US20050096750A1 - Apparatus and methods for treatment of morbid obesity - Google Patents

Abstract

Apparatus and methods are described for treatment of morbid obesity using minimally invasive techniques. The apparatus includes a system of components that may be used separately or in combination for effectively reducing stomach volume, bypassing a portion of the stomach and/or small intestines, reducing nutrient absorption in the stomach and/or small intestines and/or depositing minimally or undigested food farther than normal into the intestines, thereby stimulating intestinal responses. The components described include an artificial stoma device, a gastric sleeve device, an intestinal sleeve device, a combined gastrointestinal sleeve device and permanent and detachable attachment systems. Also described are devices for delivering and deploying the components of the system.

Description

CROSS-REFERENCE TO OTHER APPLICATIONS
• The present application is a continuation of U.S. patent application Ser. No. 10/698,145, filed on Oct. 31, 2003, which claims priority of U.S. Provisional Patent Application No. 60/422,987, filed on Nov. 1, 2002, for Apparatus and Methods for Treatment of Morbid Obesity; No. 60/430,857, filed on Dec. 3, 2002, for Biliopancreatic Diverter Tube for Treatment of Morbid Obesity; No. 60/437,513, filed on Dec. 30, 2002, for Apparatus and Methods for Gastric Surgery, No. 60/448,817, filed on Feb. 21, 2003, for Surgical Fastener System and Method for Attachment within a Hollow Organ, and No. 60/480,485, filed on Jun. 21, 2003 for Gastrointestinal Sleeve Device and Method of Use. The present application is also related to the subject matter of U.S. Provisional Patent Application No. 60/428,483, filed on Nov. 22, 2002, for Gastroplasty Clamp. These and all other patents and patent applications referred to herein are hereby incorporated by reference in their entirety.
BACKGROUND OF THE INVENTION
• Bariatrics is the field of medicine encompassing the study of overweight, its causes, prevention and treatment. Bariatric surgery is a treatment for morbid obesity that involves alteration of a patient's digestive tract to encourage weight loss and to help maintain normal weight. Known bariatric surgery procedures include jejuno-ileal bypass, jejuno-colic shunt, biliopancreatic diversion, gastric bypass, Roux-en-Y gastric bypass, gastroplasty, gastric banding, vertical banded gastroplasty, and silastic ring gastroplasty. A more complete history of bariatric surgery can be found in U.S. Provisional Patent Application No. 60/422,987 Apparatus and Methods for Treatment of Morbid Obesity and also on the website of the American Society for Bariatric Surgery at http://www.asbs.org.
• Medical sleeve devices for placement in a patient's stomach are described by Rockey in U.S. Pat. Nos. 4,501,264, 4,641,653 and 4,763,653. The medical sleeve described in these patents are said to reduce the surface area available for absorption in the stomach, however it is not configured to effectively reduce the volume of the stomach nor will the device described isolate ingested food from stomach secretions. The medical sleeve is not configured to be deployed in a patient's small intestine.
• Other sleeve devices for placement in a patient's intestines are described in U.S. Pat. No. 4,134,405 (Smit), U.S. Pat. No. 4,315,509 (Smit), U.S. Pat. No. 5,306,300 (Berry), and U.S. Pat. No. 5,820,584 (Crabb). The sleeve devices described in these patents are said to be placed at the lower end of the stomach and therefore do not serve to isolate ingested food from the digestive secretions of the stomach. These sleeve devices are not configured to be deployed in a patient's stomach or to effectively reduce the volume of the patient's stomach or small intestine.
• In U.S. Patent Application US 2003/0040804, Stack et al. describe a satiation device to aid in weight loss by controlling feelings of hunger. The patent application describes an antral tube that expands into the antrum of the stomach to create a feeling of satiation. The devices described are not configured to isolate ingested food and liquids from digestive secretions in the stomach or the intestines.
• In U.S. Patent Application US 2003/0040808, Stack et al. describe a satiation device for inducing weight loss in a patient includes a tubular prosthesis positionable at the gastro-esophageal junction region, preferably below the z-line. The prosthesis is placed such that an opening at its proximal end receives masticated food from the esophagus, and such that the masticated food passes through the pouch and into the stomach via an opening in its distal end.
• In U.S. Patent Application US 2003/0093117, Sadaat describes an implantable artificial partition that includes a plurality of anchors adapted for intraluminal penetration into a wall of the gastro-intestinal lumen to prevent migration or dislodgement of the apparatus, and a partition, which may include a drawstring or a toroidal balloon, coupled to the plurality of anchors to provide a local reduction in the cross-sectional area of the gastro-intestinal lumen.
• In U.S. Patent Application US 2003/0120265, Deem et al. describe various obesity treatment tools and methods for reducing the size of the stomach pouch to limit the caloric intake as well as to provide an earlier feeling of satiety. The smaller pouches may be made using individual anchoring devices, rotating probes, or volume reduction devices applied directly from the interior of the stomach. A pyloroplasty procedure to render the pyloric sphincter incompetent and a gastric bypass procedure using atraumatic magnetic anastomosis devices are also described.
• In U.S. Patent Application US 2003/0144708, Starkebaum describes methods and systems for treating patients suffering from eating disorders and obesity using electrical stimulation directly or indirectly to the pylorus of a patient to substantially close the pylorus lumen to inhibit emptying of the stomach.
• The present invention also relates to apparatus and methods for performing gastric and esophageal surgery that can be applied using minimally invasive techniques for creating a stoma or restriction in a patient's stomach or esophagus. The apparatus and methods are useful for treatment of morbid obesity and for treatment of gastroesophageal reflux disease (GERD). Surgical treatments for gastroesophageal reflux disease include fundoplasty and fundoplication, which can be performed using open surgical techniques or laparoscopic surgical techniques. These procedures create a valve-like structure at the gastroesophageal junction to prevent reflux of the stomach contents. Although methods have been proposed for performing fundoplication using peroral endoscopic techniques, these methods have not been widely adopted. Examples of instruments and methods for performing fundoplication can be found in the following patents: WO0185034 Devices and related methods for securing a tissue fold, U.S. Pat. No. 6,312,437 Flexible endoscopic surgical instrument for invagination and fundoplication.
• 1. Field of the Invention
• The present invention relates generally to apparatus and methods for treatment of obesity, and particularly morbid obesity. In particular, it relates to apparatus and methods that can be applied using minimally invasive techniques for effectively reducing stomach volume, bypassing a portion of the stomach and/or small intestines and/or reducing nutrient absorption in the stomach and/or small intestines
• 2. Description of the Related Art
• *
SUMMARY OF THE INVENTION
• In keeping with the foregoing discussion, the present invention provides apparatus and methods that can be applied using minimally invasive techniques for treatment of obesity, and particularly morbid obesity. The apparatus takes the form of a system of components that may be used separately or in combination for effectively reducing stomach volume, bypassing a portion of the stomach and/or small intestines, reducing nutrient absorption in the stomach and/or small intestines and/or depositing minimally or undigested food farther than normal into the intestines (thereby stimulating intestinal responses).
• In one aspect of the invention, the system may include an artificial stoma device located in the stomach or lower esophagus that can reduce the flow of food into the stomach (when located in the stomach) or back from the stomach into the esophagus (when located in the esophagus or at the gastroesophageal junction). Alternatively, the system may utilize a surgically created artificial stoma. Stomas that prevent flow of gastric contents into the esophagus can be used in the treatment of GERD. The stoma is introduced transesophageally and implanted under visualization with a flexible endoscope. The stoma may be anchored to the esophageal or stomach wall using sutures, staples or clips.
• Alternatively, the stoma may be anchored with a sutureless attachment that does not penetrate the esophageal or stomach wall. Optionally, multiple stomas can be installed, e.g. one for GERD and one for restriction of food passage. Optionally, the stoma may be used in conjunction with gastric suturing, stapling or banding to create a narrow passage for installation of the stoma and/or for reduction of gastric volume. The gastric stapling or banding may be applied using transesophageal or laparoscopic techniques. Optionally the stoma may be in multiple parts where the parts may be individually placed, replaced or exchanged. Optionally, the stoma may have an adjustable opening to vary the flow of food through the stoma and/or allow the passage of diagnostic or therapeutic devices such as endoscopes. The adjustable stoma may be adjusted at the time of implantation or it may be adjustable remotely after implantation without invasive procedures. Alternatively, the stoma may be a self-adjusting “smart stoma” that opens and/or closes in response to stomach conditions.
