Objective: Intrathoracic esophageal fistula (iTEF) is a severe clinical condition which is mainly caused by invasion of malignant tumor of esophagus or vicinal organs, as well as by traumatic or inflammatory perforation with surrounding blood vessel or airway. This condition is arguably the most lethal complication, especially when a fistula is emerged between esophagus and surrounding blood vessel or airway. Though stent implantation has been proven to be an effective approach for emergent salvage, most patients need a second stage operation due to the consistent leakage of digestive juice from the esophageal fistula and probable enlargement of the fistula. Given the compromised physical condition caused by this condition, most patients might not be able to survive the reconstruction surgery. We report here the experience of tailored surgical approach for different types of esophageal fistula. Methods: Between January 2002 and November 2007, nine benign iTEF patients were treated in the First Affiliated Hospital of Guangzhou Medical University. Among the patients, there were five males and four females, and the median age was 48 (5-73) years old. Three of these patients suffered from large esophago-tracheal fistula (ETF) caused by traffic accident, one from aorto-esophageal fistula (AEF) induced by fish bone, one from esophago-mediastinal fistula (EMF) induced by mediastinal abscess which further induced collapsed thoracic vertebra and high paraplegia, one from esophago-bronchus fistula (EBF) which further induced abscess of right upper lung and respiratory failure, one from large ETF caused by medical maloperation of photodynamic therapy for esophageal severe atypical hyperplasia, one from ETF caused by radiotherapy for mediastinal lymphatic metastasis of lung cancer, one from thoracogastric-tracheal fistula (GTF) after esophagectomy. There were seven different types of surgical approach for restoration of alimentary tract. The three patients with large ETF caused by traffic accident underwent gastrostomy and jejunostomy as first stage treatment, and the second stage treatment included substituting impaired esophagus in situ for impaired membranaceous trachea and cervical gastroesophagostomy. After salvage from twice more than 2 000 mL volume of haematemesis, the AEF patients was stabilized by thoracic endovascular aortic repair, and the second stage treatment included removal of thoracic esophagus and cervical gastroesophagostomy through the retrosternal routine. The EMF patient underwent elimination of mediastinal abscessus and rachitomy as the first stage treatment, and the second stage treatment included transhital esophagectomy and cervical gastroesophagostomy through the retrosternal routine. After stabilized by antibiotic administration, the EBF patient underwent right upper lobectomy and local repair of esophageal fistula. The patient with ETF caused by medical maloperation of photodynamic therapy experienced a failed first stage treatment of esophageal stent implantation, and the second stage treatment included extracting of esophageal stent, repair of enlarged tracheal fistula with pedicle intercostal muscle flap, removal of thoracic esophagus and cervical gastroesophagostomy. The ETF patient caused by radiotherapy also experienced a failed first stage treatment of esophageal stent implantation, and the second stage treatment was repair of esophageal and tracheal fistula with pedicle muscle flap separately. The GTF patient was cured by tracheal stent implantation. Results: Complete treatment was performed in all nine patients. The median operative time was 5 (4~9) hours, the median estimated blood loss was 380 (280~900) mL, the median postoperative hospital stay was 13 (7- 20) days. No major postoperative complication was found in seven of the patients, and the seven patients were discharged with desirable physical condition and led a normal life thereafter. The 90 days mortality was 22.2% (2/9). The patient received mechanical ventilator because of postoperative pneumonia. Though the pneumonia recovered after 15 days of mechanical ventilator, the patient died of multi-organ failure due to aspiration of gastric content. The patient experienced a bronchial obstruction due to a failed pedicle muscle flap for trachea. A acute heart failure happened when the patient underwent bronchoscopy electroblation for the bronchial obstruction. Though extracorporeal membrane oxygenation was performed, the patient died of multi-organ failure 18 days after surgery. Conclusion: The treatment for iTEF should be performed after the improvement of patients’ physical condition, and staging surgery might be a better option for these patients. Based on the experience of the three ETF patients caused by traffic accident, the “inflammatory adhesion” theory of substituting impaired esophagus in situ for impaired membranaceous trachea might be a feasible and less invasive option for this situation, while one stage operation may encounter an enlarged fistula or undesirable complication.