Prompt diagnosis and effective treatment are important for thoracic esophageal perforations. The decision for proper management is difficult especially when diagnosed late. However, there is an increasing consensus that primary repair provides good results for repair of thoracic esophageal perforations, which are not diagnosed on time. Primary repair for thoracic esophageal perforations was applied in 20 out of 25 consecutive patients. The time interval between perforation and repair was less than 24 h in six patients (group I), and more than 24 h in 14 patients (group II). The remaining five patients underwent esophagectomy with simultaneous or staged reconstruction because of incorrectable underlying esophageal pathology. Group I had much more iatrogenic causes (P < 0.05). Preoperative sepsis occurred only in group II (P=0.05) and was highly associated with Boerhaave syndrome (P=0.001). Regional viable tissue was used to reinforce the sites of primary repair (n=15, 75%). All of the postoperative morbidity (n=9, 45%) including esophageal leaks (n=6, 30%) and operative death (n=1, 5%) occurred in group II. In patients with postoperative leaks, five eventually healed, but one became a fistula that required reoperation. Primary healing with preservation of the native esophagus was achieved in all 19 patients except one operative death. In addition, the increased incidence of leak and morbidity did not lead to an increase in mortality. In the esophagectomy group, there was no mortality, but one minor suture leak. Regardless of the time interval between the injury and the operation, primary repair is recommended for non-malignant, thoracic, esophageal perforations, but not for anastomotic leaks. Reinforcement that may change the nature of a possible leak is also useful. For incorrectable underlying esophageal pathology, esophagectomy with simultaneous or staged reconstruction is indicated.