Validity and reliability of the Malay language Perception Towards Smoking Questionnaire (BM-PTSQ) among secondary school adolescents: Further validation using Confirmatory Factor Analysis.

INTRODUCTION: Perception is an essential factor influencing smoking among adolescents. Thus, a valid tool for measuring perception is a requisite in smoking studies. This study further establishes the validity and reliability of a Malay language version of the Perception Towards Smoking Questionnaire (BM-PTSQ) for assessing the perception of smoking among secondary school-going adolescents in Malaysia. METHODS: We administered the BM-PTSQ to 669 secondary school students selected through multistage sampling; 60% of respondents were male (n=398), and 69.9% (n=463) were from rural areas. Respondents were aged 13-16 years, 36.4% (n=241) were 13 years, 40.0% (n=265) were 14 years, and 23.6% (n=156) were 16 years old. We used parallel and exploratory factor analysis (EFA) to determine the domains of the questionnaire. In addition, we also employed EFA, confirmatory factor analyses (CFA), and Cronbach's alpha to evaluate the construct validity and reliability of the BM-PTSQ. RESULTS: EFA and parallel analysis identified two domains in the BM-PTSQ that accounted for 62.9% of the observed variance, and CFA confirmed the two-domain structure. The two domains' internal consistency scores ranged from 0.702 to 0.80, which suggested adequate reliability. CONCLUSIONS: The BM-PTSQ has acceptable psychometric validity and is appropriate for assessing smoking perception and intention among Malaysian secondary school-aged youth. Researchers should further evaluate this tool's applicability in a more sociodemographically diverse population.

Bezoar at Jejunojejunostomy Following Liver Transplant: A Case Report.

During pediatric liver transplant, biliary reconstruction is often performed using Roux-en-Y choledoc-hojejunostomy or hepaticojejunostomy due to size mismatch, excessive tension caused by distance between donor and recipient ducts, or for transplant to treat primary biliary pathology. This method can be associated with additional small bowel-related complications compared with end-to-end ductal anastomosis. We report a case of late small bowel obstruction secondary to an impacted bezoar that formed at a patulous jejunojejunostomy portion of the biliary-enteric anastomosis. The patient was a 26-year-old male patient, who underwent deceased donor whole liver transplant for pediatric acute liver failure. Prior to his presentation to our institution with 2 days of abdominal pain, nausea, persistent burping, and intermittent vomiting, the patient reported an uneventful posttransplant course and was followed up at the institution where his transplant was performed. There were no reported changes in diet or lifestyle and no similar episodes during his follow-up. The patient was managed surgically after a brief trial of nonoperative management. At laparotomy, the anastomosis was resected and reconstructed to improve enteric drainage and prevent recurrent bezoar formation. The patient was discharged with no postoperative complications and remained asymptomatic at 11 months follow-up. We describe the clinical course and our technical approach at initial choledochojejunostomy creation and at jejunojejunostomy revision.

Comparative Evaluation of Compressive and Diametral Tensile Strength in Die Stone Reinforced With Different Types of Nanoparticles: An In Vitro Study.

AIM: To investigate the effect of different types of nanoparticles on the compressive strength (CS) and diametral tensile strength (DTS) of type IV dental stones. MATERIALS AND METHODS: A total of 100 specimens were made from the mould for all five groups. Four commercially available nanoparticles (aluminium oxide (Al2O3), silicon dioxide (SiO2), zinc oxide (ZnO), and zirconium oxide (ZrO2)) were used in this study in a concentration of 10%. CS and DTS tests were performed in a universal test machine. The data were statistically analysed using ANOVA and Student's t-test. RESULTS: The interaction between nanoparticles and the type of dental stone was found to be statistically significant (p < 0.05). CS and DTS values decreased by adding all four nanoparticles. The lowest CS and DTS were observed in 10% ZnO nanoparticles when added to type IV dental stone. CONCLUSION: It was concluded that the addition of nanoparticles (Al2O3, SiO2, ZnO, and ZrO2) to die stone significantly decreased the CS and DTS for all groups. Among all groups, the incorporation of 10% ZrO2 nanoparticles (group E) to die stone showed significantly less decrease in CS and DTS compared to Al2O3, SiO2, and ZnO. Incorporation of ZnO nanoparticles, on the other hand, showed a significantly more amount of decrease in the CS and DTS compared to Al2O3, SiO2, and ZrO2.

