Twenty-two neonates with esophageal atresia and a distal tracheoesophageal fistula were treated by primary repair. Only if an anastomotic leak was demonstrated was a tube gastrostomy for decompression with trangastric placement of a duodenal tube for feeding performed. Twelve newborns were classified as high-risk by the presence of prematurity with low birth weight (less than 2,250 gm), significant pneumonia, or obvious significant associated anomalies. There was one operative death and 1 late death. Three babies required a tube gastrotomy and duodenal tube for anastomotic leaks. All 20 survivors are symptom free and thriving. Progress in perioperative management of neonates with esophageal atresia may obviate the need for routine gastrostomy and for staging of high-risk newborns.