Background: Patients with carcinoma of the distal esophagus and metastatic celiac lymph nodes (M I a) have a poor prognosis and are often denied surgery. In this study, we evaluated our treatment strategy of chemotherapy followed by surgery ill patients with M I a disease. Methods: Thirty-eight patients who received chemotherapy for carcinoma of the distal esophagus with celiac lymph node involvement between 2000 and 2007 were identified from a prospective database. Clinical and histopathological responses to chemotherapy were analyzed and follow-up comprised review of medical charts. Results: Twelve non-responding patients were not eligible for surgery. Twenty-six patients with partial responses or stable disease were operated oil. The resectability rate was 96% (25/26) and tumor-free resection margins (R0) were achieved in 68% (17/25). The overall survival of patients with M I a disease was 16 months. Patients who received chemotherapy alone had a median survival of 10 months; patients who underwent additional surgery had a median survival of 26 months (log-rank P<0.001). Conclusion: The overall survival of patients with carcinoma of the distal esophagus and clinical celiac lymph node involvement is poor. Tumor-free resection margins (R0) in Mla patients with clinical response to chemotherapy are likely to be achieved and contributes to prolonged survival. J. Surg. Oncol 2009;100:407-413. (C) 2009 Wiley-Liss, Inc.