LAUSR

Figure 2. Traditional primary obesity surgery endoluminal procedure involving placement of plications in the fundus and distal gastric body. (From Jirapinyo P, Thompson CC. Endoscopic bariatric and metabolic therapies: surgical analogues and mechanisms of action. Clin Gastroenterol Hepatol 2017;15:619-30. Used with permission.) A 40-year-old woman with lifelong obesity presented for consultation regarding a weight-loss procedure. Despite trying several weight-loss programs, she had been able to lose only 10 to 15 pounds and was unable to maintain this weight loss. Her medical history included polycystic ovary syndrome, hyperlipidemia, gallstone disease, and cholecystectomy. Her family history was notable for obesity, type 2 diabetes, and hypertension. Her physical examination results were notable for a weight of 228 pounds, height of 62 inches, and body mass index of 41.7 kg/m. She had previously declined bariatric surgery and wished to undergo a less invasive approach. Currently, 2 categories of devices are approved by the U.S. Food and Drug Administration for the endoscopic treatment of obesity: intragastric balloons and aspiration therapy. Additionally, 2 endoscopic devices are approved for tissue approximation in the stomach. They include the overstitch endoscopic suturing system (Apollo Endosurgery, Austin, Tex, USA) and the incisionless operating platform (IOP) (USGI Medical San Clemente, Calif, USA). After discussing all surgical and endoscopic options, the patient decided to undergo an endoscopic sleeve procedure with use of the IOP system, also known as the distal primary obesity surgery endoluminal (POSE) procedure. POSE involves the use of the IOP system to create fullthickness plications in the stomach to induce weight loss. The IOP consists of a 54F flexible transport, which has a control handle allowing 4-way tip deflection. The transport has 4 working channels to accommodate an ultraslim endoscope for visualization, a g-Lix for tissue grasping, and a g-Prox for the placement of snowshoeshaped tissue anchors (Fig. 1). Traditionally, the POSE procedure involves placement of plications in the fundus and distal body to reduce the stomach volume (Fig. 2). A small study showed that traditional POSE was associated with reduced gastric accommodation and delayed gastric emptying as possible mechanisms of weight loss. Previous studies showed the efficacy of POSE with a range of 4.95% to 19.1% total weight loss