Comparative Analysis of Three Different Impression Techniques for Impression Defects and Dimensional Accuracy Using a Digital Intraoral Scanner for Fixed Partial Dentures: An In Vivo Study.

AIM: To evaluate the impression defects and compare the dimensional accuracy of three different impression techniques (single-step, two-step without spacer, two-step with spacer) for fixed partial dentures using a digital intraoral scanner in the anterior maxillary region. MATERIALS AND METHODS: Thirty subjects, above the age of 18 years with maxillary central/lateral incisor requiring fixed prostheses were selected according to the inclusion and exclusion criteria. The impressions were rated and evaluated using Heine C2.3K Binocular loupes (Heine Ltd., Dover, NH, USA). An intraoral scanner and digital vernier calipers were used to study and compare the dimensional accuracy of all three impression techniques.  Results: Statistical analysis using the chi-square test revealed that the single-step double mix technique showed the least number of defects (40%), followed by the two-step without spacer (56.7%) and then the two-step with spacer (80%) impression techniques. Using Kruskal Wallis and Mann Whitney U test for dimensional accuracy, it was found that the two-step with spacer impression technique was closer to the control group (intraoral scanner) followed by the two-step without spacer and then the single-step double mix impression techniques. CONCLUSION: All three impression techniques showed the presence of impression defects, mainly voids and bubbles. The single-step double mix and two-step without spacer techniques had more favourable outcomes compared to the two-step with spacer impression technique. The two-step with spacer impression technique was dimensionally more accurate compared to the two-step without spacer and single-step double mix techniques for fixed partial dentures.

The Role of Red Cell Distribution Width as a Prognostic Marker in Chronic Liver Disease: A Literature Review.

Liver disease is one of the leading public health problems faced by healthcare practitioners regularly. As such, there has been a search for an inexpensive, readily available, non-invasive marker to aid in monitoring and prognosticating hepatic disorders. Recently, red blood cell distribution width (RDW) has been found to be associated with various inflammatory conditions with implications for its use as a potential marker for assessing disease progression and prognosis in multiple conditions. Multiple factors effect red blood cell production whereby a dysfunction in any process can lead to anisocytosis. Furthermore, a chronic inflammatory state leads to increased oxidative stress and produces inflammatory cytokines causing dysregulation and increased intracellular uptake and use of both iron and vitamin B12, which leads to a reduction in erythropoiesis causing an increase in RDW. This literature review reviews in-depth pathophysiology that may lead to an increase in RDW and its potential correlation with chronic liver diseases, including hepatitis B, hepatitis C, hepatitis E, non-alcoholic fatty liver disease, autoimmune hepatitis, primary biliary cirrhosis, and hepatocellular carcinoma. In our review, we examine the use of RDW as a prognostic and predictive marker for hepatic injury and chronic liver disease.

Early prediction of post-ERCP pancreatitis by post-procedure amylase and lipase levels: A systematic review and meta-analysis.

Background and study aims Post-ERCP pancreatitis (PEP) is the most common complication attributed to the procedure, its incidence being approximately 9.7 %. Numerous studies have evaluated the predictive efficacy of post-procedure serum amylase and lipase levels but with varied procedure-to-test time intervals and cut-off values. The aim of this meta-analysis was to present pooled data from available studies to compare the predictive accuracies of serum amylase and lipase for PEP. Patients and methods A total of 18 studies were identified after a comprehensive search of various databases until June 2021 that reported the use of pancreatic enzymes for PEP. Results The sample size consisted of 11,790 ERCPs, of which PEP occurred in 764 (6.48 %). Subgroups for serum lipase and amylase were created based on the cut-off used for diagnosing PEP, and meta-analysis was done for each subgroup. Results showed that serum lipase more than three to four times the upper limit of normal (ULN) performed within 2 to 4 hours of ERCP had the highest pooled sensitivity (92 %) for PEP. Amylase level more than five to six times the ULN was the most specific serum marker with a pooled specificity of 93 %. Conclusions Our analysis indicates that a lipase level less than three times the ULN within 2 to 4 hours of ERCP can be used as a good predictor to rule out PEP when used as an adjunct to patient clinical presentation. Multicenter randomized controlled trials using lipase and amylase are warranted to further evaluate their PEP predictive accuracy, especially in high-risk patients.

Application of artificial intelligence in diagnosis of pancreatic malignancies by endoscopic ultrasound: a systemic review.

