Zenker's per-oral endoscopic myotomy using bipolar radiofrequency and microwave energy device in a Parkinson's patient with deep brain stimulator implant. Clinical contraindication to use of monopolar diathermy devices limits the performance of third space endoscopy procedures. This video demonstrates Z-POEM procedure using bipolar radiofrequency and high-frequency microwave coagulation energy platform in a patient with Parkinson's disease and deep brain stimulator implant in situ. A 78-year-old gentleman with Parkinson's disease with deep brain stimulator implant since the past six years presented with dysphagia, regurgitation, and recurrent cough once following for four months. On swallowscopy, vocal cords were normal, and there was a large post-cricoid diverticulum. Endoscopy showed a 3-centimeter-long Zenker's diverticulum. Esophageal manometry did not reveal any abnormality at the level of the upper esophageal sphincter. This is the barium swallow study showing a post-cricoid diverticulum and significant holdup of contrast. Our patient was planned for a Z-POEM procedure, which would require diathermy for dissection and cutting. The presence of deep brain stimulator is a contraindication to use monopolar diathermy, as there is high risk of deep brain stimulator device malfunction. Unfortunately, all presently available diathermy knives are monopolar. The alternative would be to use a bipolar diathermy device. Hence, we decided to proceed with a novel bipolar radiofrequency and microwave energy device, which has the ability to dissect, coagulate, and inject through a single accessory. As we can see from the schematic diagram that bipolar energy is safer than monopolar as the current does not traverse the human body. This was the electrosurgical generator and a compatible bipolar energy device used in our case. Double dose of levodopa and carbidopa combination was administered on the morning of the procedure. The deep brain stimulator was turned off before induction of anesthesia. It was maintained off during the procedure. Monopolar device with lowest possible energy was used during dissection. The deep brain stimulator device was turned on before reversal of anesthesia and oral carbidopa levodopa combination was administered 6 hours post procedure. A therapeutic gastroscope with a tapered conical cap attached at its distal end was introduced. A 3 cm long post-cricoid posterior diverticulum is seen compressing upon the esophageal lumen. The bipolar energy device is seen coming out of the scope at the 7 o'clock position through the ridge on the tapered conical cap. A mixture of saline, methylene blue and adrenaline was injected into the submucosa of the septum through the built-in needle of the device. Mucosal incision was taken on the top of the septum of the diverticulum. Submucosal plane was created and dissection carried out in anti-grade direction using inject and cut technique. Submucosal dissection was initiated and an attempt was made to create submucosal tunnels on either side of the septal muscle. Submucosal tunneling was carried out till the base of the diverticulum on the diverticular side of the septum. Submucosal dissection was carried out 2 cm beyond the base of the diverticulum on the esophageal-luminal side of the diverticular septum. Tunneling was thus completed on either side of the septal muscle. After aligning the device perpendicular to the septal muscle, septal myotomy was initiated. Whole thickness septal muscle fibres were cut in a linear fashion till the base of the diverticulum. Pull thickness myotomy was extended up to 2 cm beyond the base of the diverticulum on the esophageal side of the diverticular septum. Mucosal incision was gradually closed using multiple through the scope clips perpendicular to the direction of mucosal incision. Our patient was started on clear water and oral medication 6 hours post procedure and contrast follow on postoperative day 1 showed minimal holdup of contrast at the level of the clips. Neurology team reviewed and opined that the Parkinson's disease was stable and the DBS device was functioning well. Patient's cough had reduced by more than 75% and he was discharged on postoperative day 4 on pureed diet. The bipolar microwave energy device has certain unique features such as precise bipolar cutting, controlled microwave coagulation, integrated injection needle, protective insulated hull and 1 is to 1 rotation. Certain device related and bipolar energy related features were particularly helpful in our case. The integrated coagulation and dissection device with a built in needle reduced instrument exchanges and thus the procedure time. 1 is to 1 rotatability helped device manipulation in the tight post cricoid area, reduction in bleeding and charring due to use of bipolar energy, improved vision and facilitated dissection and coagulation in this delicate area. This bipolar energy device has its own set of limitations. Its stiff core makes it difficult to manipulate in the post cricoid area. The large diameter mandates the use of a therapeutic scope. Dissection using bipolar current although cleaner is somewhat slower than monopolar. Learning curve of this device is not yet established and it requires a close coordination between the endoscopist and the assistant. There are some learning points from technical challenges that we encountered in our case. We used a conical tapered cap to facilitate manipulation of the therapeutic scope in the tight post cricoid area. We lowered the patient table to maintain straighter scope position for smoother device rotation. After precise in vitro alignment, the integrated dissection, coagulation and injection characteristics of the device were used effectively during the procedure. In conclusion, this video highlights the technical challenge for conduct of standard Z-POEM procedure due to presence of a deep brain stimulator implant in a patient with Parkinson's disease which was managed successfully by performing the procedure using bipolar radiofrequency and high frequency microwave energy platform.

Z-POEM procedure

bipolar radiofrequency

Zenker's diverticulum

deep brain stimulator

dysphagia