Endoluminal delivery of metabolic therapies - a use for endoluminal robotics?

Steve Bell discusses robotic delivery of endoluminal metabolic therapies

As we see an acceleration towards the deployment of endoluminal robotic surgical technologies and endoluminal robotic endoscopes - we will start to be able to see new ways of targeted navigation and automated deployments. For certain complex procedures I think we will move away from the traditional manual endoscopes. Instead we will start to see real time autonomous navigation. (But why?) Olympus and Revival Healthcare Capital have founded Swan Endosurgical. And as Olympus are a major player in upper and lower GI endoscopy - I cannot help but think they are looking at ESD and other more surgical procedures. But once you have a delivery endoscopic robot... there are a lot of other things you can suddenly do. Not surgery - but therapy delivery. Especially where you need precise and multiple applications.

There are multiple companies already working on some very interesting endoluminal based energy deliveries for treating or temporarily impacting metabolic diseases such as Type 2 Diabetes.

(Aqua Medical, Endogenex, Fractyl, Digma Medical)

In GI endoscopy, there is a growing understanding that many of the diseases we treat today with lifelong pills, or injections are metabolic in nature and often as a result of the complex interplay in tissues like the duodenal mucosa. T2D is the first, but many other diseases could be treated using similar energy devices.

In the world of these metabolic treatments we are seeing multiple companies emerge that are applying various energy types to alter the metabolic pathways associated with T2D. Let me dig into the mechanisms of action here a little:

1. Hydrothermal Ablation (Fractyl / Revita DMR)

Energy type: Heated water (~90°C), high-pressure jet.

Mechanism:

A catheter sprays heated saline into the duodenal mucosa for a few seconds.

Heat denatures proteins and destroys the epithelial cell layer, but spares the deeper muscle.

When the mucosa regenerates, it comes back “metabolically healthier”—less inflamed, more responsive to incretin hormones (GLP-1, GIP).

Effect: Resets abnormal nutrient sensing in the proximal small bowel, improving insulin sensitivity.

2. Pulsed Electric Field Ablation (Endogenex / ReCET)

Energy type: Short bursts of high-voltage DC pulses (micro- to millisecond duration).

Mechanism:

Electrodes contact the mucosa.

Electric fields open nanopores in cell membranes (electroporation).

At high enough energy, the pores are irreversible → cells die, but connective tissue and nerves stay intact.

Preserves the scaffold for rapid epithelial regrowth.

Effect: Clean, non-thermal injury—reduces fibrosis risk and can target tissue depth precisely.

3. Radiofrequency Vapor Ablation (Aqua Medical RFVA)

Energy type: Radiofrequency energy heats water to create steam (vapor ~100°C).

Mechanism:

Vapor is injected into the mucosa/submucosa.

Steam condenses inside tissue, rapidly releasing latent heat → uniform ablation zone.

Surrounding structures are protected because the vapor disperses only in targeted layers.

Effect: Creates controlled thermal injury with consistent depth; encourages healthy mucosal regeneration.

Here is summary table of just four of those companies and what they are currently doing.

Table 1 - Endoluminal Metabolic Therapies

In the example we can see how selective “ablation” of the duodenal mucosa in different ways it looking to impact type 2 diabetes via different metabolic pathways.

But if you watch the videos or animations you might start to put the 1+1 =2 together - when you think about these repeat energy deliveries along the length of the duodenum. Potentially every few years.

Aqua Medical Animation of their Therapy delivery

You can see that getting there will be essential - but ensuring the step wise advancements to deploy the energy - in the right place is also important. And in multiple applications you will want to minimise gaps or overlap of the energy delivery. Manually this is quite difficult, and maybe only really well done by "Experts." But robot control systems and robot driven scopes will be able to do that with incredible speed and accuracy. And anyone would be able to deliver this therapy - irrispective opf skill level. It will all be in the planning (which AI will eventually take over) and patient specific dosage of energy (Which AI / algorithms will eventually take over at a more specific patient level.)

This is where I foresee the coming together of new technologies to treat diseases from inside the lumen; treatments we never imagined a few years ago. Combining this type of energy delivery with stable, automatic and navigation guided endoluminal robotics makes sense to me. Especially in repeated applications: as many of these therapies may need.

Besides the precision - I think this can make delivery of the endoscopes faster and potentially with less trauma to the duodenum. Dare I say even “safer” - sorry big claim for today. But I do think that in the hands of the average user - a robotic assited delivery to the duodenum could achieve this.

What am I saying here? I’m starting to hopefully build an image of how we can start to apply robotics, navigation, emerging metabolic therapies to offer a realistic alternative to life long meds. I see this as just one of many emerging technologies that will combine with robotics to start to also move to precision surgery, precision medical therapy delivery via the endolumenal route, and a host of less invasive ways we treat some diseases, and even more invasive but better outcomes than say - pills. (yes you could have an invasive therapy over pills.) Look it's early days - but I am starting to see different tech stacks coming together here. I know you may say it's fanatsy - or overkill to use a robot for this. But just a few years ago using a robot to deliver mitral valves with more precision - stability - and ability to reposition was "fantasy." But Capstan Medical is reality today. Same for endovascular neurovascular robots - but they are coming thick and fast. I even think we will see the delivery of BCI (Brain computer Interfaces) via "stents" as is happening today.. using endoluminal robots to deliver them with the precision needed. So I think the robots will eventually be the enabler to mass adoption of all of these complex therapies. Similar approaches - different body areas and disease states.

What do you think? Am I delusional?

These are juyst musings and speciu;ations by the author for edicational pruproses only and to drive debate and thinking.