Background: Pancreatic cancer (PC) is a highly fatal malignancy with a global overall 5-year survival of under 10%. Screening of PC is not recommended outside of clinical trials. Endoscopic ultrasonography (EUS) is a very sensitive test to identify PC but lacks specificity and is operator-dependent, especially in the presence of chronic pancreatitis (CP). Artificial Intelligence (AI) is a growing field with a wide range of applications to augment the currently available modalities. This study was undertaken to study the effectiveness of AI with EUS in the diagnosis of PC. Methods: Studies from MEDLINE and EMBASE databases reporting the AI performance applied to EUS imaging for recognizing PC. Data were analyzed using descriptive statistics. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was used to assess the quality of the included studies. Results: A total of 11 articles reported the role of EUS in the diagnosis of PC. The overall accuracy, sensitivity, and specificity of AI in recognizing PC were 80-97.5%, 83-100%, and 50-99%, respectively, with corresponding positive predictive value (PPV) and negative predictive value (NPV) of 75-99% and 57-100%, respectively. Types of AI studied were artificial neural networks (ANNs), convolutional neural networks (CNN), and support vector machine (SVM). Seven studies using other than basic ANN reported a sensitivity and specificity of 88-96% and 83-94% to differentiate PC from CP. Two studies using SVM reported a 94-96% sensitivity, 93%-99% specificity, and 94-98% accuracy to diagnose PC from CP. The reported sensitivity and specificity of detection of malignant from benign Intraductal Papillary Mucinous Neoplasms (IPMNs) was 96% and 92%, respectively. Conclusion: AI reported a high sensitivity with high specificity and accuracy to diagnose PC, differentiate PC from CP, and differentiate benign from malignant IPMN when used with EUS.

Impact of Covid-19 pandemic on volume and surgeon professional fees generated by emergency general surgery procedures.

INTRODUCTION: The COVID-19 pandemic has changed the dynamics of healthcare in the USA. In early 2020, most states issued orders to stop non-emergent elective surgeries. This contracted the overall revenue generated by the hospital systems. The impact of COVID-19 pandemic on volume has not been well studied but effects on surgeon professional fees generated remains unexplored. The goal of this study was to assess if COVID-19 pandemic has affected surgeon professional fees and revenues generated from emergency general surgeries. METHODS: This is a retrospective review to compare surgical case volume in 2019 and 2020. We obtained our data from a tertiary care referral center database. Data were collected from February to April of 2019 and 2020, corresponding to the duration of statewide ban on non-emergent surgical cases. We used the most reported current procedural terminology (CPT) Code for each surgical procedure to calculate the surgeon professional fees generated. We calculated the percentage difference in surgeon professional fees between 2019 and 2020 for comparison. RESULTS: There was a statistically significant decrease in daily emergent operations between 2019 and 2020 time periods (6.13/day vs 4.64/day). There was a statistically significant decrease in hospital admissions for appendicitis, cholecystitis, diverticulitis, skin and soft tissue infections, small bowel obstruction and GI bleed. Additionally, a statistically significant decrease in number of appendectomy, cholecystectomy, sigmoid colectomy with anastomosis, small bowel resection, operation for incarcerated and reducible hernia procedures was observed. There is a decline in surgeon professional fees generated in 2020 compared to 2019 for all emergent surgeries. When compared to 2019, we observed an increase of 238 more inquests in February to April of 2020, which is the same time period when we noticed a significant decrease in hospital admissions and procedures for emergency general surgery. CONCLUSION: The COVID-19 pandemic has negatively impacted surgical case volumes in 2020 compared to 2019. This includes both emergent and non-emergent cases. There is a need for more broad cost analysis which considers hospital expenditures and cost benefit analysis.

Postoperative bleeding and leaks in sleeve gastrectomy are independent of both staple height and staple line oversewing.

