Objective: To evaluate outcomes associated with esophageal perforation (EP) management at a national level and determine predictive factors of 90-day mortality (90dM), failure-to-rescue (FTR), and major morbidity (MM, Clavien-Dindo 3-4). Background: EP remains a challenging clinical emergency. Previous population-based studies showed rates of 90dM up to 38.8% but were outdated or small-sized. Methods: Data from patients admitted to hospitals with EP were extracted from the French medico-administrative database (2012–2021). Etiology, management strategies, and short and long-term outcomes were analyzed. A cutoff value of the annual EP management caseload affecting FTR was determined using the “Chi-squared Automatic Interaction Detector” method. Random effects logistic regression model was performed to assess independent predictors of 90dM, FTR, and MM. Results: Among 4765 patients with EP, 90dM and FTR rates were 28.0% and 19.4%, respectively. Both remained stable during the study period. EP was spontaneous in 68.2%, due to esophageal cancer in 19.7%, iatrogenic postendoscopy in 7.3%, and due to foreign body ingestion in 4.7%. Primary management consisted of surgery (n = 1447,30.4%), endoscopy (n = 590,12.4%), isolated drainage (n = 336,7.0%), and conservative management (n = 2392,50.2%). After multivariate analysis, besides age and comorbidity, esophageal cancer was predictive of both 90dM and FTR. An annual threshold of ≥8 EP managed annually was associated with a reduced 90dM and FTR rate. In France, only some university hospitals fulfilled this condition. Furthermore, primary surgery was associated with a lower 90dDM and FTR rate despite an increase in MM. Conclusions: We provide evidence for the referral of EP to high-volume centers with multidisciplinary expertise. Surgery remains an effective treatment for EP.