Duodenal mucosa resurfacing: the endoscopic silver bullet against metabolic disorders?

With the backset of the epidemic surge of type 2 diabetes (T2D), obesity and metabolic dysfunction-associated steatotic liver disease (MASLD) the metabolic syndrome, the key role played by jejunal mucosa in the development of metabolic disorders further to its normal function in the absorption of nutrients has become increasingly appreciated. In humans compared to non-diabetic controls, diabetic patients have jejunal mucosa hypertrophy, hyperplasia of enteroendocrine cells, increased numbers of enteroendocrine cells and enterocytes. Moreover, functional changes have also been observed comprising variation of glucose transporters, enteric nerves, and composition of intestinal microbiota. Duodenal mucosa resection (DMR) starts with the assumption that resurfacing the mucosal interface will reset and correct any abnormal signaling from the duodenal mucosa and will therefore result in improved pancreatic endocrine function and glucose tolerance owing to restored normal mucosal surface. The endoscopic technique of DMR involves the hydrothermal ablation of the more superficial duodenal mucosal layers. Data reviewed indicate that DMR is a safe and well-tolerated procedure, with favorable outcomes on glucose homeostasis among those with T2D, body weight among those with obesity, and liver tests among those with MASLD. Additional studies are therefore urgently needed to ascertain, among the various surgical, endoscopic and medical choices, the best precision medicine option to fit the individual patient with T2D, obesity, and MASLD.