Recognition of the importance of early diagnosis and aggressive, definitive surgical intervention has brought about a dramatic decline in mortality related to distal esophageal perforation. In the following retrospective analysis, we have examined all cases of thoracic esophageal perforations diagnosed, consulted, and/or treated by one author (PDK) at the Inova Fairfax Hospital from June 1, 1988 through March 17, 2005. These cases consisted of 48 patients (34 male) with a mean age of 59.4 years (range, 20-92). Among 25 patients with early diagnosis (< or = 24 h), hospital survival was 92%, increasing to 96% when early diagnosis was combined with surgical treatment. Among the 23 patients with late diagnosis (> 24 h), hospital survival was 82.6%, increasing to 92.3% when treated with surgery. We recommend aggressive, definitive surgery for thoracic esophageal perforations, regardless of time of diagnosis. In the absence of phlegmon or implacable obstruction, primary repair offers excellent results with the shortest length of stay. Resection and reconstruction are the best choices in circumstances where significant phlegmon or distal obstruction render primary repair hazardous or inapplicable. Diversion, preferably with proximal and distal esophageal exclusion, may be necessary for patients too ill to undergo more formidable surgery. Conservative, medical therapy may be appropriate in patients with 'microperforations' with no continuing leak. Finally, comfort measures alone may be appropriate where circumstances merit no effort at resuscitation.