Over the last decades, the treatment of resectable esophageal cancer has evolved into a multidisciplinary process in which all players are essential for treatment to be successful. Medical oncologists and radiation oncologists have been increasingly involved since the implementation of neoadjuvant therapy, which has been shown to improve survival. Although esophagectomy is still considered the cornerstone of curative treatment for locally advanced esophageal cancer, it remains associated with considerable postoperative morbidity, despite promising results of minimally invasive techniques. In this light, both physical status and response to neoadjuvant therapy may be important factors for selecting patients who will benefit from surgery. Furthermore, it is important to optimize the entire perioperative trajectory: from the initial outpatient clinic visit to postoperative discharge. Enhanced recovery after surgery is increasingly recognized for esophagectomy and emphasizes perioperative aspects, such as nutrition, physiotherapy, and pain management. To date, several facets of esophageal cancer treatment remain topics of debate, such as the preferred neoadjuvant treatment, anastomotic technique, extent of lymphadenectomy, organization of postoperative care, and the role of surgery beyond locally advanced disease. Here, we describe the current and future perspectives in the surgical treatment of patients with esophageal cancer in the context of the available literature.

Esophageal surgery for esophageal cancer has been performed for over a century now. Minimally invasive esophagectomy (MIE) was first described in 1992, and it is now a standard approach in many countries. However, MIE is technically difficult and requires a long learning curve. It takes >100 cases to train for MIE with gastric tube reconstruction with an intrathoracic anastomosis. A possible option to overcome several challenges of MIE might be the use of a robotic system. A robot-assisted MIE was first described in 2005, and long-term results have shown its feasibility and safety. Over the years, different approaches for esophagectomy have been established. Our review discusses these developments and recent literature on open, minimally invasive and robotic esophageal surgery.

i.e. khAt'koV, r.e. iSrAiloV, S.A. DomrAcheV, P.V. kononetS, m.A. koShkin moscow clinical research center (director -i.e. khat'kov), moscow Department of health; Department of Faculty Surgery №2 (headi.e. khat'kov), evdokimov moscow State medical and Dental university; Petrovsky russian research center of Surgery (director -academician of rAS Yu.V. Belov), moscow, russia

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The post-traumatic diaphragmatic hernia is a rare type of trauma which most commonly occurs after the blunt trauma of the thorax and abdomen. In the acute period of trauma, the symptoms of the emergency diseases and nonspecific signs of the diaphragmatic rupture are the reasons of frequent diagnostic mistakes. A missed diaphragmatic rupture grows in time and leads to migration of organs from the abdominal cavity to the thoracic one due to pressure gradient. The symptoms of diaphragmatic hernia are not expressed and the duration of the asymptomatic period of the disease may vary from some years to 10 years and longer. The increasing restructuring of the abdominal wall leads to reduced abdominal cavity, which makes the standard reconstructive surgery difficult, the intraabdominal pressure grows and relapse occurs in the postoperative period. In these cases, surgeons perform complex techniques which enlarge the abdominal cavity with local tissues or an artificial graft. However, there are no clear recommendations about the extent of the abdominal wall reconstruction so that the abdominal cavity size would be adequate for organs. The authors suggested a simple method to calculate it and used it in practice. In the article, we report the clinical case of a 53-year-old woman with a giant post-traumatic diaphragmatic hernia after motor vehicle accident 48 years ago and offer an original method of treatment. The first operation including hernia resolution and repair of diaphragmatic rupture was complicated by relapse on the second day after operation due to the high intra-abdominal pressure. During the second reconstructive surgery (4 months later), the authors performed their own method of abdominal cavity enlargement and got a good result in the shortand long-term postoperative period.

