Even with early diagnosis and treatment, open surgical repair of esophageal perfo­rations is still associated with signicant morbidity and mortality. Although this chapter focuses on surgical repair of esophageal perforations, recent developments in endoscopic approaches have radically changed the management paradigm for esophageal perforations. In appropriate settings, stenting is the primary treatment modality. In retrospective series, esophageal stenting has been associated with suc­cessful exclusion of the leak in up to 89% of patients [10, 11]. However, stenting often requires repeat procedures for stent changes. In the absence of a stricture, maintaining stent position can be challenging. Hence, even when stents are success­fully placed, there can be a need for concurrent debridement or decortication of the lung via thoracotomy, which can obviate the benets of the stenting only approach [12]. Risks for stent failure include cervical esophageal perforations; perforations at the gastroesophageal junction; and perforation greater than 6 cm [13]. Overall, stenting for esophageal perforation may lead to lower costs and shorter lengths of stay (5-day shorter length of stay and earlier oral alimentation) for suitable patients [14].

With the popularization of per oral endoscopic myotomy (POEM) for achalasia and complex ESD, endoscopic clipping has emerged as an alternate endoscopic approach to close mural defects. Endoscopic clipping is best suited for iatrogenic injuries diagnosed in real time with minimal extraluminal contamination. More recently, endoscopic vacuum sponge therapy has been utilized to treat both early and late esophageal perforations. Endoscopic vacuum sponge therapy remains investigational and is generally associated with lower rates of closure than with stenting or surgical approaches [15, 16]. Its advantages are that it allows good con­trol of mediastinal sepsis and can aid in gradual closure of an abscess cavity.