Late-onset thoracogastric airway fistula after esophagectomy for esophageal cancer: a narrative review.

Background and Objective: Thoracogastric airway fistula (TGAF) is a life-threatening complication following esophagectomy with gastric conduit interposition. While early-onset TGAF has been well characterized, late-onset TGAF, which occurs months to years after surgery, remains underrecognized and lacks evidence-based diagnostic and management frameworks. This narrative review aims to synthesize current literature to address several high-priority clinical questions: which features should raise suspicion of lateonset TGAF; what is the optimal diagnostic pathway integrating imaging and endoscopy; and how to select between endoscopic and surgical intervention. Methods: We conducted a systematic search of PubMed from database inception to May 2026 using combinations of keywords related to TGAF and relevant etiological and therapeutic terms. Reference lists of included articles and relevant reviews were manually screened. Only peer-reviewed English-language publications were considered. Given the rarity and heterogeneity of late-onset TGAF, high-quality prospective studies are lacking, and a systematic review with meta-analysis is not feasible. We therefore adopted a narrative synthesis approach. Key Content and Findings: The evidence base for late-onset TGAF is limited to case reports, small series, and a few cohort studies, with no randomized trials identified. Diagnostic delay is common, driven by nonspecific symptoms and overlap with tumor progression. The pathogenesis is multifactorial, with peptic ulceration as the bestsupported mechanism. Management options include conservative support, endoscopic stenting or occluder devices, and surgical repair, though treatment decisions are guided largely by patient physiology, fistula characteristics, and institutional expertise rather than by comparative data. Long-term outcomes remain poorly characterized. Conclusions: This review presents an initial framework for managing late-onset TGAF. A high index of suspicion should be maintained in any post-esophagectomy patient presenting with recurrent pneumonia, chronic cough, or unexplained weight loss. Diagnostic workup should proceed with contrast esophagram and chest computed tomography (CT), followed by confirmatory bronchoscopy and gastroscopy. Endoscopic stenting is appropriate as firstline therapy in most patients, whereas surgical repair should be reserved for those with adequate physiological reserve and favorable local tissue conditions. The limited evidence base underscore the urgent need for prospective multicenter registries to establish standardized diagnostic algorithms and treatment guidelines for this rare but devastating complication.