Esophageal perforation is uncommon but carries a high morbidity and mortality, particularly if the injury is not detected early before the onset of systemic signs of sepsis. The fact that it is an uncommon problem and it produces symptoms that can mimic other serious thoracic conditions, such as myocardial infarction, contributes to the delay in diagnosis. Patients at risk for iatrogenic perforations (esophageal malignancy) frequently have comorbidities that increase their perioperative morbidity and mortality. The optimal treatment of esophageal perforation varies with respect to the time of presentation, the extent of the perforation, and the underlying esophageal pathologic conditions.