE can reduce the mortality and morbidity of open operations as well as allow a faster recovery. All these findings

Tumor staging is essential for planning surgical treatment, and surgery should not be performed for patients without a chance of cure, such as those with distant metastases, or in those unable to survive the physiologic insult of the operation. The main objective of surgery must be to achieve a R0 resection. Nowadays, neoadjuvant chemoradiation plays a key role because it downstages the tumor and allows an adequate micro and macroscopic tumoral resection. From a surgical perspective, the drawback is that it may further complicate the procedure by distorting the peri-esophageal microanatomy and by causing a significant postradiation fibrosis. Tissue plane may be unclear and surgery will not be easy in this

have been confirmed at the only available level I evidence study, the TIME-trial [15].

Predicting which patients are going to develop complications is not easy. Even so, we must know which indicators can increase postoperative morbidity and mortality. Many risk factors have been identified: Karnofsky score less than 80, liver cirrhosis, chronic obstructive pulmonary disease (COPD), ischemic heart disease, advanced age, locally advanced tumor, active smoking, alcoholism, and malnutrition [16–19] are some of them. Evaluating individual risk is important for patient selection and a proper preoperative management, regardless of the surgical approach to be performed (MIE or open surgery). However, there are physiological conditions of patients that cannot be improved.

The risk factors suggestive of preoperative optimization are the following:

