Transoral Esophagoscopy

Updated: Nov 28, 2022
Author: Dan C Cohen, MD; Chief Editor: Kurt E Roberts, MD 

Overview

Background

Esophagoscopy is a procedure in which a flexible endoscope is inserted through the mouth or, more rarely, through the nares and into the esophagus. The endoscope uses a charge-coupled device to display magnified images on a video screen. The procedure allows visualization of the esophageal mucosa from the upper esophageal sphincter all the way to the esophagogastric junction (EGJ).

This procedure is one of several procedures that fall under the category of upper endoscopy, including gastroscopy, esophagogastroduodenoscopy (EGD), and enteroscopy. Esophagoscopy alone is uncommon: It is generally performed as part of a more complete upper endoscopic procedure in which the esophagus, stomach, and portions of the small intestine are explored endoscopically.

In the United States, esophagoscopy is usually performed with moderate sedation, which is achieved by administering a narcotic and benzodiazepine in combination. In Europe and Asia, however, the procedure is commonly performed without sedation. Topical anesthesia is sometimes implemented to improve patient tolerance and comfort. Very rarely, general anesthesia is used in patients who are difficult to sedate or are at higher risk of airway compromise. There is some evidence for the effectiveness of unsedated esophagoscopy in monitoring pediatric esophageal disease.[1, 2]

The focus of this article is on transoral esophagoscopy. For information regarding transnasal esophagoscopy, see Transnasal Esophagoscopy.

Indications

Esophagoscopy is routinely performed in an outpatient setting, though inpatient and emergency department management of gastrointestinal (GI) diseases often require urgent inpatient upper endoscopy, including but not limited to esophagoscopy. Moreover, certain conditions necessitate routine esophageal endoscopic surveillance and therapeutics. In such cases, a procedure may be limited to esophageal exploration alone. Indications for esophagoscopy include the following:

  • Food bolus or foreign object impaction
  • Evaluation and management of  gastroesophageal reflux disease (GERD), [3]  including noncardiac chest pain.
  • Screening and surveillance of  Barrett esophagus [4, 5, 6]  (see the video below)
  • Treatment and surveillance of  esophageal varices [7]
  • Evaluation and management of  dysphagia, [8]  including dilation of esophageal strictures
  • Evaluation and management of odynophagia
  • Evaluation and management of esophageal cancer, [9, 10, 11]  including placement of esophageal stents
  • Evaluation of the esophagus after abnormal imaging studies
This video, captured via esophagoscopy, shows a long circumferential segment of Barrett esophagus. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.

Contraindications

Esophagoscopy is considered a safe procedure, with a complication risk of approximately 1 per 1000 procedures.[12, 13]  Absolute contraindications include the following:

  • Hemodynamic instability
  • Failure to obtain consent
  • Possibility of perforation

Relative contraindications for esophagoscopy include the following:

  • Anticoagulation in the appropriate setting (ie, esophageal dilation)
  • Head and neck surgery
  • Pharyngeal diverticulum
  • History of procedure intolerance

Technical Considerations

Best practices

The American Society for Gastrointestinal Endoscopy (ASGE) has recommended understanding of indications, limitations, contraindications, alternatives, principles of conscious sedation, and correct interpretation of endoscopic findings in order to achieve competency in performing upper endoscopic procedures.

Furthermore, ASGE has determined that at least 100 upper endoscopic procedures are required for trainees to attain competency in diagnostic upper endoscopy.

Therapeutic upper endoscopy poses further challenges and complexities and therefore requires additional training. ASGE recommendations for the requirements to attain competency in therapeutic upper endoscopy are available through the society Web site (see American Society for Gastrointestinal Endoscopy).

 

Periprocedural Care

Patient Education and Consent

Informed consent must be obtained prior to the procedure. The risks, benefits, complications, and alternative treatments must be reviewed with the patient.

Preprocedural Planning

Before the procedure, a full history should be obtained from the patient, and all previous and current medical records should be reviewed. A full physical examination should be performed, with special attention given to the oral cavity and pharynx. The thyroid and parathyroid glands should be palpated, and palpation for cervical and supraclavicular lymph nodes should be performed when esophageal cancer is suspected. The existence of poor dentition should be documented.

Patient Preparation

The patient is placed in the left lateral decubitus position. Moderate sedation is then accomplished by using a combination of narcotic and benzodiazepine, which are infused intravenously in incremental doses.

 

Technique

Standard Approach

With the patient properly positioned and sedation accomplished, the scope is inserted into the oropharynx with visualization of the epiglottis and vocal cords. The scope is then advanced through the piriformis sinuses and into the esophageal lumen. Air is insufflated to distend the esophageal lumen. Careful inspection of the esophagus is then accomplished, and the findings are photodocumented.

The video below shows an example of pediatric esophagoscopy.

