A review of 1,180 subdiaphragmatic vagotomies performed at the Grace Hospital during the last ten years revealed six esophageal perforations. Sliding hiatus hernia, especially when associated with long-standing esophagitis, and previous gastric or esophageal surgery were implicated as predisposing factors. All patients had anterior lacerations, and the operative reports consistently describe difficulty in dissecting the anterior vagal fibers from the muscularis of the esophagus. Five of the six perforations were recognized at the time of operation and were repaired. All but one of these patients survived. The death in the patient with a recognized perforation occurred on the fifth postoperative day, probably from pulmonary embolus. The only case in the series with an unrecognized perforation died 36 hours post-operatively from fulminating mediastinitis and sepsis.