Treatment of patients with chemical burns of the esophagus and stomach is a difficult task.Perforation of the stomach or the formation of strictures of the esophagus, stomach, duodenum, and even the initial parts of the jejunum can be the outcome of chemical burns.Patients with concomitant esophageal and gastric strictures are the most difficult to treat, which often requires multi-stage operations.This article describes a clinical case of surgical treatment of a patient with a combined chemical burn of the esophagus and stomach with hydrochloric acid. One week after hospitalization, the patient had gastric perforation. The patient was urgently operated in the course of peritonitis. The peculiarity of the operation was that the surgeons, having made a gastrectomy, removed the esophageal stump to the anterior abdominal wall in the epigastrium and applied an enterostomy. In such a state with significant alimentary depletion (body mass index — BMI 15) on 11.10.02 the patient was taken to a Moscow clinic. A year later, the main surgical reconstructive treatment was performed — retrosternal bypass esophagoplasty of the right half of the large intestine and the terminal ileum in the isoperistaltic position, as well as extirpation of the esophagus. As a result of long-term treatment and several surgical interventions, a good short-term and long-term result was obtained.

1 ГБУЗ «Московский клинический научно-практический центр», Москва; 2 ГОУ ВПО «Московский государственный медико-стоматологический университет им. А.И. Евдокимова», Москва Актуальность. Лапароскопическая холецистэктомия (ЛХЭ) является методом выбора в лечении хронического калькулез-ного холецистита. Общеизвестно, что лапароскопические операции имеют ряд несомненных преимуществ перед тради-ционными: малая травматичность, более низкий уровень послеоперационной боли, отличный косметический эффект, ускорение физической и социальной реабилитации пациентов. Тем не менее доказано, что именно послеоперационная боль является основной причиной продления сроков госпитализации у пациентов после ЛХЭ. Задачей данного исследо-вания являлась оценка влияния упреждающей местной анестезии (УМА) 1% раствором ропивакаина на течение раннего послеоперационного периода. Материал и методы. С октября 2012 г. по июль 2013 г. прооперированы 104 пациента в объеме ЛХЭ по стандартной методике. Все пациенты были разделены на две группы. Первую, основную группу (Г1) со-ставили 48 пациентов, оперированных с применением УМА 1% раствором ропивакаина. Во вторую, группу сравнения (Г2) вошли 56 пациентов, оперированных без применения УМА. Распределение в группы проходило методом рандомизации. УМА проводили следующим образом: перед кожными разрезами в точки троакарных доступов с обязательной аспираци-онной пробой вводили местный анестетик амидного типа ропивакаин 10 мг/мл (1%) (Наропин, АстраЗенека ЮК Лимитед, Великобритания) в количестве 20 мл по 6 и 4 мл на троакары 10 и 5 мм соответственно, инфильтрируя мышцы, апоневроз, предбрюшинный жир. По окончании операции в брюшную полость в область правого купола диафрагмы при помощи лапароскопического аспиратора-ирригатора 5 мм распыляли 10 мл 1% раствора ропивакаина. Оценку выраженности болевого синдрома в послеоперационном периоде проводили при помощи специальной анкеты, разработанной на основе визуальной аналогово-рейтинговой шкалы (ВАШ), через 2, 4, 8, 24, 48 и 72 ч после операции. Полученные данные подвер-гались вариационно-статистической обработке в соответствии с общепринятыми методами. Результаты. В раннем после-операционном периоде уровень послеоперационной боли в Г1 был значительно ниже, чем в Г2 (p<0,001), и не превышал 1,02±0,18 балла по ВАШ. В Г2 уровень послеоперационной боли через 4, 8 и 24 ч в среднем превышал 3 балла по ВАШ. В Г2 у пациентов значительно чаще возникали боли в покое, при кашле и при движении (p<0,001). В Г1 болевой синдром в плечелопаточной области беспокоил 10,4% пациентов, в Г2 -48,2% (p<0,001). В Г1 послеоперационная аналгезия не понадобилась 56,2% пациентов, в Г2 51% пациентов для адекватной аналгезии понадобилось 3 инъекции кеторола 30 мг. Длительность послеоперационного пребывания в стационаре у пациентов Г1 была ниже на 1,05 дня (p<0,001). Уровень послеоперационной тошноты и рвоты, сонливости и прочих побочных эффектов в обеих группах статистически не отли-чался (p<0,001). Заключение. Упреждающая местная анестезия 1% раствором ропивакаина при проведении ЛХЭ является эфф...