Esophagoscopy is an endoscopic procedure that permits visualization of the internal lumen of the esophagus. It is usually accomplished as a part of a more extended procedure called esophagogastroduodenoscopy (EGD), which includes the stomach and duodenum. This visual examination is performed by using a specially designed endoscope (flexible or rigid). Since its invention by Philip Bozzini in 1806, the endoscope, which at that time consisted of a rigid tube, external light source, and a viewer, has evolved to become smaller, flexible, and more versatile. Currently, flexible endoscopes are equipped with video imaging systems that generate magnified, clear images that can be viewed by the entire operating room staff. Although flexible esophagoscopy can be performed with topical anesthesia, conscious sedation, or general anesthesia, rigid esophagoscopy is usually performed with the patient under general anesthesia.

Esophagoscopy is the primary diagnostic tool for any disease suspected to involve the esophagus. It also can be used for many different therapeutic applications, including delivery of ablative energy (cautery and photodynamic or laser therapy) for tumors, banding of varices, cauterization or injection for bleeding, deployment of stents, removal of foreign objects, and other surgical manipulations. Expertise in esophagoscopy is a requisite for all esophageal and general thoracic surgeons, and guidelines for skill attainment have been established and published by a number of surgical societies.^1–5

The modern endoscopic system consists of an endoscope, light source, optical system, and working port. A basic understanding of these components, outlined in Table 14-1, is essential. For most applications, a flexible videoendoscope is sufficient and preferred. Flexible endoscopes come in many sizes. The larger sizes allow for wider suction and working ports while providing excellent images. The smaller sizes are more comfortable for the patient and allow sufficient room for additional devices to be placed through the lumen of the esophagus at the same time. Rigid esophagoscopes are large, inflexible metal cylinders that come in different widths and lengths. These are used only for work that requires a very wide lumen, such as removing a foreign object or repositioning a stent.

EGD is indicated when there is a clinical suspicion of pathology of the upper gastrointestinal tract, before surgery of the esophagus or stomach, and for specific therapy of known disorders. This procedure enables the surgeon to visualize the endoluminal anatomy in great detail, as well as structural anomalies, disorders, and defects of the gastrointestinal tract. In addition, endoscopy is an excellent way to obtain tissue biopsy for histologic diagnosis or to examine the mediastinum or the rest of the layers of the esophagus with ultrasound.

Endoscopy should be performed in a controlled, well-equipped setting staffed and monitored by experienced personnel. Such locations usually include freestanding endoscopy suites and operating rooms. In emergent cases, the equipment and personnel can be moved to the bedside in the ICU or emergency ward, obviating the need to move a critically ill patient. As for any other procedure, the endoscopist should be well trained and have proper credentials to perform the procedure. Clear indications and expectations for any procedure should be discussed with the patient before endoscopy. It is also important for the surgeon to be familiar with the potential complications of endoscopy and to take proactive measures to reduce overall morbidity (Table 14-2). Several good practices are (1) to avoid applying undue force when maneuvering the instrument through the patient’s oropharynx or esophagus because this may lead to perforation or unsafe instrumentation, (2) to remove all tubes that are in place (e.g., nasogastric tube) before starting the procedure, and (3) to not compromise patient care by lack of the equipment required to perform the proposed procedure, a particular concern in the office setting.

The risk of endoscopy arises from the patient’s medical condition, anesthetic management, and, the actual procedure. A careful and thorough preprocedural assessment of the patient, including evaluation, selection, and preparation, is the first step for any surgical procedure. Particular attention should be focused on history of coagulopathy (primary or secondary to medication) because this can increase the procedural risk significantly. Patients deemed high risk secondary to other comorbid disease or procedures that may require technology not readily available in the outpatient setting should be treated in a hospital setting. All patients are assessed for their relative risk of undergoing anesthesia using standard American Society of Anesthesiologists’ (ASA) guidelines.⁶ Anesthesia-related risks include aspiration, intravenous conscious sedation or general anesthesia, and anaphylaxis. Patients with an ASA score of 4, defined as a “patient with severe systemic disease that is a constant threat to life,” should not undergo endoscopy in the office setting. Patients with an ASA score of 3 (a “patient with severe systemic disease”) should undergo additional preoperative assessment to determine the appropriateness of office endoscopy. Before the endoscopic procedure, patients must be given clear instructions that stress the importance of fasting for at least 6 to 8 hours before the procedure. Aspiration can be a catastrophic complication. Procedural complications are reduced in the hands of an experienced endoscopist.