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Page 14 of 20 Nwaiwu et al. Mini-invasive Surg. 2025;9:20 https://dx.doi.org/10.20517/2574-1225.2024.112

OTHERS
Duodenal mucosa resurfacing
Duodenal mucosa resurfacing (DMR), Revita DM (Fractyl Laboratories, Inc., Lexington, MA), uses a
specialized catheter to perform circumferential hydrothermal ablation of the duodenal mucosa to improve
glycemic control [Figure 5A] [22,37,67] . To protect the outer layers of the duodenum, saline is injected to lift the
mucosa before ablation. Given that duodenal mucosal hyperplasia has been implicated in insulin resistance,
[68]
the goal of ablation with subsequent mucosal regeneration is to improve glycemic control . A prospective,
multicenter study of patients with type 2 diabetes mellitus (BMI 24-40) on stable oral glucose-lowering
medication reported a decrease in HbA1c (-10 ± 2 mmol/mol, i.e., 0.9%, P < 0.001), FPG (-1.7 ± 0.5 mmol/L,
P < 0.001), hepatic transaminase levels, and improved Homeostatic Model Assessment for Insulin
Resistance (-2.9 ± 1.1, P < 0.001) 6 months post-DMR. Weight was modestly reduced (-2.5 ± 0.6 kg, P <
[67]
0.001) but did not correlate with a change in HbA1c. There was one serious adverse event (P = 0.002) .
Among patients with baseline liver MRI proton density fat fraction (MRI-PDFF) > 5% and FPG ≥ 10 mmol/
L, the DMR group showed a significantly greater median reduction in liver MRI-PDFF compared to the
sham group (P = 0.001). One patient experienced a jejunal perforation due to endoscope manipulation
during an upper endoscopy, which required surgical repair . This technology is awaiting FDA approval.
[69]

Aspiration therapy
The AspireAssist (Aspire Bariatrics, King of Prussia, Pa, USA) was a device approved for individuals aged 22
2
and older with a BMI of 35-55 kg/m who have not achieved sustained weight loss through non-surgical
[70]
[71]
methods . Designed like a modified percutaneous gastrostomy tube [Figure 5B] that can remove
approximately 30% of ingested food, it promoted weight loss through calorie removal and reduced food
intake, with calorie removal being the primary mechanism. It was designed for long-term use alongside
lifestyle modification and continuous medical supervision [22,70] .

A meta-analysis by the ASGE found a 16.5%-17.8%, 18.3%, 19.1%, and 18.6% (all P < 0.0001) TBWL after 1,
2, 3, and 4 years, respectively, of aspiration therapy. EWL at the same time points were 46.3%, 46.2%, 48.0%,
and 48.7%, respectively (all P < 0.0001). Additionally, aspiration therapy resulted in improvement in systolic
and diastolic blood pressure, triglyceride level, HDL, HbA1c, aspartate aminotransferase level, and alanine
[72]
aminotransferase levels . The pooled serious adverse event rate was 3.8% and included buried bumper
(2.2%), peritonitis treated with intravenous antibiotics (0.5%), severe abdominal pain treated with pain
medication (0.5%), abdominal pain due to a prepyloric ulcer (0.3%), and product malfunction requiring
catheter replacement (0.3%). There were also reports of fistula formation, especially in devices that were
[73]
removed over 2 years after placement . There were no reports of new development of eating disorders or
mortality . Contraindications to its use include history of abdominal surgery due to increased risk of
[72]
gastrostomy tube placement, esophageal or gastric diseases, such as esophageal stricture, gastric varices, and
refractory gastric ulcers, severe coagulopathy, chronic abdominal pain, and eating disorders such as binge
eating syndrome and bulimia nervosa [70,72] . These findings indicate that aspiration therapy fulfilled the PIVI
[47]
criteria established by the ASGE . However, in 2022, the manufacturer withdrew the device from the
market, citing financial challenges .
[73]
Intragastric botulinum toxin A injection
Injection of botulinum toxin A (BTA) into the stomach wall [Figure 5C] inhibits the release of
acetylcholine, which causes paralysis of the injected muscle and slows down gastric emptying. It also
inhibits ghrelin secretion, potentially causing appetite suppression . A meta-analysis including 192 subjects
[74]
only showed a significant difference in weight loss from the control group after a BTA dose ≥ 200 U (mean
difference, -2.04 kg) with multiple intragastric injection sites combined with diet control. A significant mean
2
BMI decrease (-1.25 kg/m ) and an increase in gastric half-emptying time (mean difference, 11.37 min) were