We can draw several conclusions from an analysis of our series: 1. Although prematurity remains to be an important factor in the survival of infants with major surgical or medical disease, the more important risk factor in esophageal atresia and tracheoesophageal fistula concerns: a. Severity of associated anomalies that are uncorrectable and fatal b. Associated complication from the disease or surgery (especially in infants less than 1500 gm). Complications such as tracheal perforation and gastric perforation are not tolerated well and can be fatal (the case in two of our patients). 2. Premature infants weighing even less than 1500 gm tolerate a major thoracotomy well with correction of an esophageal anomaly. In this series, the smallest weighed 1220 gm. This infant had an uneventful recovery with a good outcome. 3. Simultaneous correction of associated anomalies also is well tolerated by these patients. Judgment, however, should be exercised as to the extent and length of operative procedures performed. 4. Staged reconstruction is still an excellent alternative when one is dealing with a premature infant with concomitant surgical procedures, although lengthening operations with primary anastomosis for the most part have replaced the need for staging esophageal reconstruction. 5. Radiographs indicating a high upper pouch lesion also require bronchoscopic identification of the fistula prior to operative intervention to provide a guide to the proper surgical approach to the lesion. 6. Acute anastomotic leaks should be treated aggressively by antibiotics and immediate thoracotomy, with cervical esophagostomy, closure of the distal esophagus, drainage of the mediastinum, and gastrostomy placement. immediate intervention will result in better survival.(ABSTRACT TRUNCATED AT 250 WORDS)