• In another aspect, the system may include an internal gastric sleeve that may be used separately or used with, attached to or integrated with the artificial stoma component. The gastric sleeve may have a funnel-shaped entry with a reinforced anchoring segment or other anchoring mechanism for attachment in the stomach at or near the gastroesophageal junction. Optionally, the artificial stoma component may be positioned a clinically significant distance distal to the sleeve attachment. When placed in the stomach, the entry portion of the sleeve proximate to the stoma effectively reduces the volume of the stomach because the flow of solid food is limited to the lumen of the sleeve. When combined with a restrictive stoma, the sleeve functions as the pouch in a gastric bypass or vertical banded (or other) gastroplasty. The sleeve can be designed and placed to maximize the amount of stomach wall included by the sleeve opening and therefore included in the pouch thereby formed. This will enable a maximum number of stretch receptors and other stimulating mechanisms in the stomach to transmit satiety (fullness) signals to help reduce food intake.
• The entire gastric sleeve or a portion of it can be porous or semipermeable to allow the flow of digestive secretions into the sleeve and to allow the flow of nutrients and/or fluids out through the wall of the gastric sleeve. Valves may be provided in the wall of the gastric sleeve to allow digestive secretions to enter the sleeve, but to prevent solid food and/or nutrients from flowing out through the wall of the sleeve. Alternatively, the entire gastric sleeve or a portion of it can be nonporous or impermeable to act as an internal gastric bypass. In certain embodiments, the wall of the gastric sleeve is flexible to allow the peristaltic motions of the stomach to effect movement of food through the gastric sleeve. The wall of the sleeve may be reinforced with rings or a spiral made of wire and/or plastic. Alternatively, the gastric sleeve may be attached to an artificial stoma component that includes its own anchoring mechanism. Optionally, the distal end of the gastric sleeve may be anchored in the region of the pylorus. Optionally the distal end of the gastric sleeve can incorporate an enlarged reservoir portion proximal to the pylorus. Optionally the sleeve can include coatings on its interior and/or exterior to enhance the surface properties of the sleeve in clinically relevant manners.
• In conjunction with the stoma and/or gastric sleeve, the volume of the stomach can be reduced by suturing, stapling using open, transesophageal or laparoscopic techniques. Alternatively or in addition, a gastric balloon or other volume displacement device may be used in conjunction with the gastric sleeve to provide a feeling of satiety. These adjunctive techniques have the effect of further reducing nutrient intake (in the case of a stomach reduction and pouch formation upstream of a stoma) and enhancing the effect of peristaltic motions of the stomach for moving food through the gastric sleeve intake (in the case of a stomach reduction downstream of a stoma where there is a gastric sleeve). A gastric sleeve that extends beyond the pylorus, with or without an intestinal sleeve, can allow use of the pylorus as a natural stoma by configuring the sleeve to close by the pylorus and then open to allow passage of food when the muscles of the pylorus relax.
• One advantage of using an internal gastric sleeve over prior art gastric volume reduction techniques is that volume reduction can be better defined in that the patient cannot deliberately or inadvertently increase the volume of the sleeve over time by overeating as occurs when the stomach wall stretches. Another advantage of an internal sleeve over prior art banding techniques is that stomach wall is not trapped between an external structure and ingested food whereby the stomach wall is subject to compression due to overeating.
• In another aspect, the system may include an internal intestinal sleeve that may be used separately or used with, attached to or integrated with the internal gastric sleeve and/or artificial stoma component. The entire intestinal sleeve or a portion of it can be porous or semipermeable to allow the flow of digestive secretions into the sleeve and to allow the flow of nutrients and/or fluids out through the wall of the sleeve. Valves may be provided in the wall of the intestinal sleeve to allow digestive secretions to enter the sleeve, but to prevent solid food and/or nutrients from flowing out through the wall of the sleeve. Alternatively, the entire intestinal sleeve or a portion of it can be nonporous or impermeable to act as an internal intestinal bypass. In certain embodiments, the wall of the intestinal sleeve is flexible to allow the peristaltic motions of the intestinal wall to effect movement of food through the intestinal sleeve. The wall of the sleeve may be reinforced with rings or a spiral made of wire and/or plastic. Optionally these components can include radiopaque materials for visualization of the device when it is in the body. Optionally the sleeve can include coatings on its interior and/or exterior to enhance the surface properties of the sleeve in clinically relevant manners.
• In one aspect of the present invention, there is provided a method of treating a patient. The method includes the steps of providing a gastrointestinal sleeve having a proximal end, a distal end and a length of at least about 50 cm. The sleeve is positioned with the proximal end adjacent an attachment site in the vicinity of the lower esophageal sphincter, with the distal end extending transluminally at least as far as the jejunum. At least one plication is formed at the attachment site, and the sleeve is attached to the plication. Two or three or four of five or more plications may alternatively be formed, for direct or indirect attachment to the sleeve. The distal end of the sleeve may extend into the intestine at least as far as the ligament of Treitz. The providing step may comprise providing a sleeve having a substantially constant diameter throughout its length.
• Optionally, the intestinal sleeve may have a proximal end with a reinforced anchoring segment or other anchoring mechanism for attachment in the region of the pylorus. Alternatively, the intestinal sleeve may be attached to or continuous with the internal gastric sleeve. Optionally, the distal end of the intestinal sleeve may include an anchoring mechanism.
• Optionally, the above system components can include means of separately installing, replacing and/or removing single components. This would include means of reversibly attaching and connecting components. This would allow a therapeutic device to be assembled over multiple operations or in a single procedure. Alternatively, the above components can be preassembled with a specific combination of desired features for an individual patient and thereby installed and removed in a single operation. Preferably, each component of the system includes one or more radiopaque and/or sonoreflective markers for enhanced imaging by X-ray, fluoroscopy and/or ultrasonic imaging.
• Certain implementations of the invention will achieve some or all of the following advantages:
• • 1. Minimally invasive, peroral/transesophageal implantation, with optional surgical and/or laparoscopic assist
  • 2. Customizable to each patient and revisable in-situ based upon the results of the intervention
  • 3. Completely reversible using minimally invasive techniques
  • 4. Lower morbidity, mortality
  • 5. When used with a gastric and/or intestinal sleeve, does not allow an appreciable amount of digestion to occur until the food exits the sleeve into the intestine by keeping food separate from gastric and/or intestinal secretions. This delivers undigested food to the jejunum where a dumping syndrome reaction and/or other results of overstimulation of the intestine may occur depending upon the clinical situation and the food ingested.
• The system optionally includes a biliopancreatic diverter tube for effectively reducing nutrient absorption in the small intestines by diverting the release of digestive salts and enzymes from the gallbladder and pancreas into the small intestine downstream in the gastrointestinal tract, resulting in a reduction in the location and the amount of intestine exposed to digestible nutrients, and thus reducing the digestion and absorption of fat and other sources of calories.
• The system optionally includes a surgical fastener system for removably or reversibly attaching a surgical appliance within a hollow organ in a patient's body. The surgical fastener system can be configured for many different surgical applications within a patient's body. In many applications, it is desirable to removably or reversibly attach a surgical appliance within a hollow organ such that it can be removed or revised at a later date. Examples of applications where the surgical fastener system of the present invention can be used include: attachment of an artificial stoma device or gastrointestinal sleeve device within a patient's stomach or intestines for treatment of morbid obesity, attachment of a valve or restriction in a patient's esophagus for treatment of gastroesophageal reflux disease, attachment of a filter device within a patient's vena cava for treatment of thromboembolic disease, and attachment of a valve or other device within a patient's aorta or urethra.
• With these broader applications in mind, the surgical fastener system will be described in relation to a particular application for reversibly attaching a surgical appliance within a patient's stomach or esophagus for treatment of conditions including morbid obesity and gastroesophageal reflux disease. Morbid obesity can be surgically treated by creating a restriction in a patient's stomach to limit the amount of food that can enter the stomach. Alternatively or in addition, the patient's stomach and/or intestines can be partially bypassed, for example using an internal gastrointestinal sleeve device, to reduce the amount of nutrients that are absorbed from the food as it passes through the gastrointestinal system. GERD can be treated by attachment of a valve or restriction in a patient's esophagus at the gastroseophageal junction to prevent food and digestive juices from refluxing into the esophagus.
