食道癌手術術式

當確定診斷，做完癌症分期的檢查後，面臨的即是選擇治療的方式，作下治療的計畫。在選擇治療時必須考慮的因素包括病人的健康狀態，癌症的期別，癌的類型，及其個體間的相異處。治療的主力不外以下三種方式：外科手術、化學療法與放射療法。

一、外科手術

外科手術可以除去食道癌病灶與其一些周邊組織，達到治療的目的。較常用的手術大略又可分兩大部分：食道切除術、食道胃切除術。

　　食道切除術主要用於較早期、癌症散佈不廣的病人，將受癌細胞浸潤食道割除，靠近食道的淋巴結也一併被切除。對食道較下端的病灶，包括食道腺癌，此時手術就須也切除胃的一部份，稱之食道胃切除術。剩下的胃就直接接到上端的食道。在某些情況，在切除病灶後，剩下的胃與食道距離太遠，無法直接縫合一起，就需再利用一段大腸，縫合置入兩者之間，以造成一個完整的通道，讓病患仍能進食。
　　外科手術的優點則在於能完全治癒病灶局限於食道本身，屬於較早期的病患。可惜的是如前面文章所提，大部份的食道癌很少在無症狀之前被發現，有文獻指出少於

　　如同其他手術，食道癌的外科療法也有一些危險性，例如手術中可能發生心臟或肺部的血栓症；吻合處或許會裂開；利用大腸轉置也會有多種能與預料的併發症，但隨著技術與器械的進步，重大的併發症以減少許多。
即使手術成功，術後仍會面臨不同的問離，例如胃的運動遲緩，這是由於控制受到手術的影響，結果導致容易噁心嘔吐。大約10-15% 的病人在縫合處會有結痂，引致狹窄吞嚥困難，需要再次利用其它治療手段來擴張。手術後亦由於食道下端的賁門括約肌發生了改變，食物容易反流回食道端，造成胃灼熱等症狀。

截至今日，雖然外科手術仍無法十全十美，外科療法仍是在食道癌的治療還是治癒病患的最有效方法。

二、化學療法

化學療法就是經口或靜脈注射給予抗癌藥物，當這些藥物進入體內會影響到細胞的代謝，達到對抗癌細胞的目的。而依據癌症的階段，大致又可分成兩類處置，一種化學療法本身即作為主要的治療方式，另一種用來作為輔佐療法。但一般說來，僅靠化學療法為主的治療方式是無法完全治癒食道癌的，除非再加上外科手術或放射療法。

　　對於食道癌通常有幾種情況，醫師會建議病患接受化學療法。例如某些較末期的病患採姑息性的治療，其目的在於減輕症狀，改善吞嚥困難的問題，而非求治癒疾病，有時會用一些化學治療。另外開刀前，有時也會做化學治療，目的在於減少腫瘤的大小，以求能將腫瘤完全切除，若再加上放射療法，有些文獻認為療效會更好。
　　在食道癌的化學療法中，常用的藥物包括5 - FU ，cisplatin，bleomycin，mitomycin C，methotrexate等。大約10%-40%的病患對化療的反應較佳，治療後腫瘤會縮小。但化療的效果可能只是短暫的，些時日腫瘤又長回來。近年也有文獻報告化療時合併放射治療，無論是手術前，或作為主要療法，都可以獲得較佳的結果。
　　而化學治療的副作用，決定於所選擇的藥物，通常代謝愈快的器官受影響也較厲害，常見的是如嘔吐、噁心、腹瀉、食慾不振、掉髮、口腔潰瘍。白血球數目下降，增加了發生感染症的機會。也會有出血、月經週期改變、不孕等問題。這些副作用通常在停藥一段時日後都會得到改善。

