Pivotal Aspiration Therapy With Adjusted Lifestyle Therapy Study

The Aspiration process works by "correcting" meal portions after eating by removing some of
the food left in your stomach 20 minutes after your meal, which reduces the number of
calories absorbed by your body. This is done through a tube placed through the abdomen into
the stomach with a small valve attached at the surface of your skin. An aspiration system
will attach to that valve after each major meal of the day and allow you to remove a portion
of that meal.

During this study you will also be provided with Lifestyle therapy which includes behavioral
therapy, diet and physical activity education. This Lifestyle therapy will also be provided
to the participants who do not receive the AspireAssist so that the two groups can be
compared and the benefit of aspiration for weight loss can be determined.

Inclusion Criteria:

1. Measured BMI of 35.0-55.0 kg/m2 at time of screening.

2. 21- 65 years of age (inclusive) at time of screening.

3. Failed attempt for a duration equal to 3-months at weight loss by alternative
approaches (e.g. supervised or unsupervised diets, exercise, behavioral modification
programs).

4. Stable weight (<3% change in self-reported weight) over the previous 3 months at time
of screening).

5. Women of childbearing potential must agree to use at least one form of birth control
(prescription hormonal contraceptives, diaphragm, IUD, condoms with or without
spermicide, or voluntary abstinence) from time of study enrollment through study exit.

6. Willing and able to provide informed consent in English and comply with the protocol.

Exclusion Criteria:

1. Previous abdominal surgery that significantly increases the medical risks of
gastrostomy tube placement

2. Esophageal stricture, pseudo-obstruction, severe gastroparesis or gastric outlet
obstruction, inflammatory bowel disease

3. History of refractory gastric ulcers

4. Ulcers, bleeding lesions, or tumors discovered during endoscopic examination.

5. History of radiation therapy to the chest or abdomen

6. Uncontrolled hypertension (blood pressure >160/100).

7. Diabetes treated with insulin or sulfonylurea medications

8. Any change in diabetes medication in previous 3 months

9. Hemoglobin A1C >9.5%

10. History or evidence of serious pulmonary or cardiovascular disease, including acute
coronary syndrome, heart failure requiring medications, or NYHA (New York Heart
Association) class III or IV heart failure (defined below):

Class III: patients with marked limitation of activity and who are comfortable only at
rest Class IV: patients who should be at complete rest, confined to bed or chair and
who have discomfort with any physical activity

11. Coagulation disorders (platelets < 100,000, PT > 2 seconds above control or INR > 1.5)

12. Anemia (Hemoglobin <11.0 g/dL in women and <12.5 g/dL in men)

13. Liver enzymes (ALT and AST) ≥3.0 times the upper limit of normal

14. Thyroid Stimulating Hormone (TSH) >1.5 x upper limit of normal at screening.

15. Osteoporosis (DEXA T-Score ≤ -2.5 standard deviations below normal peak values).

16. History of fragility fractures (fractures resulting from a fall from a standing height
or less, or presenting in the absence of obvious trauma)

17. Pregnant or lactating

18. Diagnosed Bulimia or diagnosed Binge Eating Disorder (using DSM IV criteria)

19. Night Eating Syndrome (diagnosed by EDE)

20. Serum potassium < 3.8 mEq/L

21. Chronic abdominal pain that would potentially complicate the management of the device

22. Taking a GLP-1 agonist < 6 months.

23. Taking prescription or over-the-counter medications for weight loss in the last 3
months before screening, or planning to participate in a commercial weight loss
program in the next 24 months.

24. Taking medication once or more per week that causes weight gain (e.g. atypical
antipsychotics, monoamine oxidase inhibitors, lithium, selected anticonvulsants,
tamoxifen, glucocorticoids)

25. Self- reported history of substance abuse in last 3 years.

26. Malignancy in the last 5 years (except for non-melanoma skin cancer).

27. Physical or mental disability, or psychological illness that could interfere with
compliance with the therapy.

28. At high risk of having a medical complication from the endoscopic procedure or
Aspiration Therapy weight loss program for any reason, including poor general health
or severe organ dysfunction, such as cirrhosis or renal dysfunction (GFR <60
mL/min/1.73 m2 at screening, calculated by using the Chronic Kidney Disease
Epidemiology Collaboration (CKD-EPI) equation).