• Certain embodiments of the fastener system utilize folding or plication of the stomach and/or esophageal wall or other hollow organ to create a reinforced attachment point for the fasteners. Various devices and methods have been previously described utilizing fundoplication to create a restriction or a valve-like structure at the gastroesophageal junction for treatment of gastroesophageal reflux disease. For example, see patents: U.S. Pat. No. 05,897,562, U.S. Pat. No. 06,312,437, US20020035370A1, WO00185034, WO00228289 and WO09922649, which are hereby incorporated by reference. By contrast, in certain embodiments of the present invention, the fastener system preferably attaches to the stomach or other hollow organ with a minimum of stress and deformation. One way of accomplishing this is by utilizing a multiplicity of independent fasteners attached around the inner periphery of the organ without causing any narrowing or restriction in the organ. Alternatively, the fastener system may utilize a continuous ring structure that is sized to fit closely with the inner diameter of the organ without significant deformation of the organ. In the alternative, when a stoma or restriction is desired at the point of attachment system, the fastener system and methods of the present invention can be modified to create a narrowing, restriction or a valve-like structure in the hollow organ simultaneously with providing a removable attachment for a surgical appliance or the like.
• Alternatively or in addition, the system may optionally include a surgical instrument for creating a stoma or restriction in a patient's stomach or esophagus using minimally invasive surgical techniques. This apparatus can also be used to create a plication or fold in the stomach or esophagus and furthermore can then be used to attach other devices to the fold thereby created. In addition, the system may optionally include a stomal ring clip device implantable within the patient's stomach for forming and maintaining the stoma or restriction. The surgical instruments and the implantable stomal ring clip devices may be used separately or in combination depending on the needs of the individual patient. Methods are described using the surgical instruments and the implantable stomal ring clip devices separately and in combination for creating a stoma or restriction in a patient's stomach or esophagus. The apparatus and methods are useful for treatment of morbid obesity and can be combined with other surgical techniques or devices as part of a complete treatment regimen. The apparatus and methods are useful for treatment of GERD by creating a restriction or a valve-like structure at the gastroesophageal junction to prevent reflux of the stomach contents.
• T-tag fasteners can be used to facilitate endoscopic attachment of the various components of the system to the tissues in or around the patient's gastrointestinal tract. In addition, T-pledgets can be used in situations where reinforcement of the tissue to be attached is desired. For example, such fasteners can be used for fastening a stoma device, a sleeve device or an attachment ring to the gastric wall. Optionally, the gastric wall may be folded into a single or double plication for attachment of the system components with the fasteners. Alternatively or in addition, where it is appropriate, laparoscopic assistance may be used for forming the plications or applying the fasteners. Expandable T-tags and T-pledgets and other structures to reduce tissue erosion are also described.
• Apparatus and methods are described for performing an endoscopic gastropexy attachment procedure for anchoring the gastric wall to the patient's diaphragm to provide greater support for the components of the system. A component of the system, such as a stoma device, a sleeve device or an attachment ring, can be attached simultaneously or in a subsequent step with the gastropexy attachment. T-tag fasteners or the like can be used to facilitate gastropexy attachment procedure.
BRIEF DESCRIPTION OF THE DRAWINGS
• FIG. 1 shows an artificial stoma device implanted within a patient's stomach with a line of gastroplasty sutures or staples to create a narrow passage.
• FIGS. 2A-2B shows a stoma device with a separate anchoring device in the form of an anchoring ring.
• FIG. 3 shows an enlarged view of an artificial stoma device with a variable diameter stoma aperture.
• FIGS. 4A-4B shows an alternate embodiment of an artificial stoma device with a variable diameter stoma aperture.
• FIGS. 5A-5B show an adjustable stoma with an inflatable bladder, pump and reservoir and with optional suture anchors.
• FIGS. 6A-6D show wire fasteners useful for attaching the stoma device and forming a gastroplasty pouch.
• FIGS. 7A-7B show an enlarged view of a smart stoma device with a stoma aperture that varies its diameter in response to conditions in the patient's stomach.
• FIG. 8A-8B show another embodiment of a smart stoma device with a stoma aperture that varies its diameter in response to conditions in the patient's stomach.
• FIGS. 9A-9B show an enlarged view of a smart stoma device with a closed loop controlled variable diameter stoma aperture.
• FIGS. 10A-10C show an artificial stoma device with a sutureless anchoring mechanism.
• FIG. 11 shows a gastric sleeve device with an artificial stoma device and a pyloric sleeve anchor implanted within a patient's stomach with a line of gastroplasty sutures or staples parallel to the sleeve.
• FIGS. 12A-12E are detail drawings showing additional features of a gastric or intestinal sleeve device.
• FIG. 13 shows a detail drawing of a gastric or intestinal sleeve device with reinforcement rings.
• FIG. 14 shows a detail drawing of a gastric or intestinal sleeve device with a spiral reinforcement.
• FIG. 15 shows a combined gastric and intestinal sleeve device with an artificial stoma device implanted within a patient's stomach with a line of gastroplasty sutures or staples parallel to the sleeve.
• FIG. 16 shows a combined gastric and intestinal sleeve device with an artificial stoma device located within a funnel-shaped entry with a reinforced suture area.
• FIG. 17 shows an artificial stoma device implanted within a patient's stomach with a line of gastroplasty sutures or staples to reduce the gastric volume. Also shown is a line of sutures or staples longitudinally dividing the small intestine to create a biliopancreatic channel separate from the intestinal lumen.
• FIG. 18 shows a cross section of the patient's small intestine showing the biliopancreatic channel.
• FIG. 19 shows an artificial stoma device implanted within a patient's stomach with a line of gastroplasty sutures or staples to reduce the gastric volume and a line of sutures or staples longitudinally dividing the small intestine to create a biliopancreatic channel with an optional stent.
• FIG. 20 shows a cross section of the patient's small intestine showing the biliopancreatic channel with an optional stent.
• FIG. 21 shows a combined gastric and intestinal sleeve device implanted within a patient's stomach with a gastric balloon to reduce the gastric volume.
• FIG. 22 illustrates an example of a gastrointestinal sleeve device deployed within a patient's gastrointestinal tract for treating morbid obesity.
• FIGS. 23A and 23B illustrate a gastrointestinal sleeve device with a healable, removable fixation system.
• FIGS. 24A-24D illustrate various gastrointestinal sleeve devices attached within a patient's stomach.
• FIG. 25 illustrates a gastrointestinal sleeve device with a coaxial inflatable balloon surrounding the sleeve within the patient's stomach.
• FIGS. 26A, 26B and26C show a cross section of the gastrointestinal sleeve device with optional features intended to keep the lumen of the sleeve open even if the sleeve collapses.
• FIGS. 27A and 27B show a cross section of the gastrointestinal sleeve device with optional internal channels intended to keep the lumen of the sleeve open even if the sleeve collapses.
• FIG. 28 illustrates an optional one-way valve feature of the gastrointestinal sleeve device.
• FIG. 29 illustrates another example of a gastrointestinal sleeve device deployed within a patient's gastrointestinal tract for treating morbid obesity.
• FIG. 30 illustrates another example of a gastrointestinal sleeve device having a reservoir located above the patient's pyloric sphincter.
• FIG. 31 illustrates another example of a gastrointestinal sleeve device having an inflatable gastric balloon.
• FIGS. 32A-32D illustrate optional features to assist in the deployment of the gastrointestinal sleeve device within a patient's gastrointestinal tract.
• FIG. 33 shows a cutaway view of a portion of a human digestive system, with an embodiment of a biliopancreatic diverter tube in situ.
• FIG. 34 shows an alternative embodiment of the biliopancreatic diverter tube in situ.
• FIG. 35 shows a method of delivering an embodiment of the biliopancreatic diverter tube.
• FIG. 36 illustrates several fastener segments, each segment having gripping fingers for attachment of a surgical appliance within a hollow organ in a patient's body.
• FIG. 37 illustrates a gastrointestinal sleeve device installed within a patient's stomach using the fasteners ofFIG. 36.
• FIG. 38 shows an alternative fastener system comprising an annular shaped member having gripping fingers for attachment of a surgical appliance within a hollow organ in a patient's body.
• FIG. 39 shows the device ofFIG. 38 with a surgical appliance attached.
• FIG. 40A shows an alternative fastener system comprising an annular shaped member wherein the surface of the annular shaped member alternates between having tissue growth promoting materials, and non-tissue growth promoting materials.