三、放射療法

放射療法是使用高能量的放射線或粒子殺死癌細胞。依放射源的位置可分從體外照射，或者體內照射，將放射源置入體內，癌症病灶附近。食道癌的治療以前者為主。放射療法在一些食道癌的病人亦做為主要療法，例如那些身體狀況不佳，無法接受手術或化學療法，此時局部放射療法就便成唯一的選擇。而對於手術後的病患。放射療法也使用來殺死那些未能清除乾淨的癌細胞。放射療法有時也是姑息(緩和)療法的一種工具，藉以減輕食道癌的症狀，譬如減少疼痛，改善吞嚥困難，治療腦部轉移等等。少有病例經由放射療法而能獲得痊癒，但放射療法對於治療吞嚥困難卻非常有效，一般超過百分之七十的病患，在接受過放射療法後吞嚥困難都會有不同程度的進步。凡事總有其風險。放射治療其本身也有一些併發症或是副作用，例如照射處皮膚的問題，胃腸不適，軟便與疲倦等等，通常不會太嚴重，治療結束後，這些症狀也大都會消失或減輕。另外由於照射食道癌常也會照射到胸腔，可能會引起肺部的傷害，甚至纖維化導致呼吸短促和困難。不過相較於前面的兩種治療方式，放射療法的副作用較小。若同時在進行化治療，放射療法的加入，也會使化療的副作用變得更厲害。

郭 鑫 (Xin GUO),* 吴 源周 (Yuanzhou WU), 贾 龙飞 (Longfei JIA), 李 雅玲 (Yaling LI), 闫 玉生 (Yusheng YAN), and 陈 群清 (Qunqing CHEN)*

郭 鑫 (Xin GUO)

南方医科大学珠江医院胸心外科，广东 广州 510280, Department of Cardiothoracic Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China

Find articles by 郭 鑫 (Xin GUO)

吴 源周 (Yuanzhou WU)

南方医科大学珠江医院胸心外科，广东 广州 510280, Department of Cardiothoracic Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China

Find articles by 吴 源周 (Yuanzhou WU)

贾 龙飞 (Longfei JIA)

南方医科大学珠江医院胸心外科，广东 广州 510280, Department of Cardiothoracic Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China

Find articles by 贾 龙飞 (Longfei JIA)

李 雅玲 (Yaling LI)

南方医科大学珠江医院胸心外科，广东 广州 510280, Department of Cardiothoracic Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China

Find articles by 李 雅玲 (Yaling LI)

闫 玉生 (Yusheng YAN)

南方医科大学珠江医院胸心外科，广东 广州 510280, Department of Cardiothoracic Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China

Find articles by 闫 玉生 (Yusheng YAN)

陈 群清 (Qunqing CHEN)

南方医科大学珠江医院胸心外科，广东 广州 510280, Department of Cardiothoracic Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China

Find articles by 陈 群清 (Qunqing CHEN)

Author information Article notes Copyright and License information Disclaimer

南方医科大学珠江医院胸心外科，广东 广州 510280, Department of Cardiothoracic Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China

郭 鑫 (Xin GUO): moc.361@5811505nixoug; 陈 群清 (Qunqing CHEN): moc.anis@5891gqqnehc

陈群清, 主任医师，硕士研究生导师，E-mail: moc.anis@5891gqqnehc

Received 2017 Oct 13

Copyright 版权所有©《南方医科大学学报》编辑部2018

Copyright ©2018 Journal of Southern Medical University. All rights reserved.

Abstract

目的

探讨微创食管癌切除术(MIE)和开放食管癌切除术(OE)对食管癌患者围术期外周血循环肿瘤细胞(CTCs)动态变化的影响。

方法

选取2015年10月~2017年10月期间收治的73例食管癌患者并随机分为MIE组(38例)和OE组(35例)，同时以10例食管良性疾病者和10例健康志愿者为对照组。采用CanPatrolTM CTCs检测技术检测两组食管癌患者及对照组外周血液中CTCs数量的分布情况。

结果

(1)在73例食管癌患者中，术前CTCs检测44例(60.3%)为阳性，对照组均为阴性；(2)73例食管癌患者术中外周血CTCs水平高于术前，术后CTCs水平高于术中，差异均有统计学意义(P＜0.001)；(3)MIE组和OE组患者术前及术中外周血CTCs水平比较差异无统计学意义(P＞0.05)，但MIE组术后外周血CTCs水平显著低于OE组，且从术前至术后CTCs增幅水平在MIE组显著低于OE组，差异有统计学意义(P＜0.001)；(4)MIE组术后(2周)总并发症发生率为28.9% (11/ 38)，明显低于OE组的54.3% (19/35)，差异有统计学意义(P=0.023)，而且在MIE组和OE组均有并发症的患者中CTCs水平明显高于无并发症的患者(P=0.001；P=0.005)。

结论

MIE有助于降低术后早期外周血中因手术播散的CTCs数量，并且动态监测CTCs水平可用于评估患者的预后。CTCs可以成为监测食管癌患者预后一个较好的辅助指标。

Keywords: 食管癌, 食管癌切除术, 循环肿瘤细胞, CanPatrolTM

Abstract

Objective

To investigate the effects of minimally invasive esophagectomy (MIE) and open esophagectomy (OE) on the level of circulating tumor cells (CTCs) in patients with esophageal cancer (EC).

