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This case series documents the management of 3 acute gastrointestinal perforations secondary to upper endoscopic procedures and presents the use of nonoperative management with percutaneous aspiration in lieu of immediate surgical intervention. A growing number of endoscopists are using more advanced resection techniques, further potentiating the risk of gastrointestinal injury, including perforation. When localized perforations occur, endoscopic management has become an effective treatment option. Perforations that cannot be localized, sealed, or successfully treated with endoscopic closure have traditionally required an exploratory laparotomy. However, this series suggests that nonoperative management with percutaneous procedures may be successfully utilized in select patients. In 2 of the cases reported, no closure techniques were used and expectant management resulted in successful outcomes. This study suggests that the use of image-guided aspiration and serial abdominal exams can be utilized successfully in select patients. Image-guided needle aspiration of pneumoperitoneum can decrease patient discomfort and allow reliable serial physical examination, potentially eliminating unnecessary surgery.