GBF is a rare complication in patients with an intra-thoracic oesophagogastric anastomosis after esophageal resection. Recurrent malignancy is the commonest cause of this complication. Non-malignant cases may occur early or late. In the early postoperative period GBF usually arises as a result of the extensive dissection, ischemia  or surgical staples . It may however present late as this case, several years after the operation. In such cases the causes are chronic peptic ulcer in the gastric conduit, traumatic anastomotic dilatation [3, 4] or infection.
The usual modes of presentation are cough associated with eating, dyspnoea, haemoptysis and recurrent chest infections. The fistula may connect at any site in the respiratory tract, from trachea down to lobar bronchus. The fistula may be difficult to locate and may not be visualized at endoscopy of respiratory or upper GI tract. In such cases a methylene blue dye test may show bluish sputum when the patient is asked to swallow the dye. CT scan or upper GI contrast radiology is also helpful in arriving at the correct diagnosis. Multiple biopsies help to rule out recurrence of malignancy as the cause. Left untreated, GBF is usually fatal due to chronic pulmonary sepsis and one should not rely on conservative treatment .
Patients often present in poor general condition with malnutrition and chronic pulmonary infection. Prompt institution of broad-spectrum antibiotic cover, gastric drainage, attention to fluid and electrolyte balance, nutritional support and chest physiotherapy are essential steps in preparation for definitive surgery. In acute cases with the presence of gross mediastinal sepsis cervical oesophagostomy and return of the stomach tube to abdomen with débridement is performed. The continuity can be restored at a later date with an alternative conduit e.g. colonic interposition.
The ideal operation consists of re-thoracotomy and resection of fistula with direct closure of the openings in the esophagus and the respiratory tree, preferably with an intervening viable tissue. A variety of tissue and pedicles of muscles like pectoralis major, intercostal, latissimus dorsi  and sternocleidomastoid  have been used to interpose between the two repaired tubes. Where required the membranous portion of airway can be substituted with fascia lata, autologous pericardium or bovine pericardium to close the defect. A defect in the lower lobe bronchus is most often managed by lower lobectomy where as a defect in the main-stem bronchus may be resected and repaired . GBF arising around the level of the oesophagogastric anastomosis may not be amenable to resection and direct closure. A tension free well-vascularized closure is crucial in the success of this procedure and an alternative conduit may be required. No one single procedure is suitable for all the patients and the surgeon should be aware of the options available.
Late development of GBF is a rare complication of esophageal surgery that may be difficult to diagnose. Surgical resection and direct closure is the treatment of choice. However where patients are debilitated or if there is insufficient length of airway available for resectional surgery, alternative, less invasive endoscopic stenting procedures may be used .