OBJECTIVE: To evaluate the results of conservative and surgical management of esophago-gastric anastomotic leaks after esophagectomy for carcinoma. MATERIALS AND METHODS: A retrospective analysis of 510 patients subjected to esophagectomy and gastric pull-up with intra-thoracic or cervical anastomosis was performed. RESULTS: Twenty four cases (6.1%) of intra-thoracic anastomotic leaks and 17 (13.9%) cervical leaks were observed and treated. The conservative treatment was adopted in 19 intra-thoracic leakages (79%) and in 10 cervical leakages (59%). The leak-related mortality rate was 16.6% in patients with intra-thoracic leaks and 11.7% in those with cervical leaks. DISCUSSION: The introduction of staplers has dramatically decreased, but not eliminated, the risk of intra-thoracic and cervical anastomotic leaks. In our series the choice of the therapeutic approach was based on clinical and endoscopic findings. Patients with anastomotic dehiscence and gastric graft ischemia required reoperation, whereas conservative treatment was possible in the majority of cases. CONCLUSION: The treatment of esophago-gastric anastomotic leaks must be tailored to the individual patient. Early endoscopy is crucial for recognition of ischemia of the transposed stomach.