Endosonography is very accurate for the preoperative staging of esophageal carcinoma. Approximately 20-38% of patients with esophageal carcinoma present with high-grade malignant strictures that preclude passage of the dedicated echoendoscope. In patients with such strictures, endosonographic staging of esophageal tumors may be performed after aggressive esophageal dilatation. However, aggressive dilatation and passage of the echoendoscope in patients with high-grade malignant strictures is not without risk. A detailed assessment of the tumor stage in patients presenting with high-grade malignant stenoses has not been previously reported to the authors' knowledge. Seventy-nine patients with esophageal carcinoma were staged preoperatively using endosonography. The results of preoperative staging were compared with the pathologic stage of the esophagectomy specimen when available or the surgical stage (detection of adjacent organ involvement [Stage T4] or metastatic disease [Stage M1] at the time of surgery). Twenty-one patients (26.6%) presented with high-grade malignant strictures precluding endosonographic examination without prior esophageal dilatation. Nineteen of the 21 patients (91%) with high-grade malignant stricture had Stage III or IV disease by histopathologic examination of the surgical specimen. Five of these 21 patients (24%) sustained an esophageal perforation as a result of either wire-guided dilatation, or as a direct consequence of the endosonographic staging procedure. The discovery of metastatic lymph nodes proximal to the stricture resulted in successful staging (assessment of depth of tumor penetration and lymph node involvement) in only 2 of these 21 patients before esophageal dilatation (incomplete staging). Staging of the proximal aspect of the tumor was obtained in the remaining 19 patients before dilatation; however, the accuracy for such incomplete staging was only 33%. The majority of patients with esophageal carcinoma presenting with high-grade malignant strictures precluding endoscope passage without prior dilatation have a relatively advanced stage of disease (Stage III or IV) compared with those patients presenting with less severe stenoses. There is a significant risk for esophageal perforation (24%) when patients with high-grade malignant esophageal strictures undergo preoperative staging using endosonography. Patients with high-grade malignant strictures, therefore, present a relative contraindication to endosonography using the dedicated echoendoscope.