Duodenal mucosal ablation: An emerging therapeutic concept for metabolic dysfunction-associated fatty liver disease

Table 1 Comparison between various available endoscopic bariatric and metabolic therapies

Therapy	Mechanism	Benefit	Risk	TBWL	Metabolic effects	Quantitative risk data	Study period	Ref.
Intragastric balloon	Space-occupying balloon induces satiety	Minimally invasive, well-studied	Gastrointestinal symptoms, risk of deflation or migration	8%-15%	Improved insulin sensitivity, reduced liver fat	Overall complication rate: 5%-22%, balloon rupture: 0.7%, severe complication: 0.17%	12 months	[40,41]
Transpyloric shuttle	Delays gastric emptying via the anchoring bulb-pair device	Targets appetite and satiety, reversible	Gastric ulceration, device migration, and limited long-term data	9.5%-14.5%	Improved glycemic control and improved lipid profile	Device-related adverse events: 2.8%	12 months	[25]
Endoscopic sleeve gastroplasty	Endoscopic suturing to reduce gastric volume	Durable, anatomy-preserving, repeatable	Requires expertise, rare bleeding/perforation risk	16%-20%	Improved HbA1c, transaminitis, insulin resistance	Serious adverse events: 2.2%, perforation: 0.1%-0.4%	3 months	[42,43]
Aspiration therapy	Removes part of ingested food via PEG tube	Effective long-term behavioral modification	Requires an external device, social stigma, and risk of electrolyte imbalance	18%-20%	Improved glycemic control and improved lipid profile	No severe adverse events; buried bumper syndrome: 3.3%	12 months; 4 years	[44,45]
Endoluminal bypass liner	Endoscopic liner bypasses the duodenum and proximal jejunum	Mimics gastric bypass, no surgery, improves metabolic markers	Gastrointestinal symptoms, risk of hepatic abscess, and early removal	10%-15%	Improved HbA1c, hepatic steatosis, and insulin resistance	Perforation: < 1%; overall serious adverse events: 3%-5%	26 weeks; 3 months	[46,47]
Duodenal mucosal ablation	Thermal or electrical ablation of the duodenal mucosa to reset signaling	Restores metabolic function, with no permanent implant	Experimental, safety/durability still under evaluation	7%-10%	Reduced fasting glucose, improved insulin sensitivity, and liver steatosis	Adverse event: At least one adverse event in 52% (81% mild)	12 months	[48]
Incisionless magnetic anastomosis system	Creates jejuno-ileal bypass using self-assembling magnets	Incisionless, mimics surgical bypass, promotes malabsorption	Still under evaluation, may cause malabsorption and diarrhoea	14%-18%	Improved glycemic control and potential GLP-1 elevation	Perforation: 10%	12 months	[49]

TBWL: Total body weight loss; PEG: Percutaneous endoscopic gastrostomy; HbA1c: Glycated hemoglobin; GLP-1: Glucagon-like peptide-1.