• FIG. 40B shows a fastener system comprising fastener segments connected with a bioresorbable material to ease installation.
• FIG. 41A shows an alternative fastener system comprising an annular shaped member wherein the surface of the annular shaped member alternates between having tissue growth promoting materials, and non-tissue growth promoting materials.
• FIG. 41B shows an alternative fastener system comprising an comprising an annular shaped member wherein the surface of the annular shaped member alternates between having tissue growth promoting materials, and non-tissue growth promoting materials.
• FIG. 42A shows an alternative fastener system comprising an annular shaped member wherein the surface of the annular shaped member alternates between having tissue growth promoting materials, and non-tissue growth promoting materials.
• FIG. 42B shows an alternative fastener system comprising an annular member of rough segments having hooks coupled to smooth segments that are made of a bioresorbable material.
• FIGS. 43-45 show various embodiments of a fastener system that also functions to create a stoma within a passageway that is more narrow than the original passageway.
• FIG. 46A shows an alternative embodiment of a fastener system.FIG. 46B shows the device ofFIG. 46A being driven through a single tissue layer, with the attachment means positioned within the passageway and the cone shaped spring positioned on the opposite side.
• FIG. 47A shows a clip that can be used to plicate tissue, and also provide a platform for attaching another device or hanger. The clip is shown being used with one embodiment for a plication tool.
• FIGS. 47B-47D show the sequence of steps used to deliver the clip ofFIG. 47A. This process may be repeated to collectively form a support structure for another device.
• FIG. 47E shows another device that is positioned to hang from several clips positioned within a passageway.
• FIG. 47F shows an alternative clip embodiment having two separate attachment platforms.
• FIG. 48 shows another embodiment of a fastener system comprising a hanger that also functions to hold two layers of folded tissue together. This fastener has a toggle that pivots on a hinge so that is can be aligned with the post as it is passed through tissue layers, and can then be pivoted to hold the tissue layers together.
• FIGS. 49-51 illustrate a surgical instrument for fastening tissue.
• FIG. 52 shows a cross section of one possible configuration of the surgical instrument shown inFIGS. 49-51.
• FIG. 53 shows a surgical instrument comprised of a fastener delivery mechanism, and an anvil hingedly attached to an extension arm, used for creation of a stoma or restriction in a patient's stomach that is sized for passage through an endoscope.
• FIG. 54 shows a stoma created using fasteners.
• FIGS. 55-57 show the sequence of steps for inserting a fastener in greater detail.
• FIG. 58 shows an example of a stomal ring clip device with only an upper ring implanted in a patient's stomach, held in place with fasteners.
• FIGS. 59-64 show a sequence of steps for using a surgical instrument to implant a device similar to the device ofFIG. 58.
• FIG. 65 is an exploded view of a stomal ring clip device having upper and lower rings for forming a stoma or restriction in a patient's stomach.
• FIG. 66 shows an assembled view of the stomal ring clip device implanted in a patient's stomach.
• FIG. 67 shows an example of a stomal ring clip device with an upper ring and a lower ring implanted in a patient's stomach.
• FIG. 68 is an exploded view of an embodiment of a stoma ring clip with a dependent gastrointestinal sleeve device.
• FIG. 69 shows the device ofFIG. 68 in situ.
• FIG. 70 shows an embodiment of gastrointestinal sleeve device.
• FIG. 71 shows the device ofFIG. 70 in situ.
• FIG. 72 illustrates another embodiment of a surgical instrument for fastening tissue.
• FIG. 73 is an exploded view of a surgical fastener for use with the surgical instrument ofFIG. 72.
• FIG. 74 shows the surgical fastener ofFIG. 73 in a deployed condition.
• FIGS. 75A-75F show a sequence of steps for deploying the surgical fastener ofFIG. 73.
• FIG. 76 shows the surgical fastener ofFIG. 73 being removed.
• FIG. 77 shows a top view of an attachment ring device for attaching a gastrointestinal sleeve device within a patient's stomach.
• FIG. 78 shows a cross section of the attachment ring device ofFIG. 77.
• FIG. 79 shows a cross section of the attachment ring device ofFIG. 77 with a gastrointestinal sleeve device installed.
• FIG. 80 shows a cross section of the attachment ring device and the gastrointestinal sleeve device ofFIG. 79 with an optional leak shield installed.
• FIG. 81 shows a top view of another embodiment of an attachment ring device for attaching a gastrointestinal sleeve device within a patient's stomach.
• FIG. 82 shows a cross section of the attachment ring device ofFIG. 81.
• FIG. 83 shows a cross section of the attachment ring device ofFIG. 81 with a gastrointestinal sleeve device installed.
• FIGS. 84A-84C show a gastrointestinal sleeve device with an integral leak shield.
• FIG. 85 illustrates the components of a kit for delivering and deploying a gastrointestinal sleeve device.
• FIGS. 86A-86C illustrate three options for preloading a gastrointestinal sleeve device for delivery and deployment.
• FIGS. 87A-87D illustrate four options for sealing the distal end of a gastrointestinal sleeve device during delivery and deployment.
• FIGS. 88A-88B illustrate a method of delivering and deploying a gastrointestinal sleeve device.
• FIGS. 89A-89D illustrate an alternate rivet design.
• FIG. 90A illustrates a method of laparoscopically assisted formation of a double plication.
• FIG. 90B illustrates a device for laparoscopically assisted formation of a double plication.
• FIGS. 91A and 91B illustrate T-tag and T-pledget ring attachment.
• FIG. 92 illustrates a gastropexy apparatus.
• FIGS. 93A-93D illustrate examples of expanding T-tag fasteners.
• FIGS. 94A-94C illustrate placement of T-tag fasteners.
• FIG. 95 illustrates extragastric laparoscopic attachment of an intragastric ring.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT
• The present invention provides apparatus and methods for treatment of obesity, and particularly morbid obesity. The apparatus takes the form of a system of components that may be used separately or in combination for effectively reducing stomach volume, bypassing a portion of the stomach and/or small intestines and reducing nutrient absorption in the stomach and/or small intestines. Each of the components can be implanted using minimally invasive techniques, preferably using a transesophageal approach under visualization with a flexible endoscope. Optionally, laparoscopic surgical techniques may be used to assist in the implantation of the components and/or for adjunctive therapies in the digestive tract.
• In the following, the word endoscope (and endoscopic) will refer to an instrument for visually examining the interior of a bodily canal or a hollow organ. For procedures performed via a peroral route, a flexible endoscope, such as a gastroscope, is generally preferred. The word laparoscope (laparoscopic) will refer to rigid endoscopes generally passed through surgically created portals. Also in the following the terms biodegradable and bioresorbable will be used interchangeably. Also in the following the term stoma will be used to refer to an opening formed in a hollow organ which may or may not be configured to restrict flow of food and/or digestive juices. Endoscopic overtube and orogastric tube sleeve are also used interchangeably.
• In one aspect of the invention, the system may include anartificial stoma100 located in the stomach or lower esophagus that can optionally reduce the flow of food into the stomach.FIG. 1 shows anartificial stoma device100 implanted within a patient's stomach. Thestoma device100 is introduced transesophageally and implanted under visualization with a flexible endoscope. The stoma may be optionally restrictive or non-restrictive of food flow. The stoma may be anchored to the esophageal or stomach wall using sutures, staples, clips or other anchoring mechanisms as described herein. Optionally, thestoma100 may be used in conjunction with gastric suturing, stapling or banding to create a narrow passage for installation of the stoma and/or for reduction of gastric volume. The gastric suturing, stapling or banding may be applied using open, transesophageal or laparoscopic techniques. In the example shown inFIG. 1, a line of gastroplasty sutures orstaples104 has been used to create a small gastroplasty pouch with a narrow passage for installation of thestoma100. The gastroplasty sutures orstaples104 may be applied using open, transesophageal or laparoscopic techniques.
• Theartificial stoma100 may include a fabric cuff on the outer circumference to facilitate ingrowth of tissue to secure thestoma device100 in place. In-growth can be further facilitated by partial transection of the gastric wall through the mucosa.
• This will put the fabric cuff in contact with muscularis. Alternatively or in addition, a number of suture attachment points can be included on the outer circumference of the stoma device. The suture attachment points may take the form of suture attachment loops attached to the outer circumference of the stoma device or a ring with suture attachment holes formed in it.
