Resetting the Metabolic Setpoint: Duodenal Mucosal Resurfacing (DMR) and the Future of Obesity Care with Dr. Harith Rajagopalan

Is the duodenum the "early warning beacon" for metabolic disease? In this episode, we sit down with Dr. Harith Rajagopalan, MD, PhD, Co-Founder and CEO of Fractyl Health, to discuss the revolutionary shift from treating downstream symptoms of diabetes and obesity to addressing the upstream root cause in the gut.

We dive deep into the science and technique of Duodenal Mucosal Resurfacing (DMR)—an automated, 45-minute endoscopic outpatient procedure designed to reset the metabolic setpoint. Dr. Rajagopalan explains how high-fat, high-sugar diets pathologically alter the duodenal mucosa and how "resurfacing" this tissue can provide a durable off-ramp for patients on GLP-1 therapies.

Key highlights include:

The "Reset" Mechanism: How the duodenum acts as the body's nutrient-sensing center and why it becomes dysfunctional.

Technical Deep Dive: A look at the automated circumferential saline injection and thermal ablation process (and the future of through-the-scope devices).

The "Remain" Trial Data: Breakthrough insights into post-GLP-1 weight maintenance and craving reduction.

The Rejuva Platform: A look at the first-in-class EUS-guided gene therapy targeting the pancreas.

Whether you are a fellow learning the ropes or an attending looking for the next frontier in interventional GI, this episode explores a future where endoscopists own the management of metabolic disease.

In this episode, I explore the rapidly evolving world of Endobariatrics. As a bridge between lifestyle intervention and invasive surgery, these endoscopic procedures are fundamentally changing how I look at metabolic health and weight loss.

In this episode, I discuss:

Why I see endobariatrics as the "middle ground" for weight loss.

My breakdown of Endometabolic Endoscopy and its impact on Type 2 Diabetes.

Identifying the ideal candidate for these "incision-less" interventions.

My thoughts on the future of gut-brain signaling and metabolic care.

Whether you are a healthcare professional or someone curious about modern weight-loss tech, join me for a comprehensive look at the tools shaping the next decade of medicine.

Listen here: https://bit.ly/TheIE-Ep42

EUS gives us phenomenal imaging — but tissue acquisition has historically been the weak link. In this episode of The Interventional Endoscopist, host Mankanwal Sachdev speaks with Dr. Charles Walther, a Swedish interventional cytopathologist and tumor genetics expert who has sampled 15,000+ patients and helped develop a new approach to obtaining high-quality specimens: EndoDrill.

Walther shares the “lightbulb moment” that shaped the device: instead of advancing a needle by punching forward (“stabbing”), use high-RPM rotation to advance with low forward force — aiming for one pass and a more cohesive sample. They discuss how EndoDrill works in practical terms (setup, foot pedal activation, specimen expulsion), contamination concerns, compatibility across major scope platforms, and why tissue quality is becoming even more important in an era of precision medicine, molecular profiling, and organoids.

They also cover early human experience, the learning curve, optimization for different tumor biologies, and the key cost/value debate: when does a premium tool make sense—especially for cases like nodules, GISTs, and lymphoma where yield can be inconsistent?

Plus: Rapid-fire questions, technique pearls, and a reminder to seek help if you’re struggling with mental health.

Links:

https://bibbinstruments.com/en/

Dan shares his journey from New Jersey soccer goalie to medical student, resident, fellow and ultimately interventional endoscopy fellow. He discussed how early mentorship, showing up in the endoscopy suite, and consistently doing excellent work shaped his trajectory.

Together, they walk through how to think about competitiveness, building a portfolio (clinical performance, procedural exposure, research, and leadership), and how to strategically approach the ASGE Advanced Endoscopy Match—from choosing programs and asking for letters to understanding program culture, case volumes, and general GI expectations.

They also dive into wellness, boundaries, and the “human side” of a very long training road, including protecting physical health, finding community, and keeping hobbies alive. Dan closes with concrete advice for residents and fellows: be present, do excellent work, say yes early in your career, and leverage mentors who genuinely want to see you succeed. This is a practical, candid roadmap for anyone seriously considering a career in advanced endoscopy.

https://www.asge.org/home/education-meetings/training-trainees/advanced-endoscopy-fellowship-(aef)

In this episode of The Interventional Endoscopist, I sit down with Matt Schwartz, Co-Founder and CEO of Virgo Surgical Video Solutions, a company that transforms procedural video into structured, searchable, AI-ready data.

Matt shares the early spark that led him to leave Intuitive Surgical to start Virgo, the challenges of installing early systems in GI units, and how automated, zero-click video capture evolved into a massive national dataset powering the next generation of AI in endoscopy.

We dive into:

Why video is one of the most overlooked datasets in medicine

The medicolegal reality (and why video can actually protect physicians)

Foundation models for endoscopy and site-level customization

The future of training, credentialing, and outcome prediction from routine colonoscopy and EGD video

Leadership lessons from building a healthcare startup

If you're interested in digital endoscopy, AI, clinical training, or med-tech innovation, this episode offers a look into the future of how GI will be practiced.

