Transhiatal Esophagectomy for distal and cardia cancers: Implications of a positive gastric margin

Background. A common operation for cancer of the esophagus and cardia consists of transhiatal esophagectomy, proximal gastrectomy, and a cervical esophagogastric anastomosis. The oncologic adequacy of dividing the stomach 4 to 6 cm distal to palpable tumor is not well documented, and when a positive gastric margin is present on the final pathologic analysis, the appropriate management is not established. This study was undertaken to determine the incidence of a positive gastric margin in these patients and the impact of adjuvant treatment. Methods. A retrospective review was performed of 1044 patients undergoing transhiatal esophagectomy for adenocarcinoma of the distal esophagus or cardia. Twenty (1.9%) had a positive gastric margin on final the pathologic evaluation and met inclusion criteria for this study. Results. Nine patients (45%) received adjuvant therapy consisting of radiation in 3, chemotherapy in 4, or both in 2. Their average postoperative survival was 477 days, compared with 455 days in those not receiving adjuvant therapy ( p = 0.898). Local tumor recurrence developed in 1 patient (11%) in the treatment group and in 3 (27%) in the no treatment group ( p = 0.386). Conclusions. A transhiatal esophagectomy and proximal gastrectomy for carcinoma of the distal esophagus and cardia, dividing the stomach 4 to 6 cm from palpable tumor, provides a negative gastric margin in 98% of patients. In the few patients who have a positive gastric margin, 80% die with distant metastases, which would not be influenced by more extensive gastric resection, and in about 20%, local tumor recurrence develops in the intrathoracic stomach, seldom causing dysphagia. Adjuvant therapy for a positive gastric margin neither improves survival nor reduces local tumor recurrence.