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Metabolic endoscopy is a novel field of gastroenterology that aims to treat patients living with type 2 diabetes (T2D). One of the main procedures under investigation is duodenal mucosal ablation (DMA) that aims to replicate the glycaemic benefits of gastric bypass surgery by endoscopically ablating up to 15 cm of the abnormal, hypertrophied postampullary mucosa. 1 The short ablation zone is due to limitations of current over-the-guidewire ablation technologies including hydrothermal (REVITA system; Fractyl Laboratories, Lexington, Massachusetts) and electroporation (ReCET system; Endogenex, Plymouth, Minnesota).2 3 We hypothesised that a longer ablation, more akin to the biliopancreatic limb length after bypass surgery (50–75 cm), would yield improved and more durable glycaemic control. In our first in-human study (NCT05887635), we showed that radiofrequency vapour ablation (RFVA) using a through-the-scope (TTS) RFVA catheter was a safe and feasible modality for DMA.4 The RFVA catheter has 510(k) clearance for ablation within the gastrointestinal tract but is still under investigation as a treatment for T2D. In an extension to our first in-human trial, we introduced a second-generation mesh tip catheter (figure 1) that enables a longer ablation up to 60–70 cm. We subsequently developed a novel procedure known as ‘proximal intestinal mucosal ablation (PIMA)’, which we demonstrate in this video as a potential new treatment for T2D pending further investigation and regulatory approval.