• In certain embodiments, the outer circumference of thestoma100 is flexible and elastic with properties to minimize the resistance of thestoma100 to motion of the stomach at the stomal attachment points. This also serves to minimize the forces that can lead to tissue erosion.
• In an alternative embodiment, the artificial stoma device may include a separate anchoring device that may be in the form of an anchoring ring or a series of anchoring points for attachment to the gastric or esophageal wall.FIGS. 2A-2B shows astoma device100 with a separate anchoring device in the form of ananchoring ring108. Theanchoring ring108 may include a sutureless anchoring mechanism and/or a fabric cuff or other attachment points for sutures, staples, clips or other anchoring mechanisms. Theanchoring device108 is initially implanted in the stomach or lower esophagus, as shown inFIG. 2A. Preferably, the tissue is allowed to heal for a number of weeks before theartificial stoma100 is installed by attaching it to theanchoring device108 in a subsequent procedure, as shown inFIG. 2B.
• Optionally, thestoma100 may have anadjustable opening110 to vary the flow of food through the stoma.FIG. 3 shows an enlarged view of an artificial stoma device100 a variablediameter stoma aperture110. Theadjustable stoma100 may be adjusted at the time of implantation and/or it may be adjustable remotely after implantation without invasive procedures.
• Theadjustable stoma100 may be formed as a cylinder that can be collapsed for insertion, and then expanded when in place. Preferably, the outer diameter will maintain a set, but somewhat elastic, diameter to facilitate fixation in the body. The outer circumference may be supported by ametal lattice114 that is deformed permanently by the initial deployment. Possible materials for themetal lattice114 include 304 and 316 stainless steel. Deployment can be by a coaxial balloon catheter.
• In certain embodiments, the inner circumference of the adjustable stoma is supported by ametal lattice116 made of a NiTi alloy where the deformation needed to deploy the device and set the size of the inner diameter can be reversed by the application of heat. Heat could be applied by a balloon catheter with circulating heated fluid, RF energy or other known means. TheNiTi lattice116 can then be expanded and deformed to the desired diameter by a balloon catheter inflated in thestoma aperture110. Alternatively, thelattice116 may be made of a material that is plastically deformable, such as stainless steel, to adjust thestoma aperture110 larger using a dilator, such as an inflatable balloon.
• In the example ofFIG. 3, the entireadjustable stoma100 is covered by abiocompatible material118, such as an elastomer, to prevent ingress of fluids into the interior of theadjustable stoma100. Examples of suitable materials include silicone (e.g. Dow Silastic or similar material from Nusil Technology) and polyurethane (e.g. Dow Pellethane). The stoma could alternately be constructed from or coated with a fluoropolymer such as a PFA, FEP or PTFE (e.g. Dupont Teflon). The outer circumference is adapted for accepting sutures or staples for attachment within the body.
• FIGS. 4A-4B shows an alternate embodiment of anartificial stoma device100 with a variablediameter stoma aperture110. The inner circumference of the adjustable stoma is supported by awire coil126 that helps to maintain theadjustable stoma aperture110. In certain embodiments, thewire coil126 is made of a shape-memory NiTi alloy, so that thestoma aperture110 can be adjusted larger or smaller using the method described below. Alternatively, thewire coil126 may be made of a material that is plastically deformable, such as stainless steel, to adjust thestoma aperture110 larger using a dilator, such as an inflatable balloon. Alternatively or in addition, a lattice or other easily deformable structure may be used in place of thewire coil126. Thewire coil126 may be Stomas of this type are preferably inserted in a collapsed state to facilitate passage through the esophagus. This type of stoma and other collapsible stomas can utilize a removable sleeve or other means for temporarily holding the stoma in the collapsed state.
• Any of the restrictive stoma devices described herein can be placed in the lower esophagus or near the GEJ to prevent reflux. Esophageal or anti-relux stomas will preferably be configured to allow one-way flow and seal against or resist retrograde flow. This could be accomplished with a smart type stoma as described herein, preferably one that closes in response to gastric secretions, or a one-way valve, such as a duckbill or flap type valve.
• In one embodiment, thestoma device100 may be implanted and adjusted according to the following method:
• Stoma placement
• • 1) place oral-gastric tube into the patient's stomach, the oral-gastric tube can optionally include a separable sleeve;
  • 2) insert a guidewire through the oral-gastric tube into the stomach;
  • 3) remove the oral-gastric tube, optionally, the sleeve may be left in place to protect the esophagus;
  • 4) position the adjustable stoma over the balloon on a primary dilatation catheter;
  • 5) insert the dilatation catheter and the adjustable stoma over the guidewire into the stomach;
  • 6) inflate the balloon on the dilatation catheter to expand the adjustable stoma;
  • 7) exchange the dilatation catheter and repeat if necessary to achieve the proper outer diameter;
  • 8) suture or staple the stomach wall to approximate a gastric pouch, this can be done with open surgery, laparoscopically or, preferably, transesophageally;
  • 9) reinflate the balloon on the dilatation catheter to grip the adjustable stoma;
  • 10) withdraw the dilatation catheter until the adjustable stoma is positioned within the suture line in the desired stoma position;
  • 11) secure the adjustable stoma in place and suture, staple and/or glue to seal the adjustable stoma to the gastric pouch;
  • 12) withdraw the dilatation catheter;
  • 13) insert the heat application means over the guidewire and position it within the stoma aperture;
  • 14) apply heat to shrink the inner diameter of the adjustable stoma;
  • 15) withdraw the heat application means;
  • 16) if necessary, insert a dilatation catheter and inflate the balloon to dilate the stoma aperture to the desired diameter;
  • 17) withdraw the dilatation catheter, guidewire and orogastric tube sleeve (if used)
• This method can be modified for installation of a fixed diameter stoma device or a smart stoma device that does not require heating and/or dilatation to adjust the inner diameter of the stoma aperture. The method can also be modified for installation of a stoma device with a self-expanding metal lattice on the outer circumference, obviating the need for the primary dilatation catheter. The order of the method can also be modified, for example the pouch can be created first or the artificial stoma can be placed in a pre-existing pouch where the surgically created stoma has become enlarged. Other methods of attachment described herein may also be used for placement of a stoma device.
• The adjustable stoma device may be initially implanted with the stoma aperture larger than clinically useful. This would allow food to pass easily through the stoma aperture and minimizes the stress on the attachment points for the stoma device and the sutures or staples forming the gastric pouch. This will allow the stomach wall to heal before the stoma aperture is reduced to a clinically significant diameter, which will naturally place more stress on the tissue and the attachment points.
• Alternatively, theadjustable stoma100 may be configured such that theinner diameter110 is adjusted by inflation by transferring fluid from a reservoir into the annulus between the inner and outer circumference.FIGS. 5A-5B show anadjustable stoma100 with aninflatable bladder120, pump122 and reservoir124 and with optional suture anchors112.
• Stapling or suturing for placement of theadjustable stoma device100 is preferably accomplished transesophageally with the use of a flexible endoscope. Sutures may be placed into the muscularis, through the muscularis and/or full thickness through the muscularis and serosa based upon the clinical situation. One method for accomplishing this involves the use ofwire fasteners130 that are formed with a “button”end132 and a “twist tie”end134, which are shown inFIGS. 6A-6D. In certain embodiments, thewire fasteners130 are formed from a superelastic NiTi alloy so that the fasteners can be straightened out and passed through adelivery cannula136, as shown inFIG. 6A. Thedistal tip138 of the wire can be sharpened so that it will penetrate tissue. A portion of the distal end of the wire is formed so that it will assume a circular or spirally curled “button”shape132 after it has passed through the tissue, as shown inFIG. 6B. The “button”shape132 attaches the fastener to the stomach wall and prevents it from being pulled out through the tissue. The curl of the “button”132 can be shaped so that it protects the sharpeneddistal tip138 of the wire and prevents it from damaging the stomach wall or surrounding tissues after the fastener is deployed. There is an approximately 90degree bend140 in the wire just proximal to the “button”portion132. A portion of the proximal end of the wire is formed to create the “twist tie”134, which reforms when thewire fastener130 is pushed out of thedelivery cannula136, as shown inFIG. 6C. The “twist tie”134 can be a helical curl or other shape that will entangle and interlock with a mating fastener when the two are approximated to one another, as shown inFIG. 6D. Alternately, theproximal end134 of thewire fastener130 can form a loop for attachment of standard suture materials.
