We are grateful to Drs. Villalonga and Himpens for their interest and thoughtful comments in reference to our article on the Primary Obesity Surgery Endolumenal (POSE) procedure [1] and we appreciate the opportunity to respond. The POSE procedure is not intended to primarily reduce gastric volume but to impact fundal gastric accommodation and overall gastrointestinal motility. Since the publication of the first POSE outcomes, we have presented the preliminary data of a prospective study of 18 patients in whom physiological changes in gastric function were achieved with 12–14 plications in the stomach, representing a statistically significant improvement in satiety and post-prandial peptide response at both two- and six-month follow-up (August 2013, IFSO World Congress, Istanbul, Turkey) [2].

We agree that until more trials and long-term results are available, POSE should be limited to patients with classes I and II and obesity and those who refuse or cannot have surgery, as surgery is still the first option for treatment of morbid obesity. A treatment gap exists for a large segment of the obese population that have failed medical management but who are not candidates for traditional bariatric interventions. Though POSE outcomes have not been demonstrated over the long term, its success since 2011 in >100 patients, low adverse-event profile, and minimally invasive endoscopic approach make this intervention an attractive, compelling option for both clinicians and patients.

As noted by Drs. Villalonga and Himpens, comparison of the POSE procedure to a diet and exercise control group is warranted to gauge its efficacy. The company is currently undertaking such studies in Europe and the USA. Unlike the mechanisms of some endolumenal therapies, POSE-sutured plications have shown excellent durability in repeat endoscopy at one- and two-year follow-up. Until randomized controlled trial results are available, we can report what we know: POSE results in a mean excess weight loss of approximately 60.0 % at 1 year and high levels of patient satisfaction. POSE meets ASGE guideline benchmarks for endoscopic bariatric therapies for efficacy, safety, and durability [3].