Long gap esophageal atresia occurs in approximately 5% of patients with tracheoesophageal anomalies. A small group of such patients have a rudimentary or diverticular distal esophagus that is not amenable to primary repair. These children usually require staged procedures and esophageal replacement using other parts of the intestinal tract. To circumvent the morbidity and delayed repair associated with cervical esophagostomy, colon interposition, or delayed gastric tube interposition, the authors propose the use of a primary gastric tube for early establishment of esophageal continuity in the neonate. Three cases of early esophageal replacement using a gastric tube are described. All three patients were born prematurely, with comorbid conditions, and had a rudimentary distal esophagus. The results of the operation were successful. The authors believe that primary repair of the esophagus, when possible, is the gold standard.