Methods

A total of 73 patients with EC undergoing MIE (n=38) or OE (n=35) in our department between October, 2015 and October, 2017 were enrolled, with 10 patients with benign esophagus disease and 10 healthy volunteers as controls. The levels of CTCs in the peripheral blood of the participants were detected using CanPatrolTM technique and analyzed for their association with the operation methods and perioperative complications.

Results

CTCs were detected in 60.3% (44/73) of the EC patients but in none of the control subjects. CTC level after the surgery was significantly higher than that during the surgery, and CTC level during the surgery was significantly higher than that before surgery (P < 0.001). The preoperative and intra-operative CTC levels were not significantly different between MIE and OE groups (P > 0.05), but the postoperative CTC level was significantly lower in MIE group than in OE group, and postoperative increment of CTC level (from the preoperative level) was significantly lower in MIE group than in OE group (P < 0.001). The total incidence of postoperative complications was significantly lower in MIE group than in OE group (28.9% vs 54.3%, P=0.023), and in both groups, CTC levels in patients with complications were significantly higher than those in patients without complications (P=0.001 and P=0.005 in MIE and OE groups, respectively).

Conclusion

MIE may help to reduce the number of peripheral blood CTCs early after the operation, and dynamic monitoring CTCs level assists in evaluation of the prognosis of EC patients. CTC level may serve as an indicator for monitoring the prognosis of EC.

Keywords: esophageal cancer, esophagectomy, circulating tumor cells, CanPatrolTM

食管癌是由食管鳞状上皮或腺上皮异常增生导致的恶性消化道肿瘤，我国是食管癌发病率和死亡率最高的国家[1]。目前，外科手术切除仍是治疗食管癌的基本措施，具体的手术方式多种多样，常用的开放式食管癌切除术(OE)有3种：包括左胸单切口手术、胸腹双切口手术和颈胸腹三切口手术[2]。最近随着国内外微创手术的发展，其在食管癌切除术中的应用也越来越广泛。与传统的OE相比，微创食管癌切除术(MIE)具有创伤小、疼痛少、安全性高、术后恢复快等优点[3]。

目前，食管癌的手术治疗已经非常成熟，但预后不良且5年生存率只有20% [4]，其主要原因是由肿瘤的转移和复发引起的[5]。当前临床发现和诊断肿瘤的主要方法是肿瘤标志物检测和影像学检查[6]。肿瘤标志物检测有助于早期发现肿瘤，其缺点是特异性较差，易出现假阳性结果。影像学检查一般只能发现生长到一定大小的肿瘤，因此患者用这些方法检查出肿瘤时，往往已经失去了早期治疗的机会[7]。循环肿瘤细胞(CTCs)是指由肿瘤原发灶或转移灶进入血液循环的肿瘤细胞[8]，在2007年CTCs被ASCO推荐为肿瘤标志物[9]。相关研究已明确可以在食管癌中检测到CTCs，并且动态监测CTCs对于评估食管癌患者的治疗效果有重要意义[10]。然而截至目前不同食管癌手术方式对CTCs水平是否存在影响罕有报道，且尚未有较全面的研究，本研究采用第二代CTCs检测技术-CanPatrolTM，对食管癌患者围手术期外周血CTCs进行动态监测，并对比分析MIE和OE术式在治疗食管癌患者中的作用及其对外周血CTCs水平的影响，为临床手术方式的选择及食管癌患者的预后判断提供参考。

