Reset, endoscopic recellularization by electroporation therapy. Type 2 diabetes mellitus is a metabolic disorder of fuel homeostasis characterized by hyperglycemia and altered lipid metabolism. These derangements in patients with diabetes can cause damage to various organ systems leading to the development of disabling and life-threatening health complications. There needs to be a paradigm shift in the way we treat diabetes, from focusing on treating the downstream effects and consequences to trying to reset the metabolic clock and pushing back the natural progression of the disease. As gastroenterologists, we are in a unique position to help reset this metabolic clock by using the duodenum as an easily accessible therapeutic target. The duodenum is the sensing portion of the gut and the key regulator of metabolic signals, be it through neurohormonal signaling or altering the gut microbiota. Studies have shown a distinct change in the duodenal architecture with diabetes. The reset procedure uses pulsed electric fields to induce mucosal regeneration that is intended to improve glycemic control in patients with type 2 diabetes. In an individual with diabetes, when in the duodenum, we see unhealthy duodenal mucosa and an unhealthy microbiome. Reset is a unique device that delivers pulsed electric fields in this region. This electricity destabilizes the cellular membrane and induces apoptosis. Subsequently, there is healthy regeneration of the duodenal mucosa. This is reflected in these histology slides from preclinical studies. Instead of the necrosis generated by ablation, electroporation leads to apoptosis and healthy regeneration. You can now see that the duodenal mucosa is healthy with a healthy and diverse microbiome. Reset uses a novel generator and flexible catheter with a novel electrode to deliver 750 volts of current. It has the advantages as follows. It is capable of ablating and regenerating a large surface area without heat. It penetrates deeper than traditional modalities and may impact underlying enteric nervous system. And no submucosal lift is required, hence it is repeatable. We now move on to our case presentation. We have a 68-year-old male with obesity and a BMI of 34 and type 2 diabetes for the past five years. His A1c is 8.4 and fasting glucose 170. He's currently on two oral medications for his diabetes and he decides to undergo reset therapy. After doing an EGD to check for any abnormalities, a guide wire is placed. Then the catheter is advanced under fluoroscopy until positioned in the stomach near the pylorus. Both the scope and the catheter are advanced into the duodenal bulb and then continued till approximately one to two centimeter distal to the ampulla. At this point, the flex circuit is expanded and suction is applied to achieve wall contact for energy delivery. At this point, the flex circuit is repositioned by retracting slightly and expanding once more. This repositioning maneuver is to deliver the second dose of energy. After treatment is completed, the catheter and endoscope are withdrawn together. Then the endoscope is reintroduced to complete a final inspection after the treatment. This is the typical appearance of the mucosa following reset therapy. In total, there were seven segments of the duodenum that were treated with two doses of the electrical current at 750 volts each. To conclude our case, we see that there is a tremendous improvement in our patient's blood glucose range, and we see that his A1c has decreased from 8.4 to 6.8. Reset is a novel, safe, precise, and non-thermal modality that overcomes many limitations of thermal-based ablative therapies. It is repeatable and a therapy that can potentially change the disease progression of diabetes. It represents an exciting new therapy for the future. In literature, various opportunities for the use of endoscopic therapy for type 2 diabetes have been described. Further large clinical studies will help us understand the true potential of these modalities. Thank you.

reset, endoscopic recellularization by electroporation therapy

type 2 diabetes

metabolic clock

duodenum

glycemic control