Background: Nasogastric tubes (NG) are commonly used for maintaining conduit decompression after esophagectomy. We investigated the use of retrograde tube gastrostomy (RG) after esophagectomy. Methods: Patients underwent either NG or RG placement for postoperative conduit decompression. Both tubes were maintained on low continuous suction. Results: Between 2000 and 2008, 306 patients underwent esophagectomy with reconstruction. One hundred ninety-three patients underwent NG and 113 underwent RG placement. The 2 groups were comparable in age, gender, tumor stage, and smoking status. Patients in the NG group were more likely to have received neoadjuvant therapy and to have a thoracotomy for esophagectomy. The incidence of respiratory complications was lower in the retrograde group compared with the NG group: Pneumonia, 9 of 113(8.0%) vs 50 of 193 (25.9%), p < 0.001; respiratory failure requiring bronchoscopy or reintubation, 12 of 113 (10.8%) vs 46 of 193 (23.8%), p = 0.004; aspiration, 4 of 113 (3.5%) vs 20 of 193 (10.4%), p =0.045. The incidence of cardiac dysrhythmias was also lower in the retrograde group (18 of 113 [15.9%] vs 69 of 193 [35.8%], p < 0.001). The incidence of wound complications, myocardial infarction, stroke, and conduit necrosis-anastomotic leak was similar between groups. In a multivariate regression model an NG tube was the strongest predictor for postoperative pneumonia (odds ratio 3.27, 95% confidence interval 1.50 to 7.12). The other predictors were prior chest surgery, smoking, and thoracotomy incision. There were 4 minor complications related to the retrograde tube (wound infection n = 1, broken tube requiring endoscopy n = 2, tube caught in anastomosis detected intraoperatively n = 1). Conclusions: Retrograde gastrostomy decompression of the conduit after esophagectomy is effective and diminishes complications compared with NG tube drainage.