1. 资料和方法

1.1. 临床资料

随机选取2015年10月~2017年10月期间在本研究中心确诊的食管癌患者的临床资料，具体纳入标准为：(1)基于术前全身骨扫描和其他器官的影像学检查有手术指征且无转移性病变者；(2)通过术前常规检查对食管癌切除术可耐受者；(3)根据术前影像检查，肿瘤最长横径≤6 cm且无明显外侵的患者；(4)无明显因胸膜广泛粘连延长手术时间者；(5)术前未接受放疗和化疗的患者；(6)术后病理结果由第8版UICC/AJCC食管癌TNM分期系统进行病理分期[11]。排除标准：(1)不能耐受手术者；(2)手术资料不全者；(3)随访24周内患者死亡。最终，共73例食管癌患者被纳入MIE组(n=38)和OE组(n=35)。同时选择同期在本研究中心检查良性食管疾病患者(包括5例食管憩室症，3例贲门失弛缓症和2例食管良性肿瘤)和10例志愿者为对照组。本研究由我院伦理委员会批准，所有患者均签署书面知情同意书。

1.2. 手术方式

1.2.1. MIE组Ivor-Lewis术式

患者常规双腔气管内麻醉，腹部手术区消毒、铺巾。先平卧位腹腔镜游离胃，Hemolock钳闭胃左动脉后超声刀切断，保留胃网膜右血管弓，清扫腹腔及胃血管周围淋巴结后制作管状胃。然后取左侧卧位，胸腔镜下游离食管上至胸膜顶下至膈肌裂孔，清扫胸腔内淋巴结后上提管状胃至胸腔，经口置入Orvil钉砧行胸顶食管胃吻合。

Mc Keown术式：麻醉满意后，先左侧卧位，胸腔镜下游离食管上至胸膜顶下至膈肌裂孔并清扫胸腔内淋巴结，后平卧位，腹腔镜游离胃并进行腹腔淋巴结清扫，制作管状胃。于左侧颈部做一3~4 cm切口，游离颈段食管，上提管状胃至颈部行食管胃吻合。

1.2.2. OE组

麻醉满意后，取右侧卧位。于左胸第6肋间后外侧做约20 cm切口进胸。游离食管，清扫胸腔内淋巴结，再经膈游离胃并清扫腹腔淋巴结，制作管状胃并提至胸腔，行主动脉弓上或弓下吻合。

1.3. 检测方法

本研究采用广州益善生物公司开发的将生物化学和细胞物理性质相结合的分离方法-CanPatrolTM技术检测食管癌患者外周血中的CTCs [12]。其原理为：首先裂解外周血中的红细胞，并利用CTCs与白细胞的大小差异通过纳米技术进行CTCs的分离和富集，然后通过多重mRNA原位分析方法对富集的CTCs进行特异性基因核酸定位，从而达到对CTCs进行分型和鉴定的目的[13]。

每例患者分别于术前、术中、术后进行血液样本采集。术前血液样本于手术前3 d采集；术中血液样本于肿瘤切除及淋巴结清扫完毕后采集；术后血液样本分别于术后3 d及术后2周采集。使用8号采血针和枸橼酸抗凝管采取8 mL外周血，血样采集后将采血管上下颠倒混匀10次，后将标本放置于冰袋中，24 h内送往广州益善生物公司实验室进行检测。CTCs阳性界定标准：食管癌患者外周血中检测到的CTCs数量≥2个/5 mL为阳性，而CTCs数量＜2个/5 mL为阴性[14]。

1.4. 统计方法

使用SPSS22.0软件进行统计学分析。计量资料以均数±标准差表示。每一项资料均进行正态性检验及方差齐性检验。将正态分布的数据使用t检验和方差分析进行配对比较，而不成正态分布的数据则进行非参数秩和检验。计数资料以百分比和率表示，比较采用χ2或Fisher确切概率法检验。P＜0.05认为差异具有统计学意义。

2. 结果

2.1. 两组食管癌患者一般资料比较和术前CTCs检测情况

MIE组和OE组分别由38例和35例食管癌患者组成。两组间患者在年龄、性别、吸烟史、肿瘤部位、组织学类型及术后病理分期等方面差异均无统计学意义(P＞0.05，表 1)。按照CTCs阳性界定标准，对照组10例食管良性疾病者和10例健康志愿者CTCs检测结果均为阴性。73例食管癌患者中，MIE组阳性率为55.3% (21/38)，OE组阳性率为65.7% (23/35)，两组之间CTCs阳性率比较差异无统计学意义(χ2=0.831，P=0.362，表 2)。

1

两组患者临床病理资料的比较

Comparison of clinicopathological factors of the patients in the two groups[n (%) unless specified otherwise]