• Thedelivery cannula136, which may be configured with a torquable shaft with a fixed orvariable curve144 at the distal end, is used to deliver thewire fasteners130 to the desired location. The distal end of thedelivery cannula136 is advanced until it contacts the stomach wall, then a pusher wire or the like is used to advance thewire fastener130 through thedelivery cannula136, as shown inFIG. 6A. As thewire fastener130 exits thedelivery cannula136, the sharpeneddistal tip138 penetrates the stomach wall. The “button”portion132 of the wire assumes its curved configuration distal to the stomach wall as thefastener130 is advanced farther out of thedelivery cannula136, as shown inFIG. 6B. These steps are repeated to place asecond wire fastener130 in the opposite wall of the stomach. Then, the twodelivery cannulas136 are withdrawn while continuing to advance the wires out of the delivery cannulas to allow the “twist tie” portions to assume their helical curled shape proximal to the stomach wall and the two fasteners are approximated to one another so that the two “twist tie” portions intertwist with one another as they exit the delivery cannulas to attach the two walls of the stomach together, as shown inFIG. 6D. Alternatively, thewire fasteners130 can employ a loop, rather than a “twist tie” to enable approximation using a secondary means such as sutures. A line offasteners130 can be thus deployed to create a gastroplasty pouch or band.
• In an alternate embodiment, the wire fasteners may be configured to have a “button”portion132 on both ends of the wire. These fasteners can be deployed laparoscopically to penetrate both walls of the stomach with a “button”132 placed on each side of the stomach to attach the walls together. Such fasteners can be combined with buttressing reinforcements such as pledgets made from Teflon, bovine or porcine tissue or other know materials. “T-tag” type fasteners could be applied to this use and type of application.
• T-tag fasteners can be used to attach many of the structured described herein. A T-tag is basically a cross member or “T” that is attached to an elongated member or tail at or near the mid-point of the T. A “stem” may be a structure at the joining point of the T and tail. T-tag fasteners are generally configured to flex at the juncture of the T and tail to allow delivery along the axis of the T through a minimal puncture diameter. T-tag fasteners can be configured with an extended tail that may extend out the mouth and optionally be used to parachute devices for attachment into position in vivo. Other T-tag configurations can include, crimp, snap, screw or other means of securing the T-tag tail when appropriate. One embodiment of a T-tag fastener could include a dual tail. Such a dual tail could be combined with extended tails that could then be tied out side the body with the ensuing knots then tightened within the body. Such a dual tail could be constructed of one of a number of non-biodegradable suture materials known in the art including polypropylene, nylon, braided Dacron or silk. In some clinical situations biodegradable tails could be indicated and could be constructed using materials described herein.
• FIGS. 94A-94C illustrate a method of placing T-tag fasteners918 through the gastric wall that prevents accidental damage to other structures. One method of accomplishing this end could involve the use of anendoscope920 with two (2) working channels. One channel could be used to deliver a grasping means921 that would grasp the gastric wall (as illustrated inFIG. 93A) and invaginate it to displace the area grasped away from adjoining structures (e.g. spleen). The second working channel can then be used to deliver a T-tag fastener918 through, for example, a hollow needle type delivery system922 (e.g. T-ANCHOR INTRODUCER GUN (Moss Tubes)) that has been redesigned so it can be passed through the working channel of an endoscope and then rotate 90 degrees into position (as illustrated inFIGS. 94B and 94C). Laparoscopic or other extragastric means could also be applied to the end of preventing damage to adjoining structures.
• For each subsequent T-tag fastener918, the previously placed fastener(s) may be used to grip and invaginate the gastric wall. The fasteners may be used to assist in forming of a plication or in retracting and positioning the gastric wall for fastening another component, such as a stoma, sleeve or attachment ring. Similarly, other gripping means, such as vacuum, transmural hooks and the like, may be used to facilitate placement of fasteners to assist in forming of a plication or in retracting and positioning the gastric wall for fastening another component of the system.
• An example of a method of use of one configuration (dual tail T-tag) of the structures described above when used to attach an attachment ring as inFIG. 77 could be as follows:
• • 1. Position endoscope overtube
  • 2. Insert endoscope (2-channel) and, using grasper and T-tag delivery device, deploy a T-tag and position the T-tag tails externally (Repeat 6 times)
  • 3. Pre-thread T-tag tails through an attachment ring matching each pair of the 2-tailed T-tags to capture a predetermined portion of the attachment ring material
  • 4. Prepare to parachute the attachment ring through over tube and pass the ring through overtube.
  • 5. Snug T-tag tails to position attachment ring and ready for final attachment
  • 6. Using appropriate instruments partially tie the knots externally and advance the partial knots into position to be secured and trimmed (Repeat 6 times)
  • 7. Remove all instrumentation
• The final result is now illustrated asFIG. 91A. This attachment method can be modified by the use of multiple rows of T-tag fasteners as described herein.
• Peroral extra-gastric buttress reinforcement—Buttresses are preferably placed in locations subject to forces to which there will be clinical benefit to distributing forces. The buttressing material is generally configured perpendicular to the axis of the attachment means (e.g. suture, rivet or staple) and therefore best distribute forces along the axis of the attachment means. When a device is attached to the intragastric wall such forces can be directed inward from the gastric wall. Therefore, if the buttress is attached to the intragastric wall, the buttress may not be along the axis best suited to resist the applied force.
• Many of the apparatus and methods described herein use a plication to redirect these forces to allow intragastric buttresses to distribute these forces in a beneficial, i.e. more perpendicular, direction. Other apparatus and methods described use other structural means to distribute forces on the extragastric wall in which case inwardly directed forces would be in a beneficially perpendicular direction. The following describes an exemplary apparatus and method to embody and deliver extragastric buttresses.
• Use of a curved needle to deliver a buttress that, in one configuration is a teflon pledget, to a location on the extra gastric wall from the inside of the stomach. This pledget would be captured in an invaginating (into the stomach) plication that could then be secured by sutures, staples, rivets et al. The buttress could be a tubular shapes segment of expanded teflon similar to a small diameter vascular graft. This could be delivered on the outside of a curved needle, which, upon withdrawal retrograde from the direction of delivery, would leave the pledget in position outside the stomach. The plication would be preferably secured prior to the removal of the needle. The buttresses could be delivered in a similar manner through the lumen of a hollow needle. In this case it may be preferred to partially withdraw the needle and deploy the buttress prior to securing the plication.
• This system, as can others described herein, could use 4-10 or more primary fixations to resist tension and optionally use intermediate sutures, rivets, etc. if appropriate to resist leaks.
• Fastener (T-tag) buttress (T-pledget) method and structure—An alternate method of delivering these buttresses would be using a T-fastener (T-tag) where the “T” portion was constructed of a material with properties that would be useful as a buttressing material. T his would be a T-tag buttress or a T-tag pledget. Hereinafter T-pledget. These T-tags could be delivered through a hollow needle type delivery system (e.g. T-ANCHOR INTRODUCER GUN (Moss, Moss Tubes)) that has been redesigned/modified so it can be passed through the working channel of an endoscope. One advantage of the use of T-pledget is that a T-tag can be designed with an elongated tail that can extent out through the mouth and be used to parachute structures into place in-vivo. T-pledget tails could include preloaded needles. Needles could be curved or straight.
• The suture, staple, rivet or other fastener used to secure the sleeve attachment ring or other device into place could, based upon the clinical situation, capture the pledget portion of the T-pledget to fix it in place in relation to the attachment means.
• A method of use of one configuration of the T-pledget structures described above when used to attach an attachment ring could be as follows:
• • 1. Position endoscope overtube
  • 2. Insert endoscope (2-channel) and using grasper and T-pledget, deploy T-pledget and position tails externally
  • 3. Pre-thread T-pledget tails through attachment ring
  • 4. Prepare to parachute attachment ring through over tube and pass the ring through overtube
  • 5. Snug T-pledget tails to position the ring and ready for final attachment
  • 6. Using tails, guide the PLICATOR (NDO Surgical Inc.) into position and fire the PLICATOR to form a plication over the T-pledget
  • 7. Trim tails and remove all instrumentation
• The final result is now illustrated asFIG. 91B (showing a dual attachment face ring as described below).