BACKGROUND: Over 100,000 sleeve gastrectomy procedures are performed annually in the USA. Despite technological advances, postoperative bleeding and gastric staple line leak are complications of this procedure. We analyzed patient-specific and perioperative factors to determine their association with these complications. METHODS: We performed a retrospective cohort analysis of patients who underwent sleeve gastrectomy between 2005 and 2019 at our institution. Patient demographics, comorbidities, and procedure details including type of energy device, staple type, staple height, staple line oversewing, and staple line clipping were compared using multiple logistic regression for combined postoperative complications (blood transfusion, bleeding, and staple line leak). Postoperative bleeding was defined by requiring blood transfusion and/or re-operation to control bleeding. Staple line leak was confirmed radiographically. RESULTS: There were 1213 patients who underwent sleeve gastrectomy. Fifty-two high-risk patients were excluded due to cirrhosis, end-stage renal disease, and anticoagulation use for left ventricular assist device. Of the remaining 1161 patients, twenty-five (2.2%) received postoperative blood transfusion, nine (0.8%) had postoperative bleeding, two (0.2%) had staple line leak, and twenty-eight patients (2.4%) had combined postoperative complications. The median age was significantly higher for patients with combined postoperative complications (43 vs 49; p = 0.02). There was no difference in postoperative blood transfusion, bleeding, staple line leak, or combined postoperative complication with different energy devices (p = 0.92), staple types (p = 0.21), staple heights (p = 0.50), or staple line suturing/clipping (p = 0.95). In addition, there was no difference in bleeding when comparing staple line sewing techniques (p = 0.44). Predictably, patients with combined postoperative complications had increased length of stay (3 days vs 1 day; p < 0.001). CONCLUSION: Sleeve gastrectomy procedure has tremendous variability in technique and devices used. We observed no difference in the combined postoperative complications of bleeding or staple line leak with respect to different energy devices, staple height, or oversewing of the gastric staple line. Patient selection is crucial, as patient age and coagulopathic comorbidities were found to lead to higher combined postoperative complications.

Percutaneous Endoscopic Gastrostomy Tube Placement in COVID-19 Patients.

Intensive care units (ICU) around the world are overburdened with COVID-19 patients with ventilator-dependent chronic respiratory failure (VDRF). Gastroenterology evaluations are being made to address the provision of chronic enteral feeding with the help of percutaneous endoscopic gastrostomy (PEG) placements in these patients. The placement of the PEG tube along with tracheostomy in patients with COVID-19 and prolonged VDRF may expedite discharge planning and increase the availability of ICU beds for other patients. Herein, we describe a multidisciplinary approach of PEG tube placements for patients with SARS-CoV-2-induced chronic VDRF for continued enteral feeding to avoid complications and decrease the length of stay.

Emerging Role of Fascin-1 in the Pathogenesis, Diagnosis, and Treatment of the Gastrointestinal Cancers.

Gastrointestinal (GI) cancers, including esophageal, gastric, colorectal, liver, and pancreatic cancers, remain as one of the leading causes of death worldwide, with a large proportion accounting for fatalities related to metastatic disease. Invasion of primary cancer occurs by the actin cytoskeleton remodeling, including the formation of the filopodia, stereocilia, and other finger-like membrane protrusions. The crucial step of actin remodeling in the malignant cells is mediated by the fascin protein family, with fascin-1 being the most active. Fascin-1 is an actin-binding protein that cross-links filamentous actin into tightly packed parallel bundles, giving rise to finger-like cell protrusions, thus equipping the cell with the machinery necessary for adhesion, motility, and invasion. Thus, fascin-1 has been noted to be a key component for determining patient diagnosis and treatment plan. Indeed, the overexpression of fascin-1 in GI tract cancers has been associated with a poor clinical prognosis and metastatic progression. Moreover, fascin-1 has received attention as a potential therapeutic target for metastatic GI tract cancers. In this review, we provide an up-to-date literature review of the role of fascin-1 in the initiation of GI tract cancers, metastatic progression, and patients' clinical outcomes.

Endobariatric procedures for obesity: clinical indications and available options.

Obesity remains a growing public health epidemic that has increased healthcare costs and related comorbidities. Current treatment guidelines encourage a multidisciplinary approach starting from patient selection, interventions, and long-term follow-up to maintain weight loss. However, these conservative interventions are largely ineffective at reducing body weight due to low adherence to the treatment regimen. Recently, endoscopic bariatric therapies have become an attractive alternative to traditional invasive bariatric surgeries due to their improved efficacy, safety, and cost-effectiveness. Endoscopic bariatric therapies include intragastric balloon placement, endoscopic sleeve gastroplasty, gastric bypass revision, and aspiration therapy. These procedures fall into two separate categories depending on the primary mechanism involved: restrictive or malabsorptive. Restrictive methods, such as the Orbera® and ReShape™ intragastric balloons, increase satiation and delay gastric emptying while decreasing the amount of food that can be ingested. In contrast, malabsorptive devices, such as the EndoBarrier®, interfere with the small intestine's ability to absorb food while restoring normal gastrointestinal hormone levels regulating satiation. Together, these techniques provide useful alternatives for patients in whom pharmacological or lifestyle modifications have proven ineffective. Despite these advantages, the long-term effects of these procedures on metabolic changes remain to be studied. Furthermore, the management of complications from these procedures continues to evolve. In this review, we aim to elaborate on the clinical indications and efficacy of the endobariatric procedures, together with various types of available endoscopic bariatric therapy procedures.