CharacteristicsMIE group (n=38)OE group (n=35)t/χ2PMIE: Minimally invasive esophagectomy; OE: Open esophagectomy. a: hypertension, diabetes, pulmonary tuberculosis, cardiovascular disease, previous tumors, COPD.Genderχ2=0.5710.450  Male30(78.9)30(85.7)  Female8(21.1)5(14.3)Age(year, Mean±SD)59.4±7.659.6±7.7t=0.0990.921Esophageal cancer siteχ2=01360.892  Upper3(7.9)3(8.6)  Middle25(65.8)22(62.9)  Bottom10(26.3)10(28.5)Histologyχ2=0.2310.631  Squamous carcinoma34(89.5)29(82.8)  Adenocarcinoma4(10.5)6(17.2)Clinical Stageχ2=0.4670.642  Ⅰa2(5.3)1(2.9)  Ⅰb5(13.2)5(14.3)  Ⅱa10(26.3)9(25.7)  Ⅱb7(18.4)4(11.4)  Ⅲa4(10.5)5(14.3)  Ⅲb10(26.3)11(31.4)T Stageχ2=7.6290.054  T1a4(10.5)2(5.7)  T1b3(7.9)4(11.4)  T211(28.9)12(34.3)  T320(52.6)17(48.6)N Stageχ2=13310.514  N024(63.2)19(54.3)  N110(26.3)9(25.7)  N24(10.5)7(20.0)Preoperative complicationsaχ2=2.0170.156  Yes4(10.5)8(22.9)  No34(89.5)27(77.1)Smoking historyχ2=0.7360.391  Yes19(50.0)21(60.0)  No19(50.0)14(40.0)

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2

MIE组和OE组患者术前CTCs阳性率的比较

Comparison of circulating tumor cell-positive rate between MIE group and OE group[n (%)]

GroupCasesCTCs
(positive)CTCs
(negative)χ2PMIE: Minimally invasive esophagectomy; OE: Open esophagectomy.MIE group3821 (55.3)17(44.7)0.8310.362OE group3523 (65.7)12 (34.3)

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2.2. 不同手术阶段CTCs水平的变化

通过CanPatrolTM技术检测术前和术后CTCs水平。统计分析显示：在73例食管癌患者中，术中CTCs水平高于术前(z=-6.231，P=0.000)，术后3 d CTCs水平高于术中(z=-7.381，P=0.000)，差异均有统计学意义。MIE组和OE组CTCs水平在术前与术中比较差异无统计学意义(P＞0.05)，但MIE组术后(3 d)外周血CTCs水平显著低于OE组(z=-5.141，P=0.000，表 3)。CTCs增幅水平从术前至术后(3 d)在MIE组显著低于OE组(图 1)，差异有统计学意义(z=-6.068，P=0.000)。

3

分别比较CTCs在MIE组和OE组各时点的水平

Comparison of CTC levels at different stages in MIE group and OE group (Mean±SD)

GroupPre-operativeIntra-operativePostoperative (3days)Postoperative (2weeks)①P < 0.001 between intra-operation and pre-operation; ②P < 0.001between postoperation and intra-operation; ③P < 0.001, compare the postoperation between OE and MIE group.MIE group (n=38)2.74±3.094.55±3.328.05±3.693.81±2.06OE group (n=35)2.86±3.085.00±3.2416.51±8.20 ③6.28±3.56Total (n=73)2.79±3.064.54±3.28 ①12.11±7.54 ②5.00±3.11

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1

不同手术途径对围术期CTCs水平的影响

Effect of different surgical methods on CTC levels during the perioperative period.

2.3. CTCs水平与术后2周并发症之间的关系

两组食管癌患者在手术时间、术中出血量及术后(2周)并发症的发生均有显著性差异(P＜0.05，表 4)。MIE组术后(2周)总并发症发生率为28.9% (11/38)，明显低于OE组的54.3%(19/35)，差异有统计学意义(z=-2.277，P=0.023)，术后2周再次检测每组患者的CTCs水平，在每组患者中，有严重并发症患者的CTCs水平显著高于手术结果良好的患者(P=0.001；P=0.005，表 5)。

4

两组患者术中、术后恢复情况及术后并发症的比较

Intra-and postoperative complications in MIE group and OE group (Mean±SD)

