Organ preservation strategy is an important direction in the current treatment of digestive system tumors. Particularly, the strategy has received widespread attention in esophageal cancer and rectal cancer. Although radical surgery improves survival, it often compromises organ function and quality of life. With the development of neoadjuvant therapy and the application of immunotherapy, some patients have achieved complete clinical remission (CCR). It provides the possibility for conservative treatments such as " watchful waiting" or local excision. Rational screening of patients with CCR combined with precise evaluation can achieve functional preservation while ensuring tumor control. Currently, however, there is a lack of unified evaluation criteria and long-term follow-up evidence. In the future, the integrated application of new tools such as biomarkers, imaging technology and artificial intelligence may further promote the implementation of the strategy. This article reviews the development of neoadjuvant therapy, clinical practice and evaluation technology of organ preservation for esophageal cancer and rectal cancer. The article also discusses the feasibility and challenges of the strategy.