Esophagoscopy on a 3-year-old child. The esophagoscope is introduced via the mouth. As the scope enters the esophageal inlet, you can see the larynx with an endotracheal tube passing through the vocal folds. The esophagocscope meets some resistance as it passes through the upper esophageal sphincter. The esophagus is then entered, and the mucosal lining of the esophagus is evaluated. The esophagus is then passed through the lower esophageal sphincter, entering the stomach. The rugae of the stomach are very distinct. The pylorus is visualized first, and then the scope is turned 180º, and the lower esophageal sphincter is visualized. You can see the scope coming through the lower esophageal sphincter. Video courtesy of Ravindhra G Elluru, MD, PhD.

Diagnostic and therapeutic applications of esophagoscopy include the following:

  • Performance of biopsies (see the first video below)
  • Banding of esophageal varices (see the second, third, and fourth videos below)
  • Retrieval of a food bolus or foreign object using nets, baskets, forceps, and snares
  • Cauterization and endoscopic clip deployment
  • Dilations using balloon or Savary-Gilliard dilators (see the fifth video below)
  • Performance of injections
  • Deployment of stents (see the sixth video below)
  • Resection and/or ablation of mucosal tissue (see the seventh, eighth, ninth, and 10th videos below)
  • Deployment and/or insertion of instruments such as capsules and tubes
This video, captured via esophagoscopy, shows biopsies being obtained from the esophagus. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
This video, captured via esophagoscopy, shows band ligation of esophageal varices. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
This video, captured via esophagoscopy, shows band ligation of esophageal varices. One of the varices has a red wale sign, which is a sign of recent bleeding. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
This video, captured via esophagoscopy, shows band ligation of esophageal varices. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
This video, captured via esophagoscopy, shows balloon dilation of the distal esophagus. This is performed in patients with dysphagia who are found to have an esophageal stricture or ring. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
This video shows circumferential Barrett esophagus via esophagoscopy. The HALO 360 device is in the esophageal lumen ready to perform radiofrequency ablation. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
This video, captured via esophagoscopy, shows the use of a HALO 360 device to perform radiofrequency ablation for Barrett esophagus. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
This video, captured via esophagoscopy, shows the Barrett esophagus after having just undergone a treatment with radiofrequency ablation using the HALO 360. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
This video shows a stent that has successfully been deployed into the esophageal lumen. This patient had a small esophageal perforation, and the stent was placed to allow him to heal and eat. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.

The videos below depict normal findings on esophagoscopy.

This video shows a normal esophagogastric junction (EGJ). This is where the esophageal squamous mucosa meets the gastric columnar mucosa. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
This video shows esophagoscopy with normal findings. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
This video shows esophagoscopy with normal findings. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
This video shows esophagoscopy with normal findings. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.

Once the procedure is completed, the endoscope is removed from the patient, and the patient is monitored postprocedurally for any possible complications and allowed to recover from sedation. If the procedure was performed in the outpatient setting, the patient is discharged from the endoscopy unit with an escort after approximately 1 hour.

Alternative Approaches

Transnasal esophagoscopy is a procedure in which an ultrathin 4-mm flexible endoscope is introduced into the esophagus through the nares. It is a safe and well tolerated procedure that can be performed without sedation in an office-based setting. Transnasal esophagoscopy has been shown to have good results in visualizing the esophageal mucosa; however, its main limitation stems from the small channel caliber, through which it is not possible to pass many of the instruments necessary to perform therapeutic interventions.[2, 14, 15, 16, 17]

Esophageal capsule endoscopy is a procedure in which a capsule the size and shape of a pill with a tiny camera is swallowed by the patient. Multiple images of the esophagus are then obtained for viewing. The procedure does not require sedation and is therefore safer for the patient than traditional esophagoscopy is.

Additionally, esophageal capsule endoscopy has been shown to yield improved patient tolerance and therefore may have implications with regards to patient willingness to proceed with endoscopic screening and surveillance. This has especially been studied in the setting of esophageal varices. Multiple studies have shown that esophageal capsule endoscopy is good at detecting esophageal varices.[15, 18, 19, 20, 21, 22]  In a multicenter trial that evaluated 288 patients undergoing screening or surveillance for esophageal varices with both traditional upper endoscopy and esophageal capsule endoscopy, overall agreement between the two procedures for detecting varices was 85.8%.[23]

Complications

Esophagoscopy is considered a safe procedure, with a complication risk of approximately 1 per 1000 procedures. Mortality is in the range of 0.5-3 deaths per 10,000 procedures.[12, 13, 24]  Common complications include the following[25] :

  • Bleeding
  • Infection
  • Perforation
  • Cardiopulmonary problems
  • Adverse reaction to medications

Aspiration, oversedation, hypoventilation, and airway obstruction account for more than 50% of major complications related to upper endoscopy.[26, 27]