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Introduction: Lung transplantation (LTx) is the ultimate treatment for patients suffering from end-stage pulmonary conditions. Despite vast improvements in surgical techniques over the last several years, complications are still frequent. Development of an esophageal fistula after LTx is a rare complication, characterized by significant morbidity, requiring re-intervention, a prolonged stay in the intensive care unit and a long period of nil per os. Given the rarity of this complication, limited literature on this topic is available. The aim of this case series is to describe this complication in detail, its clinical presentation and treatment options as well as to discuss potential risk factors. Methods: This study is a retrospective case series on the development of an esophageal fistula after bilateral LTx at the University Hospitals Leuven Belgium between 2019 and 2020. A total of 4 patients presented with an esophageal fistula post-LTx. Case series: Case 1: A 63-year-old male received a bilateral LTx for end-stage combined pulmonary fibrosis and emphysema. 26 days after LTx, he developed a right-sided hydropneumothorax with subcutaneous emphysema. Gastroscopy revealed an esophageal fistula. The fistula was closed by an intercostal muscle flap, hemo-clips and stenting. Follow up showed no remaining fistula. He was discharged after a 156-day stay in the hospital. Case 2: a 33-year-old female underwent a bilateral lobar transplant for end-stage cystic fibrosis. 13 days after LTx, she deteriorated due to hemorrhagic shock. Bilateral redo anterior thoracotomy showed a fistula that was subsequently covered by an intercostal muscle flap. Follow up showed remaining leakage of the fistula and conservative therapy was set. Control CT confirmed a positive evolution of the fistula and after 98 days in the hospital, she was discharged home. Case 3: A 62-year-old male underwent a bilateral LTx for terminal interstitial lung disease due to systemic sclerosis with secondary severe pulmonary and right heart failure. 16 days post-LTx, he developed a pneumopericardium with bilateral pneumothorax. A week later he showed acute respiratory decline and a gastroscopy showed an esophageal fistula. A conservative management was set. However, control endoscopy showed a larger fistula and clips were placed. 109 days after LTx, CT showed a relapse of the esophageal pleural fistula and the fistula was primarily closed and covered with two intercostal muscle flaps. Follow up showed no remaining fistulas. After a 273-day hospital-stay, he was discharged to a rehabilitation center. Case 4: A 38-year-old male received a bilateral LTx because of idiopathic pulmonary arterial hypertension. 42 days after LTx, the patient presented with persistent respiratory distress. CT scan showed an esophagobronchial fistula due to bronchial dehiscence. The fistula was surgically revised with an intercostal muscle flap. Afterwards, there was limited leakage of the fistula and a conservative management was set. The fistula showed a favorable evolution. After an 88-day stay in the hospital he was discharged. Conclusion: An esophageal fistula is a rare, but severe post lung transplantation complication that presents itself in patients in poor condition with a high morbidity. A high level of clinical suspicion is required, followed by rapid diagnosis and management. If treated in time, this complication has a good short-term outcome.