OBJECTIVE The purpose of this article is to investigate the incidence and management of esophageal rupture caused by balloon dilation in patients with benign esophageal strictures. MATERIALS AND METHODS Fluoroscopically guided esophageal balloon dilation was performed on 589 patients with benign esophageal strictures during an 18-year period. The strictures had a range of causes: postoperative anastomotic stricture, corrosive stricture, postradiation stricture, esophageal achalasia, esophageal reflux, congenital stricture, esophageal web, esophageal ulcer, medication fibrosis, chronic inflammation, and posttraumatic stricture (in descending order of frequency). Esophageal rupture was assigned to one of three categories: type 1 was intramural, type 2 was transmural with a contained leak, and type 3 was transmural with an uncontained mediastinal leakage. RESULTS A total of 1421 procedures were performed in 589 patients, with each patient undergoing 1-29 procedures. The technical success rate was 99.8%, and the clinical success rate was 91.7%. Patients with corrosive stricture underwent the highest number of procedures (mean, 4.38 procedures). The incidence of esophageal rupture was 14.7%. All esophageal ruptures were detected immediately after the procedure. Most ruptures (98.6%) were types 1 and 2 and were successfully managed conservatively. Only 1.4% of the ruptures were type 3 and required active management. One of the type 3 ruptures was successfully treated with a retrievable covered stent. Two patients with type 3 ruptures (0.96% of ruptures) underwent surgery and were successfully treated. The rupture rate was not statistically related to the diameter of balloon used. CONCLUSION The incidence of esophageal rupture after fluoroscopically guided esophageal balloon dilation was 14.7%. Almost all ruptures were type 1 or 2 and were successfully managed conservatively. Only 1.4% of the ruptures were type 3 and required active management. There was no procedure-related mortality in any patient. Therefore, in spite of the high incidence of ruptures, fluoroscopically guided balloon dilation is a safe procedure, particularly if a rupture is identified early and managed appropriately.