• T-pledgets can be structured using a variety of means. A portion of standard Teflon pledget material can have a suture tied or otherwise attached, at or near its mid point. This can be structured or otherwise prepared for delivery by means such as rolling and/or compressing to facilitate passage through tissue with a minimum disruption of the tissue layer. Ideally the T-pledget would have a minimum diameter when passing through tissue. Depending upon the clinical situation varying deployed diameters/areas could be preferred. A hollow needle or other hollow tube can be used to facilitate passage through tissue. Structure and/or material selection to enhance axial rigidity along the axis of delivery will be beneficial is some clinical situations. A piercing point on the leading edge of the “T” may be useful with some deliver mechanisms.
• Many of the features described above can be achieved with construction using a single piece of Polypropylene, Nylon, or other polymeric material well known in the art for use in construction sutures, which forms the “T” and tail as a single unit. Alternately 2 different materials can be combined, for example by insert molding, to achieve different properties of the “T” and tail. In another embodiment this could be combined with a “T” portion that is coated with a material selected for specific clinical properties such as encouraging or discouraging either in-growth or adhesion. The “T” portion may also be surrounded by another material such as Teflon pledget material or Dacron graft material. “T” diameter will vary according to the material used for example ranging from 0.5 mm to 3.0 mm in diameter for nylon or polypropylene with the typical “T” having a diameter of 1-2 mm. A tail could be the dimension of a standard suture and could generally vary from 5-0 to 0 (USP standard classification) though smaller or larger sizes may be appropriate in certain clinical situations.
• In one configuration that could have advantages in certain clinical situations the “T” and/or tail portions of the T-pledget could be constructed in part or in toto of a biodegradable material as described herein. In one such configuration the “T” portion would be constructed of a flexible buttress material that is not biodegradable. In some embodiments this could have a tubular configuration. This would include a core of a more rigid material that is biodegradable. The tail in this situation could be optionally biodegradable. This combination T-pledget can have advantages in that its “T” portion will1) have increased rigidity for insertion; 2) maintain its ridgidity during the time period while the tissue goes through its healing period and ideally until it regains its strength; and 3) become softer and more flexible to minimize the potential for erosion over the length of time the pledget is in position. Various buttress materials, both biodegradable and not, are described herein.
• In an alternative embodiment a porous buttress material could be impregnated with a biodegradable material to achieve a similar result. Similarly a biodegradable material could coat a buttress material. The rigidity of both the permanent buttress material and the biodegradable material may be selected and modified to suit specific clinical situations. In some situations the biodegradable material may be of a lesser rigidity compared to the buttress material. Embodiments that include a biodegradable tail portion could have an advantage in certain clinical situations, as this would eliminate the tail as a focus for a leak after it has degraded. Bioresorbable materials such as polyglecaprone (Monocryl, Ethicon), polyglactin (Vycril, Ethicon) or other as well know in the art can be appropriate for use in these applications.
• Bio-stable, solvent dissolvable pledget material—In other situations the pledget material could be made from a material that is stable in the body but could dissolve in the presence of a biocompatible solvent, or a biocompatible solution including a chemical or catalyst that will initiate the pledget's dissolution. This would allow simplified removal of the pledget material via lavage of the peritoneum if the stomach attachment means were to be released through an endoscopic procedure or were otherwise desirable based upon the clinical circumstances.
• Dual attachment faces and T-tag or T-pledget extra-gastric buttress reinforcement—As illustrated inFIG. 91B, in one embodiment of attachment to a plication, the structure of the device being attached can include attachment faces that capture both sides of the plication thereby forming a buttressing means for the means used to secure the plication.
• As discussed herein, forces can be applied inwardly by devices attached to the intragastric wall. Other forces are applied to the gastric wall due to the natural muscular action of the gastric wall. These forces can serve to be applied in the plane of a gastric wall and, in this case, can serve to apply tension to separate a plication. Use of a T-pledget as an extragastric buttress in combination with a device that includes attachment faces that capture both sides of the plication as shown inFIG. 91B can be particularly beneficial in resisting these forces.
• Dual attachment faces926 can be integrated with the ring, or other attachment means, used to secure other devices, e.g. a sleeve, to the stomach or they could be separable to facilitate delivery, attachment and/or removal. If separate, the ring can optionally include structures such as holes or other guide means that would facilitate parachuting the device into position. These attachment faces can be made of materials that either encourage or discourage in-growth and/or epithelialization as dictated by the clinical situation. Dual attachment can also be used without extragastric buttressing.
• Use of attachment face materials and buttress materials that discourage in-growth along with securing means that initiate minimal scar formation could enhance the reversibility of the procedure if and when the securing means were to be released and removed. Attachment faces, along with any structures attached to or incorporated within, could then be sloughed and passed naturally and/or removed via a transoral route as indicated by the device and the clinical situation. Use of an overtube to protect the esophagus during transoral removal of certain devices can be clinically indicated based upon the size and shape of the device being removed.
• The concept of using attachment faces that capture both sides of a plication can be applied to other attachment means described herein. The concept of using one or more separable attachment faces as a means to capture other devices can optionally be applied to other attachment means described herein.
• A method of use of one configuration of the structures described above could be as follows:
• • 1. Position endoscope overtube
  • 2. Insert endoscope (2-channel) and using grasper and T-pledget device, deploy T-pledget and position tails externally (Repeat 6 times)
  • 3. Pre-thread T-pledget tails through attachment face material (and, if used, thread through separate sleeve ring)—Note that the tails are passed through the attachment face material at a location that will provide for an appropriate amount of attachment face material on either side of the plication as indicated by the clinical situation.
  • 4. Prepare to parachute devices through over tube and pass device(s) through overtube
  • 5. Snug T-pledget tails to position device(s) and ready for final attachment
  • 6. Using tails, guide the PLICATOR (NDO Surgical Inc.) into position and fire the PLICATOR to form a plication over the T-pledget (Repeat 6 times)
  • 7. Trim tails and remove all instrumentation
• In an alternate example of the above-described method using a dual tail T-tag or a T-tag device with securing structure, step6 can be replaced with tying or otherwise securing each T-tag as the final attachment.
• In a similar manner to a T-pledget, a pledget can be delivered to the extragastric surface using an expanding tip configuration similar to a 2-wing Malecot catheter. The expandable Malecot tip would be detachable from its delivery cannula.
• In this case the Malecot pledget could include:
• • 1. a pointed distal tip for penetration through the gastric wall (note in some embodiments this tip may be dissolvable to reduce the potential for long term tissue irritation)
  • 2. a suture-like tail attached to distal tip (to retract and expand the tip)
  • 3. a method that would include applying tension to the suture tail to expand the tip after it has been positioned beyond the extragastric surface
  • 4. a delivery cannula that can support the proximal portion of the pledget (support to translate suture retraction into pledget tip expansion)
• Retraction of the delivery cannula/pusher would leave the expanded Malecot pledget on the extragastric surface.
• In-line pledget (alternative to curved needle delivery)—In this case the pledget material would be in line and coaxial with the suture. The pledget would include at least one tapered end for passage through tissue and may be expandable over time (to allow a small hole or passage through the tissue and a greater buttress area). The needle on the end of the suture would be passed through the gastric wall twice (first inside-to-outside and then, approximately a pledget's length apart, outside-to-inside). This could be accomplished with laparoscopic assistance; a large radius curved needle or other means. The suture would be advanced until the pledget is in position and excess suture would be trimmed. The suture could be biodegradable.
• T-tag918 and T-pledget920 embodiments designed for expandability—A T-tag or T-fastener can be used to provide knot free means to apply tension to a suture and an associated anatomic structure. A further advantage of a T-tag is that the forces applied to the suture tail of the “T” are distributed over a larger area than a single stitch. This is accomplished by using a “T” dimensioned with a width wider than the diameter of the suture and a length longer than a typical bite or stitch. A disadvantage of a T-tag is that insertion of a T-tag through tissue requires a hole many times, for example 5-15 times, the diameter of the suture tail.
• To deliver an improved buttressing capability in a T-tag fastener or T-pledget with a minimum delivery hole it is beneficial to use a “T” or pledget designed to expand after delivery. This can be beneficial in many clinical situations. In addition to rolling or compressing, alternate structures can include materials that expand when exposed to water such as hydrogels.FIGS. 93C and 93D show how a T-pledget920 or T-tag918 of woven cylindrical meshes that may be compressed or elongated to achieve a reduced diameter and expanded or shortened to become wider. Compared to a rectangular sheet, alternate configurations of a rolled and unrolled sheet can achieve a T-pledget920 or T-tag918 with increased projected width relative to its rolled diameter through the use of matching cutouts, as shown inFIGS. 93A and 93B. Though not as efficient in diameter-to-projected width ratio, is some cases it may be clinically desirable to have a “T” that is in a circular shape.