GroupMIE group (n=38)OE group (n=35)t/χ2Pa: pulmonary infection, pulmonary atelectasis, hydropneumothorax and fiberbronchoscope suction.Operation time (min)368.9±33.0268.3±32.4t=-13.1200.000Intra-operation blood loss (mL)205.5±79.4250.9±90.1t=2.2860.025Lymph node dissection count (each)11.3±5.312.0±3.4t=0.6860.495Intrathoracic drain removed (days)5.8±1.26.2±1.5t=1.1610.250Postoperative eating time (days)6.5±0.86.8±0.9t=1.9420.056Hospital stays (days)19.8±1.820.3±1.9t=1.2430.218Pulmonary complicationsa (case)510χ2=2.6510.103Anastomotic fistula (case)23Anastomotic stricture (case)12Chylothorax (case)11Delayed gastric emptying (case)12Recurrent laryngeal nerve injury (case)21Arrhythmia (case)22Perioperative death (case)01

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5

术后2周并发症的发生与CTCs水平的关系

CTCs levels and occurrence of complications at 2 weeks after surgery (Mean±SD)

GroupCTCs levelzPWithout complicationsWith complicationsMIE group (27/11)2.96±1.195.91±2.30-3.2880.001OE group (16/19)3.81±1.648.37±3.42-2.8190.005

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3. 讨论

目前，手术仍然是治疗食管癌最有效的措施，因为手术治疗可以将肿瘤整体切除并进行局部淋巴结清扫，使术后TNM分期更加精准，这对延长患者生存期、提高患者生活质量有重要作用[15-16]。随着科学技术的发展和医疗设施的不断完善，越来越多的研究人员开始探索MIE对食管癌的治疗效果[17]，理论上，MIE术中腔镜的放大效果可以提供更加清晰的解剖层次，并可完成更加精细的操作。采用MIE治疗食管癌的患者手术切口小可以避免切断正常的肌肉组织，保留胸腔的固有结构，降低术后呼吸系统并发症的发生[18]。此外，MIE可以减少术中出血量，降低围术期死亡率，这些都充分说明MIE在治疗食管癌中的重要性[19-20]。

本文关于食管癌患者围术期不同阶段CTCs的研究表明，术中及术后CTCs的数量较术前有所增加，提示术中挤压肿瘤可促进肿瘤细胞机械性入血[21-22]，术者应尽量避免挤压肿块，坚持术中无瘤原则。术后CTCs的数量显著高于术前及术中，提示术后早期机体免疫系统的紊乱可能会影响CTCs的动态变化。此外，食管癌患者术后，不仅其免疫系统紊乱，其自身内环境的改变导致其杀死肿瘤细胞的能力下降，由于CTCs的数量增加，使肿瘤细胞复发和转移发生的可能性显著增加[23]。对于大多数食管癌患者，尽管在其体内没有检测到多余的肿瘤细胞，但他们仍死于术后肿瘤的复发和转移，这些都可能与CTCs有关[24]。作为肿瘤复发和转移的新型诊断标准，CTCs可用于评估食管癌患者的预后效果[25-27]。

本研究对不同手术方式食管癌患者CTCs的变化研究结果显示，无论在MIE组还是OE组，术后有并发症患者的CTCs水平显著高于无并发症的患者，提示术后并发症的发生可能导致CTCs数量显著增加，加快肿瘤的复发和转移。此外，MIE组和OE组术中CTCs数量的变化无明显差异，但MIE组术后CTCs的水平显著低于OE组，而且MIE组术后有并发症患者的CTCs水平显著低于OE组，这些均提示MIE在控制CTCs方面比OE更有效[28]。有研究报告说明[29]，OE术式简单容易、手术时间短、术中只需单一体位、手术器械较MIE便宜而且OE更广泛适用，MIE不能应用于晚期食管癌患者。因此，虽然MIE在控制CTCs方面更有效，但仍不能完全替代OE。然而，根据患者的实际情况，OE仍可是治疗食管癌的一个良好选择[30]。

综上所述，我们比较了MIE和OE对食管癌患者外周血CTCs的影响。结果表明，MIE在控制CTCs方面优于OE。然而，本研究在样本选择方面受到限制，因此得出的结论有一定偏差。我们还需进一步研究探讨CTCs与食管癌发病机制之间的联系、MIE较OE降低术后CTCs水平的机制及其与患者长期生存率之间的相关性。

Biography

• 

郭鑫，硕士研究生，E-mail: moc.361@5811505nixoug

Funding Statement

广东省科技计划项目(2016ZC0085)

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