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Common postprocedural adverse events included pain (54.2%), nausea and vomiting (36.7%) with no
[31]
[31]
serious adverse events . Contraindications to the POSE procedure are similar to those for ESG .
Weight loss outcomes in ESG vs. POSE
A 2019 meta-analysis of twenty-two studies including 2,475 patients with a mean baseline BMI of 37.8 ±
2
4.1 kg/m demonstrated an average 6- (P = 0.02) and 12-month (P = 0.04) EWL of 57.9% ± 3.8% and 44.4% ±
[32]
2.1% after ESG, compared to 68.3% ± 3.8% and 44.9% ± 2.1%, respectively, after the POSE . Another meta-
analysis of 12 studies showed mean 6- and 12-month EWL of 49.67% and 52.75%, respectively, following
ESG, compared to 43.79% and 44.91% EWL, respectively, after POSE. With a mean %EWL difference of
6.17% (P = 0.01) and 7.84% (P = 0.06) in favor of ESG, the authors concluded that ESG was superior to the
[33]
POSE in terms of weight loss . Given the development of POSE 2.0 , studies comparing ESG and POSE
[29]
2.0 are needed to elucidate long-term outcomes.
Transoral gastroplasty
Transoral gastroplasty (TOGA) involves using two stapling devices to create a small, restrictive gastric
pouch along the lesser curvature. This pouch was designed to induce early and prolonged satiety after small
meals. An early pilot trial reported EWL of 19.2%, 33.7%, and 46.0% at 1, 3, and 6 months, respectively, with
no serious adverse events . A study involving individuals with an average BMI of 42.16 ± 3.80 kg/m
2
[34]
demonstrated improved glucose metabolism, with half of the participants experiencing a reversal of diabetes
to either normal glucose tolerance (NGT) or impaired glucose tolerance (IGT), as well as a reversion of IGT
and impaired fasting glucose (IFG) to NGT after 1 year . One prospective, multicenter RCT (67 patients)
[35]
showed EWL of 33.9%, 42.6%, and 44.8% at 3, 6, and 12 months, respectively. After 12 months, hemoglobin
A1c levels dropped to 5.7% from a baseline of 7.0% (P = 0.01). Triglyceride levels decreased to 98 from 142.9
mg/dL (P < 0.0001), while high-density lipoprotein (HDL) levels rose to 57.5 from 47.0 mg/dL (P < 0.0001).
Two complications were reported: respiratory insufficiency and a case of asymptomatic
pneumoperitoneum, which were managed conservatively . This device did not meet the FDA trial
[36]
endpoints and it is not commercially available.

SPACE-OCCUPYING TECHNIQUES/GASTRIC VOLUME REDUCTION
Intragastric balloons
Intragastric balloons (IGBs) are anatomy-preserving, space-occupying devices that are temporarily placed in
the stomach [Figure 2] . It is thought that by filling a significant portion of the stomach, decreasing its
[37]
potential capacity and delaying gastric emptying, IGBs also activate GI neurohormonal pathways that
induce early satiety and, consequently, reduce food intake [38-42] . They are designed for patients with a BMI of
30-34.9 kg/m who also have one or more obesity-related comorbidity or BMI of 30-40 kg/m , for whom
2
2
medical or lifestyle interventions have not been successful . US FDA-approved IGBs include Orbera,
[41]
ReShape, Obalon, TransPyloric Shuttle (TPS), and Spatz3, while the Allurion (formerly Elipse) Balloon
remains under study. IGBs are often placed endoscopically, but in some cases, they are swallowed as
capsules [38-41] . They are most commonly left in place for 6 months (4-12 months, depending on the type) and
are either removed endoscopically or spontaneously excreted from the body. Advances in IGB technology
have improved safety and efficacy, with modern designs addressing early challenges such as complications
(e.g., gastric erosions and ulcers) and limited weight-loss success [38-41,43,44] . While other methods may be
favored in adults due to weight recidivism, IGBs may serve as a good alternative to less reversible
[45]
procedures in adolescents who are more amenable to lifestyle modification . There are several available
IGBs worldwide, but fewer have regulatory approval for use. While most systems have one balloon, the
Obalon system uses up to three balloons . Most balloons are made of silicone or polyurethane and may be
[44]
classified as either fluid-filled or gas/air-filled .
[44]