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Page 6 of 20 Nwaiwu et al. Mini-invasive Surg. 2025;9:20 https://dx.doi.org/10.20517/2574-1225.2024.112

Primary obesity surgery endoluminal
Similar to ESG, primary obesity surgery endoluminal (POSE) is an endoscopic gastric plication and suturing
procedure with the goal of inducing weight loss by reducing the capacity for caloric intake through gastric
remodeling. Performed with the Incisionless Operating Platform (USGI Medical, San Clemente, CA,
TM
USA) under general anesthesia, full-thickness suture-anchor plications are placed along the fundus and
distal body of the stomach to create endoluminal folds, invaginating the fundus and lowering the
gastroesophageal junction [Figure 1B] [21-26] . The resultant decrease in gastric compliance reduces its capacity
for food intake, induces earlier and prolonged satiety, and improves glucose homeostasis [24,27] . Furthermore,
it produces delayed gastric emptying and changes in GI neuroendocrine physiology (decreased ghrelin and
increased peptide YY).

The MILEPOST multicenter randomized controlled trial (RCT) compared weight loss and satiety outcomes
after 12 months of conventional diet and exercise counseling therapy with (treatment group) and without
(control group) the POSE procedure in individuals with classes I and II obesity. TBWL at 6 and 12 months
were 12.5% and 13.0%, respectively (EWL, 45.5% and 45.0%, respectively) after POSE and 4.7% and 5.3%
(14.5% and 18.1%, respectively) with diet and exercise only. At 12 months, individuals who underwent
POSE showed significant reduction (P < 0.001) in the three satiety parameters evaluated (satiety volume,
satiety calories, and time to satiety). The control group, however, only had mild to marginal reductions in
satiety volume (P = 0.041) and satiety calories (P = 0.036) but no reduction in time to satiety . No major
[23]
intraoperative complications or serious adverse events related to the procedure were reported. Two patients
experienced minor postoperative bleeding that resolved within 24 h without sequelae, and some patients
[23]
reported postprocedural abdominal and throat pain, which resolved prior to discharge home . Another
multicenter (ESSENTIAL) trial that evaluated the safety and efficacy of the POSE procedure randomized
332 patients with classes I and II obesity into active and sham groups, and 34 patients to an unblinded lead-
[28]
in cohort . At 12 months, the TBWL was 7.0% ± 7.4% in the lead-in, 4.95% ± 7.04% in the active, and 1.38%
± 5.58% in the sham cohorts. The responder rates (percent of individuals with ≥ 5% TBWL) were 41.55% in
the active group and 22.11% in the sham group (P < 0.0001). However, this did not meet the predefined
responder rate goal of 50% in the active group. Pain, nausea, and vomiting were the most common adverse
events and often presented immediately post-procedure or within 1 week and quickly self-resolved or with
supportive therapy (pain medication, antiemetics, and intravenous fluids). Procedure-related serious
adverse event rates were 5.0% (active) and 0.9% (sham) (P = 0.068). No unanticipated or serious adverse
events were reported .
[28]
A modified POSE procedure (POSE 2.0, Figure 1B ) aimed at narrowing and shortening the stomach by
[21]
decreasing its anteroposterior diameter and decreasing its vertical length was reported by Lopez-Nava et al.
in 2020 . The POSE 2.0 was performed on 73 obese patients, resulting in a TBWL of 15.7% at 6 months.
[29]
There were no reported adverse events at 6 months. However, further studies that include a control group
are needed to assess the efficacy of POSE-2 . A recent prospective multicenter study of 44 patients (mean
[29]
2
BMI 37 ± 2.1 kg/m ) with POSE 2.0 showed a mean TBWL of 16.3% ± 6.4% and 15.7% ± 6.8% at 6 and 12
[30]
months, respectively . Additionally, 98%, 86%, and 58% of patients achieved a TBWL of > 5%, > 10%, and
> 15%, respectively, at 12 months. Extended follow-up of outcomes on 26 patients demonstrated TBWL 14%
± 7.3% and 12.2% ± 9.6% at 18 and 24 months, respectively. At 24 months, 77%, 61.5%, and 27% of patients
in this group maintained > 5%, > 10%, and > 15% TBWL, respectively . A retrospective cohort study of 49
[30]
patients who underwent POSE 2.0 (mean BMI 34.6 kg/m ) demonstrated a TBWL of 11.5%, 13.2%, and
2
14.8% at 3, 6, and 12 months, respectively.