Endoscopic Enteral Access.

Various approaches for enteral access exist, but because there is no single best approach it should be tailored to the needs of the patient. This article discusses the various enteral access techniques for nasoenteric tubes, gastrostomy, gastrojejunostomy, and direct jejunostomy as well as their indications, contraindications, and pitfalls. Also discussed is enteral access in altered anatomy. In addition, complications associated with these endoscopic techniques and how to either prevent or properly manage them are reviewed.

Scope of Artificial Intelligence in Screening and Diagnosis of Colorectal Cancer.

Globally, colorectal cancer is the third most diagnosed malignancy. It causes significant mortality and morbidity, which can be reduced by early diagnosis with an effective screening test. Integrating artificial intelligence (AI) and computer-aided detection (CAD) with screening methods has shown promising colorectal cancer screening results. AI could provide a "second look" for endoscopists to decrease the rate of missed polyps during a colonoscopy. It can also improve detection and characterization of polyps by integration with colonoscopy and various advanced endoscopic modalities such as magnifying narrow-band imaging, endocytoscopy, confocal endomicroscopy, laser-induced fluorescence spectroscopy, and magnifying chromoendoscopy. This descriptive review discusses various AI and CAD applications in colorectal cancer screening, polyp detection, and characterization.

A Template for Curriculum Development to Teach Complex Surgical or Endoscopic Techniques With Logistical Challenges.

OBJECTIVE: The current, unprecedented pace of change in medicine challenges healthcare professionals to stay up-to-date. To more effectively disseminate new surgical or endoscopic techniques a modern paradigm of training is required. Our aim was to develop a curricular framework for complex techniques that provide logistical challenges to training in order to increase safe, effective use. We use colonic endoscopic submucosal dissection (cESD) as an example. DESIGN: Curriculum development followed a multistep process representing best practice in training and education. First, a Clinical Needs Assessment established the demand for/sustainability of training. A Training Needs Analysis then identified the knowledge, skills, and attitudes required to perform cESD. A modified Delphi process defined desired learner characteristics, identified indications/contraindications to cESD, and developed a procedural task list. A pilot simulation program gathered feedback from cESD faculty experts and learners. Finally, a Behavioral Observation Scale was developed as a clinical assessment tool to assess procedural performance. SETTING: The Houston Methodist Institute for Technology, Innovation and Education. PARTICIPANTS: The first Curriculum Design Summit engaged 11 clinical SMEs, 4 education and training SMEs, 3 market development SMEs, and 1 medical device research and design engineer. The second Curriculum Design Summit engaged 10 clinical SMEs, 4 education and training SMEs, and 4 market development SMEs. We also engaged 12 Learner SMEs at both hands-on pilot courses who currently are training to perform cESD. RESULTS: Desired learner criteria were defined (e.g., in practice >2 years, available case volume ≥25/year) to ensure ability and motivation of learners. Lesions were classified by (1) suitability for cESD (Clinical T1N0M0, Paris 0-IIa +1s  > 2 cm, 0-IIc + IIa, 0-IIc), and (2) suitability for trainee experience level. A comprehensive cESD task list was constructed and an assessment tool created based on SME review of key characteristics (e.g., comprehensiveness and usability). CONCLUSION: We describe a comprehensive framework to develop educational curricula for complex surgical/endoscopic techniques with logistical challenges. To illustrate the sustainability of this training model and impact on patient outcomes, we plan to further develop and implement this program nationally.

Task Deconstruction of Colonic Endoscopic Submucosal Dissection (cESD): An Expert Consensus.

