They do use much more flexible tubes than they used to. They can use smaller tubes if they think they are going to have difficulty. I've had them done with and without sedation. I really don't like it without - you get the nasty gagging as it goes down, and to me, its always felt very uncomfortable when they push it down into my stomach. But its just uncomfortable rather than painful, so if you really don't like sedation, then its manageable without, and it is over and done with fairly quickly with little or no after effects. My neck isn't good, and I do have the feeling of my vertebrae jagging into my throat when my neck is bad, as well as intermittent swallowing problems, but I managed to have an endoscopy done without sedation, and without any problems. I did take a squishy microbead cushion with me into the procedure room, to make sure that I could lie comfortably on my side (cushion supporting my neck) while they did it, and I think that helped.