Introduction The need for gastrostomy tube placement after free jejunal transfer for circumferential pharyngo-esophageal reconstruction is controversial. Our management has changed over the past 12 years such that intraoperative gastrostomy tube placement is now rarely performed. Instead, only patients who fail to maintain adequate nutrition or have postoperative complications are treated with PEG tube placement. The purpose of this study was to review our experience with pharyngeal reconstruction and to establish useful guidelines for enteral tube placement in these patients. Methods A retrospective review of all patients treated with microvascular jejunal transfer over a 12-year period was performed. Chart review and data from a prospectively maintained microsurgical database were used to evaluate patient demographics and variables such as free flap failures, clinical nutrition evaluation of swallowing, timing of enteral tube placement and removal, and complications Results 108 patients underwent microvascular free jejunal transfers during the study period. Of the 108 jejunal reconstructions 63% did not require any enteral feeding tubes. Forty patients (37%) did have an enteral feeding tube at some stage. Of these patients 52.4% had preoperative PEG tubes, 28.6% had intraoperative gastrostomy tubes, and 19% had postoperative enteral tubes. Of the 8 patients who underwent postoperative PEG tube placement, 5 (62.5%) were for persistent dysphagia, 2 (25%) for treatment of persistent salivary fistulas, and 1 (12.5%) for stricture formation. The mean timing of the postoperative PEG tube placement was 2.9 months (2 weeks-9 months). 91 of 108 patients (83%) were able to maintain adequate nutrition by oral intake alone while 3 patients (2.7%) required tube feed supplementation, and 14 patients (12.9%) were totally dependent on tube feeds. Of the 12 patients who had intraoperative gastrostomy tubes 10 patients (83.7%) could maintain adequate per oral nutrition and only 2 patients (16.7%) remained tube feed dependent. Five complications (2 infections, 3 leaks) were directly attributable to enteral tube placement corresponding to a morbidity rate of 12.5%. There were no flap related or suture line complications in patients who underwent postoperative PEG tube placement. Conclusion Most patients who undergo free jejunal flaps will eventually be able to swallow, eat and maintain an adequate nutritional status without the need for permanent feeding tubes. A majority of enteral feeding tubes placed pre/intraoperatively will be removed within a short period of time post jejunal free flap transfer. Therefore, routine intraoperative gastrostomy tube placement is rarely indicated.