We experienced a case of esophageal-bronchial fistula in a hemodialysis patients with chronic renal falure who was saved by operation on a two-step approach. A 55-year-old woman on hemodialysis from 1990 was addmitted to the department for refractory esophageal-bronchial fistura on March 7, 1995. She had been treated conservatively under the diagnosis of esophageal rupture and mediastinitis after upper gastrointestinal fiberscopy. Although a huge cavity and a fistula to the left bronchiole (B⁶ and B¹⁰) were recognized, severe inflammation, malnutrition, low cardiac function and low respiratory function prohibited from aggressive surgery. Therefore, we first tried to improve her general condition by enteral diet assisted with parental nutrition and transfusion. At operation, a two-step approach was adopted. The first operation was performed on September 19, 1995, including esophagectomy, esophagostomy, gastrostomy and closure of the fistura by suture and bond. Sixty-three days lator, the second operation was performed including reconstruction with gastric tube through the retrosternal routs. Postoperative course was uneventful. She was discharged from the hospital 37 days after the second operation.