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

Metabolic dysfunction-associated fatty liver disease (MAFLD) is currently the leading cause of end-stage liver disease and liver cancer in the world because of the obesity pandemic. Insulin resistance resulting from abdominal adiposity is the main cause of MAFLD and type 2 diabetes mellitus among these patients. Although very common, therapeutic options for MAFLD are currently limited. Metabolic and bariatric surgery is the best treatment option for weight loss that can also improve MAFLD in a very high proportion of patients. However, surgical interventions are expensive, technically challenging, and carry significant immediate and long-term postoperative risks. Duodenal mucosal ablation, a malabsorptive endoscopic bariatric intervention, has shown beneficial effects in the management of obesity with an improvement of insulin resistance. It alters the duodenal mucosal lining, which helps maintain cellular homeostasis and better intestinal endocrine function. This process helps reduce lipid deposition in the liver, maintain serum lipid levels, and promote weight loss, especially in patients with type 2 diabetes mellitus-related MAFLD. However, some of these effects were independent of weight loss and food intake. As a minimally invasive procedure, it is beneficial for patients who have not had success with drug therapy alone, though this approach needs to be tested and further developed in future clinical trials. A basic study by Yu et al in the recent issue of the World Journal of Gastroenterology on duodenal mucosal ablation using irreversible electroporation, when experimented on rats, has shown fewer complications compared to other metabolic surgeries. This editorial describes the minimally invasive endoscopic bariatric strategies for the management of obesity and MAFLD in light of this experimental study.