perations on the esophagus are highly complex interventions that place exacting demands both on the surgeon and on the whole team involved in pre-, peri-, and postoperative care. It has long been recognized that there is a strong association between the outcome of esophageal surgery and the volume of patients treated. Meta-analyses of studies from different countries have shown that the in-hospital mortality following esophageal interventions to treat malignant neoplasia is inversely related to the number of operations carried out at the institution concerned (1-3). A recently published German study confirmed this association and showed that in this country esophageal procedures often take place in hospitals with very low case volumes (4).

Background: The modern therapy of early esophageal carcinomas (pT1) requires an excellent cooperation between experienced gastroenterologists, pathologists, and esophageal surgeons. While endoscopic resection (ER) is accepted as the standard curative treatment for mucosal esophageal carcinomas, submucosal tumors are regarded as a strict indication for surgery. There is an ongoing discussion about the operative approach and the extent of lymph node dissection in these cases. Methods: A literature review was performed to evaluate the operative treatment of early esophageal cancer. In view of oncological risk factors, treatment strategies, and operative procedures, current studies are summarized and compared to the results of our own center. Results and Conclusion: In early esophageal cancer, lymph node involvement is the only independent risk factor for survival and recurrence rates. There is evidence that infiltrated lymph nodes (N+) are significantly correlated with tumor infiltration depth, lymphovascular (L1) and microvascular invasion (V1), and poor tumor differentiation (G3). Several studies suggest that early squamous cell carcinomas (eSCCs) and early adenocarcinomas (eACs) have a different tumor biology and therefore need a different treatment strategy. While eSCCs in stage m1 and m2 can be cured by ER, tumors infiltrating the submucosal layer (sm1-3) show a high rate of lymph node metastasis (LNM); thus, surgical resection (SR) is clearly indicated. In tumors with invasion into the deep mucosa (m3) the risk of LNM is up to 11%; however, reliable data are rare and the type of therapy should be discussed with the patients individually. In eACs, ER is the standard curative treatment for all mucosal tumors (m1-m4) and sm1 tumors with low-risk constellation (G1, L0, VO, R0). All high-risk sm1 tumors and those with deeper submucosal infiltration (sm2, sm3) show a high rate of LNM and require SR. The standard operative proce- dure for early esophageal carcinomas is an Ivor-Lewis esophagectomy with radical, at least two-field lymphadenectomy.

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ER within the extended criteria with a meticulous histological workup should be performed in EGC to determine whether risk factors for LNM are present. If lymphatic infiltration is observed, surgery with lymphadenectomy is recommended. Tumors exceeding the extended criteria should undergo primary surgery with adequate lymphadenectomy.

ECC led to hemodynamic impairment with post-ischemic reactive hyperemia. OPCAB created hemodynamic depression but left RMP unchanged. Hemodynamic depression can be reduced by the Impella pump, however regional myocardial blood flow is decreased.