Background: Nonoperative, particularly endoscopic techniques are playing an increasing role in the management of acute and chronic esophageal perforation. We hypothesize that selective application of non-surgical treatment can lead to improved outcomes.Patients and Methods: Retrospective assessment of a prospectively-collected, IRB-approved database assessing all patients presenting with esophageal perforation with respect to presentation, management and outcome between June 1989 and December 2007.Results: 72 patients, mean age 64 years (22-96 years), presented with esophageal perforation, iatrogenic (42), barogenic (19), spontaneous (5), other (1). ASA level 3 or 4 was assigned in 73% and 75% had diagnosis and treatment early (<24 hours), 25% late (>24 hours). Decisions regarding approach were based on CT scans 51%, GI contract studies 75%, and upper endoscopy 45%. 48 patients were managed operatively; primary repair 34, resection 6, drainage alone 6 (9 intraoperative stents and 2 T tubes were also used in this group). 24 patients were managed nonoperatively, using a variety of percutaneous nasoenteric drains and endoscopic stents. The number of patients treated late (>24 hours) was 61% in the operative, and 39% in the non-operative group. When the study period is divided into three equal periods, the incidence of nonoperative therapy progressively increased 16.7%, 41.2%, 46.4%. Mean length of stay decreased 23.5, 22.5, 16.4 days, in spite of mean times from perforation to treatment increasing 27, 40, and 75 hours. Mortality and complications (including persistent leak rates) were not significantly different through the three study periods. Overall, mean LOS was 20.5 days (1-87), and was significantly shorter in the non-operative group 15.1 vs. 23.2 days (p=0.003). 43 postoperative complications occurred in 31 patients; 45.8% operative therapy, 37.5% nonoperative therapy (p=0.62). Mortality occurred in 3 patients 4%, 1 operative, 2 nonoperative.Conclusion: Initial therapy for esophageal perforations is evolving towards increasing application of non-operative techniques. This process can occur while maintaining and improving overall outcome parameters. Time between perforation and treatment remains important but not as critical as appropriate assessment and initial management.