The use of fluoroscopic guidance for Maloney dilation is controversial. In order to determine if fluoroscopic analysis would enhance the success of dilation and increase recognition of adverse events, we prospectively studied 125 Maloney dilations in 80 patients (mean age, 69.3 years) with mild esophageal strictures. Most strictures (89%) resulted from acid-peptic disease. Operators included two staff physicians (5 and 25 years of experience) and one trainee (1 year of experience). Dilations were performed with the patient seated upright and the operator noting the presence and amount of resistance (dilator size, 36F to 60F; median, 50F). The fluoroscopic monitor was not visible to the operator, and the results were recorded by an observer who did not communicate with the operator. Operator assessment of Maloney dilation was correct in 122 of 125 procedures. Two failures were interpreted as no passage by the operator when passage had occurred as confirmed by fluoroscopy. One failure was interpreted as passage when no passage had occurred as indicated by fluoroscopy. Adverse events included 1 episode of tracheal intubation and failure to recognize the dilator tip curling in the esophagus as observed by fluoroscopy in 6 of 125 (4.8%) procedures. Operator assessment of resistance was more often associated with curling of the dilator on the greater curve of the stomach than with an esophageal stricture. Greater operator experience tended to correlate with increased success and correct interpretation of dilation. Maloney dilations performed with patients at 30° rather than upright at 90° were associated with a marked increase in unsuccessful dilator passage and curling of dilator tip. We conclude that fluoroscopy is not necessary for successful Maloney dilation of uncomplicated, benign esophageal strictures when the procedure is performed with the patient seated upright. (Gastrointest Endosc 1995;41:11-4.)