After the patient has been inducted with general anesthesia, the endoscope is placed into the oropharynx and esophagus by extending the lower jaw anteriorly and placing the endoscope behind the endotracheal tube (Fig. 12-1). The conscious patient is positioned on his or her side, usually the left, and asked to swallow the endoscope. Then the endoscope may be maneuvered by rotation in the hands of the operator, who at all times should be attempting to center the lumen on the video monitor, using insufflation as needed, before advancing the endoscope farther along. The scope should be in the unlocked position. Keeping the lumen in the center of the image decreases the chance of perforation. The scope is advanced with minimal force. After the scope is beyond the first narrowing of the upper esophageal sphincter at the cricopharyngeus, the esophagus is insufflated with air and the mucosa examined as the scope is advanced (Fig. 12-2). A second narrowing occurs in the area of the aortic arch and carina, approximately 24–25 cm from the incisors. The final anatomic narrowing occurs at the lower esophageal sphincter (LES), which is about 40 cm from the incisors. The esophageal, gastric, and duodenal mucosae are examined visually for lesions, strictures, webs, ulcers, dilatations, diverticula, and other pathology (Fig. 12-3). The Z-line is identified, and the length is measured (incisors to Z-line) and documented. The stomach is entered, insufflated, and examined in its entirety. Retroflexion is performed by advancing the scope into the greater curvature and then angling it to achieve maximal retroflexion. The scope is pulled back toward the gastroesophageal junction and turned 360 degrees, providing good visualization of the gastroesophageal junction and its relation to the hiatus from within the stomach. The greater and lesser curvatures of the stomach, as well as the antrum and pylorus, are insufflated and examined. The scope is then passed into the second part of the duodenum to exclude the presence of additional pathology and determine how tight the pylorus may be. In our practice, endoscopy routinely includes visualization up to and including the second part of the duodenum. Before withdrawing the scope from the duodenum, air is removed by suction.
Depending on the indication for esophagoscopy, after visual examination, diagnostic procedures such as biopsy using flexible biopsy forceps or therapeutic procedures can be performed. In the event of stricture, a guidewire may be inserted to cross the stricture before (if the stricture is very tight) or after the scope has traversed it. The scope is withdrawn, and serial dilations are carried out using Savary dilators. Alternatively, a pneumatic dilator can be placed over the guidewire and the stricture dilated using preset pressure and diameter (see Chap. 27). Completion endoscopy is then carried out to evaluate the results of the dilation and to rule out procedure-related injury.