Pneumonectomy is associated with gross anatomic and physiologic changes of the esophagus. So far, only a few studies have examined the influences of anatomic changes of the esophagus and the resulting physiologic consequences. When pneumonectomy is performed without pulmonary replacement, the esophagus is displaced to the side of pneumonectomy and posteriorly. Indentation of the esophagus by the trachea, bronchus, or aortic arch and dilatation at various levels are present. After pneumonectomy, the peak amplitude of esophageal peristaltic contractions is reduced. This feature is more pronounced in patients who are more than 60 years old and in patients who had their pneumonectomy performed more than 6 years ago. Injury of the vagal nerves, local ischemia, scarring of the esophagus and mediastinum after surgery, and disturbance of the autonomic nervous systems are the major reasons leading to esophageal dysmotility and delayed gastric emptying. Despite the severe morphologic and physiologic changes of the esophagus observed after pneumonectomy, few patients complain of gastrointestinal symptoms after pneumonectomy. Esophageal functional abnormalities may be present in patients with lung cancers before pneumonectomy because of a close anatomic relationship between the esophageal vagal nerve supply and the pulmonary hilum, making the vagal nerves susceptible to disturbances by the tumors or by involved hilar or mediastinal lymph nodes. After pneumonectomy, esophageal dysmotility is exaggerated. After recipient pneumonectomy for thoracic organ transplantation, esophageal dysmotility and delayed gastric emptying are common, but their relationship to gastroesophageal reflux, chronic aspiration, or subsequent development of bronchiectasis and obliterative bronchiolitis is controversial. To reduce the incidence of esophageal dysmotility after pneumonectomy, every effort should be made during surgery to prevent direct injury of the esophagus or the vagal nerves. A prospective study involving a larger patient population is needed to precisely define the problem and its management.