Helpful links referenced in the podcast

This conversation traces Dragonfly from an idea “in the back of a cab” to a clinically focused cholangioscopy platform that rotates through the biopsy channel for predictable, millimeter-level control. We delve into the mechanics (≈1.7 mm channel supporting 1.5 mm forceps and 4.5 Fr EHL), exploring how the catheter’s suppleness and internal rigidity enhance distal duct stability and device passability, and why micro-movements and neutral ergonomics are crucial for case efficiency.

We map where cholangioscopy shifts the algorithm—medium/large stones, altered anatomy, tight distal duct work, and stricture evaluation with larger bites—and talk learning curve (~3–5 cases), setup tips, and the Medtronic distribution partnership. Finally: adoption math, fair-use evaluations despite contracting realities, and a look toward accessory innovation and AI-aided visualization.

Key takeaways

Rotation-first control → faster targeting, less wall fighting, better stability in tight anatomy.

Larger working channel enables bigger biopsies and higher-energy lithotripsy.

Aim for complete fragmentation in session one; repeat procedures should be the exception.

Ergonomics: neutral hand position and micro-movements reduce fatigue.

Practical adoption requires training support and a fair, multi-case evaluation window.

Links

Medtronic: https://www.medtronic.com/en-us/healthcare-professionals/products/digestive-gastrointestinal/ercp-devices/dragonfly-pancreaticobiliary-system.html

In this deep-dive, Mankanwal Sachdev explores how cholangioscopy moves us from fluoroscopic silhouettes to direct mucosal visualization—and why that changes diagnosis and therapy across indeterminate strictures, PSC dominant lesions, and difficult stones. We walk through the current platform landscape (SpyGlass™ DS2, eyeMAX™, and Dragonfly™), practical biopsy technique to improve yield, and real-world lithotripsy choices (EHL vs Holmium laser) with a focus on workflow, cost, and verification of clearance. We also look ahead to AI-assisted interpretation, robotic/telerobotic control, and how training is evolving with ESGE 2025 standards and ASGE/ACG guidance. If you’re building or refining a pancreatobiliary program, this episode offers an evidence-based framework you can put to work tomorrow.

Key takeaways:

Use cholangioscopy when results will change management; pair with EUS for maximal diagnostic yield.

Standardize biopsy protocols and specimen handling with pathology.

Choose energy based on stone density, access, and resources; confirm clearance by direct inspection.

Build a training pathway (simulation + supervised volume) and consider tiered credentialing.

Selected references: ESGE 2025 (PMID: 40588224); ACG 2023 biliary strictures; ASGE 2023 malignancy in biliary strictures; Amaral 2023 laser vs EHL (PMID: 37203215); Mauro 2023 review (PMID: 37761300).

In this episode of The Interventional Endoscopist Podcast, I dive into how AI-powered scribing has transformed my clinical workflow. Using Doximity’s AI scribe, I share step-by-step insights into documentation, patient engagement, and time savings in daily practice. I outline the advantages, limitations, and customization strategies while reflecting on the broader role of AI in reducing burnout and enhancing the physician–patient connection. Whether you’re an interventionalist, general GI, APP, or any healthcare professional curious about real-world AI integration, this episode offers a practical look at how scribing can change the way we practice medicine.

https://blog.doximity.com/articles/meet-doximity-scribe

Description:

I discuss:

The clinical value of ESD and why adoption has been slow

How reimbursement barriers have held the technique back

What Category I CPT code approval by the AMA actually means

A detailed timeline of what happens between now and 2027

The role of the RUC, CMS, and commercial payers

How GI practices, hospitals, ASCs, and coders should prepare

Why this could signal a tipping point for training, education, and device innovation

If you’re performing ESD, planning to learn, or managing coding and billing for a GI practice, this episode is your roadmap.

📬 Be sure to subscribe, follow on LinkedIn, and share this episode with colleagues in advanced GI

In this episode of The Interventional Endoscopist, I sit down with Dr. Jessica Widmer—Division Chief of Gastroenterology at NYU Langone Hospital–Long Island—for an honest, insightful, and inspiring conversation.

Dr. Widmer shares her journey from a small town in Pennsylvania to becoming a leader in interventional endoscopy. We discuss her training path, early exposure to ERCP and cholangioscopy, and her decision to pursue advanced training at Cornell. She reflects on mentors who shaped her career, including Dr. Stavros Stavropoulos and Dr. Michel Kahaleh, and offers practical tips on teaching and performing cholangioscopy and pancreatoscopy.

The episode also touches on the evolution and future of GI, training Challenges women face in interventional endoscopy, and balancing demanding careers with family life. We discuss the value of mentorship and society involvement

Whether you're an advanced fellow, practicing endoscopist, or simply curious about the human side of medicine, this conversation delivers wisdom, humor, and heart.

Subscribe, rate, and share—and stay tuned for more episodes exploring the minds shaping the future of GI.

Link to the GOLD program: https://www.asge.org/home/education/advanced-education-training/leadership-development/gi-organizational-leadership-development-program