BACKGROUND: Slow adoption of colonic ESD (cESD) in the US is multifactorial due to: lack of clinical training construct (e.g., gastric ESD in Japan), complication risks, and technical difficulty. More than 28,000 patients/year undergo colonic resection for benign lesions that could be managed effectively with cESD. Selected patients could avoid surgery if procedural adoption of cESD increased due to more accessible training. Current US cESD training is scarce, and existing programs are piecemeal. There is a need to develop an effective national training program for practicing endoscopists. A prerequisite to training development is a comprehensive task list delineating procedural steps. The aim of this work was to describe an evidence-based method of deconstructing cESD into the essential steps to provide a task list to guide teaching and assessment. METHODS: Subject-matter experts (SMEs) performed a literature review to create an initial procedural step list. Eleven clinical cESD SMEs and four educational SMEs formed a 'cESD Working Group' to develop consensus regarding steps. Through a two-stage modified Delphi process, a consensus on a comprehensive standard cESD deconstructed task list was reached. The aim was to standardize cESD teaching to efficiently bring a novice to safe performance. RESULTS: A literature review identified eight initial cESD steps. First-round Delphi consensus was gained on seven steps. Semi-structured focus group discussions resulted in consensus on a modified version of 7 of the initial steps, with addition of two steps. Consensus on procedural actions needed to perform each step was achieved after the hands-on laboratory. The final result was a ten-step deconstructed task list for standard cESD. CONCLUSION: The development of a standardized cESD procedural task list provides a foundation to safely and efficiently teach cESD to practicing endoscopists. This list can be used to develop a training pathway to increase procedural adoption. Selected patients currently undergoing colonic resections could benefit from increased adoption of cESD.

Lack of proper reimbursement is hampering adoption of minimally invasive gastrointestinal endoscopy in North America.

Endoscopic submucosal dissection (ESD) and related procedures are minimally invasive and cost-effective alternates to surgery. However, there is no approved or listed current procedural terminology (CPT) for ESD. We aimed to review the current reimbursement process hurdles for ESD procedures in private practice model in United States. We reviewed the data of two advanced endoscopists (one in New York and other in Pennsylvania State) performing ESD in their private practice set-ups. We found the reimbursement process was complex, with number of refusals varied from 0-9 for ESD procedures. It was not paid at all in 8.3% of cases by the medical insurance. Endoscopic mucosal resection, which is considered inferior as compared to ESD, but has a listed CPT, was denied in only 0.83% cases. Our data highlights the billing hurdles by the endoscopists to adopt ESD-related procedures in private practice model.

Robotic and per-oral endoscopic myotomy have fewer technical complications compared to laparoscopic Heller myotomy.

BACKGROUND: Achalasia is an uncommon disease treated by decreasing the lower esophageal sphincter resting pressure. This study compared the safety and efficacy of esophago-gastric myotomy via laparoscopic, robotic, and per-oral endoscopic approaches. METHODS: A retrospective review of data on patients with achalasia or other esophageal dysmotility disorder undergoing laparoscopic, robotically assisted, or per-oral endoscopic myotomy (POEM) procedures between 2013 and 2017 was performed. Patient demographics, comorbidities, procedure details, length of stay, 30-day readmission rate, and combined technical complication (full-thickness injury, conversion to open, and delayed perforation) were compared. Multiple logistic regression analysis was performed to determine which factors contributed to combined technical complication. RESULTS: There were 171 patients who underwent esophago-gastric myotomy with 161 (94.2%) having achalasia. There were 40 laparoscopic Heller myotomies with partial fundoplication, 44 robotic Heller myotomies with partial fundoplication, and 87 POEM procedures performed during the study period. Baseline statistical differences were found among the groups in regard to gastroesophageal reflux symptoms, arrhythmia, hypertension, and congestive heart failure. Laparoscopic Heller myotomy had significantly higher combined technical complications (7, 17.5%) compared to robotically assisted Heller myotomy (0, 0%) and POEM (1, 1.1%). Multivariate analysis showed that laparoscopic Heller myotomy (OR 32.22; 95% CI 2.66, 389.83; p = 0.01), myocardial infarction (OR 27.94; 95% CI 1.66, 471.10; p = 0.02), and history of smoking (OR 8.87; 95% CI 1.29, 61.15; p = 0.03) were risks for developing combined technical complications. CONCLUSION: Robotically assisted Heller myotomy and POEM are safe and efficacious treatments for achalasia with lower rates of technical complications compared to laparoscopic Heller myotomy. With the advancements in endoscopic instruments and robotic surgery, POEM and robotically assisted Heller myotomy should be considered in the treatment of achalasia and esophageal dysmotility disorders.