• To resist bending perpendicular to the axis of the suture, it may be beneficial to use metals, for example Ti, SS or NiTi. In some clinical situations, encapsulating or coating the metal with a fluoropolymer or other coatings as described herein may also be beneficial.
• T-tag with inflammatory reaction or other additives—The pledget material could be optionally coated or impregnated with materials and/or medicaments as described herein. For example the pledget can be coated with a material that would enhance inflammation and scar formation. Alternatively, a coating or medicament that would either encourage or discourage in-growth can be applied.
• In some clinical situations it may be beneficial to use both these types of coatings. For example, though inflammation can lead to scarring fibrosis and ultimately strengthen tissue, the inflammatory process initially results in tissue weakening that can include tissue liquefaction. Therefore, it can be desirable that a fastener that induces an inflammatory response for long term strength also include means to support the tissue during the weakened stage.
• Inflammatory reaction materials would be limited to a portion of the T-tag or T-pledget as the inflammatory response weakens tissue before the scarring fibrosis occurs. Therefore, for example, having the area at the center of the T or pledget with this inflammatory material and the ends of the “T” without this material could have an optimized balance of short term and long term strength.
• Drug-eluting coatings may be used to encourage or discourage tissue ingrowth into the fasteners or other device attachment mechanisms described herein. A low inflammatory response is generally desirable for encouraging tissue ingrowth. Anti-inflammatory drugs that may be used include steroidal anti-inflammatory drugs, e.g. prednisone, and nonsteroidal anti-inflammatory drugs (NSAID), e.g. chromalin. Conversely, drugs that may be used to control or reduce tissue ingrowth include Taxol (paclitaxel) (Bristol-Myers Squibb) and Sirolimus (rapamycin) (Wyeth-Ayerst Laboratories).
• Embodiments designed for improved erosion resistance—The purpose of the “T” in a T-fastener is to distribute and resist the forces that could act to pull it through tissue, in this case the gastric wall. To better achieve this result the “T” should resist bending. Though a T-fastener is generally held parallel to the surface of the extragastric wall, at the ends of the “T” the gastric wall extends outward from the plane of the surface and the axis of the “T”. In this case, the gastric wall could be at a 90-degree angle, or greater, to the ends of the “T”. To reduce the potential for erosion at the end of the “T” in some clinical situations it could be beneficial for the ends of the “T” to have increased flexibility which will result in a reduction of the angle between the gastric wall and the ends of the “T”. This would reduce the forces between the “T” and the gastric wall and therefore reduce the potential for erosion at the ends. Structures that could accomplish this could include tapered thickness or cross section to reduce the bending moment. Alternatively or in addition, changes in material properties such as hardness, bending modulus and/or elongation can accomplish the same result. For example the “T” near the stem could be of a material of a durometer such as Shore 65D or higher the material may change as one moves out along the arms of the “T” transitioning through 55D/100A to 90A durometer or lower. Rounding, smoothing and structures that otherwise distribute forces over a larger area will also serve to reduce erosion at the ends of the “T”. A circular shaped “T” may be particularly desirable to reduce erosion.
• Another method of intragastric stapling utilizes a pair of vacuum or mechanical graspers to capture the tissue to be joined, for example the stomach wall. The graspers approximate the tissue and present it to a stapling mechanism. Once the tissue has been presented to the stapling mechanism, a number of methods may be used:
• • 1) a staple or clip may be applied to join the tissue together;
  • 2) a precurved wire fastener, which may be constructed of a NiTi alloy or other material, may pierce the tissue on one side and then pierce the tissue on the other side as it curls to capture both;
  • 3) a curved needle with attached suture can be passed through the tissue using known endoscopic suturing techniques.
• These two methods (vacuum approximation and NiTi buttons) can also be combined.
• Intra gastric stapling can be facilitated by external manipulation in a combined endoscopic/laparoscopic approach. Internal endoscopic manipulation can be combined with external laparoscopic stapling or external manipulation can be combined with internal endoscopic manipulation. Laparoscopic techniques can also be used inside the stomach.
• In an alternative embodiment, the stoma may be a self-adjusting “smart stoma” that opens and/or closes in response to stomach conditions.FIGS. 7A-7B show an enlarged view of asmart stoma device150 with astoma aperture152 that varies its diameter in response to conditions in the patient's stomach. In one embodiment shown inFIGS. 7A-7B, thesmart stoma device150 includes a fluid-filledbladder154 surrounded by anosmotic membrane156. One example of a suitable material for theosmotic membrane156 is silicone (e.g. Dupont Silastic). Theosmotic membrane156 may be made of microporous silicone or other material similar to those used for hemodialysis membranes. In response to changing conditions, for example if the patient drinks a glass of water, water will move across theosmotic membrane156 to swell thebladder154 and shrink thestoma aperture152 to restrict food intake.
• In another embodiment shown inFIG. 8A-8B, thesmart stoma device150 may include atoroidal member158 made of a swellable material, such as a hydrogel (e.g. Akina HydroTab). In response to changing conditions, for example if the patient drinks a glass of water, thetoroidal member158 will swell and shrink thestoma aperture152 to restrict food intake. Alternately the hydrogel can expand in the presence of a specific chemical such as the glucose sensitive hydrogel material used in the Glucose Biosensor (M-Biotech)
• FIGS. 9A-9B show an enlarged view of asmart stoma device150 with a closed loop controlled variable diameter stoma aperture. Similar to the embodiment shown inFIGS. 7A-7B, thissmart stoma device150 includes a fluid-filledbladder154 surrounded by anosmotic membrane156. Afirst electrode160 is connected to theosmotic membrane156. Thefirst electrode160 and aground electrode166 placed elsewhere on the body are connected to avoltage source162 such as a battery via acontrol circuit164. When a voltage is applied between thefirst electrode160 and theground electrode166, it increases the flow rate across theosmotic membrane156 to quickly swell thebladder154 and shrink thestoma aperture152 to restrict food intake. Note that the polarity of the circuit inFIGS. 9A-9B is for reference only and can be altered based on material selection and fluid polarity. Similarly this type of stoma can use a polyacrylic acid hyrdogel which responds to applied positive polarity field by contracting and expelling water. Thestoma device150 may be configured to operate automatically in response to changing conditions, for example thecontrol circuit164 may include asensor168 for sensing water or certain nutrients, such as sugar, or an activity related to ingestion, such as swallowing or gastric response. Alternatively, thestoma device150 may be configured to be remotely operated in response to a control signal from outside of the patient's body.
• Alternatively, the artificial stoma may be anchored with a sutureless attachment that does not penetrate the esophageal or stomach wall. Sutureless attachment mechanisms may be used in conjunction with any of the stoma configurations discussed herein.FIGS. 10A-10C show anartificial stoma device170 with asutureless anchoring mechanism172. Thestoma device170 has a retracted/compressed position wherein thestoma device170 and theanchoring mechanism172 have a small diameter that can easily pass through the patient's esophagus into the stomach, as shown inFIG. 10A. Thestoma device170 may be introduced mounted on a flexible endoscope or on a separate insertion device. Once thestoma device170 is in the selected position in the stomach or lower esophagus, thesutureless attachment mechanism172 is actuated to expand and hold thestoma device170 in place, as shown inFIGS. 10B and 10C.
• In one embodiment, thesutureless attachment mechanism172 may be configured as an expandable wire stent that expands against the stomach or esophageal wall to hold thestoma device170 in place. Preferably, the expandable wire stent is surrounded by an elastomeric membrane or the like to prevent leakage of liquids or food past thestoma device170. The surface of the membrane may be treated to encourage tissue ingrowth to permanently anchor thestoma device170 in place. Alternatively, or in addition, thesutureless attachment mechanism172 may include hooks or barbs that pierce the tissue for additional anchoring. Such hooks or barbs may have an undeployed position in which they lie against the device and a deployed position in which they rotate or extend outward to grip the tissue. The stomach wall should be positioned such that theattachment mechanism172 will grip the stomach wall when it is actuated.
• In an alternative embodiment, thestoma device170 may be configured to have a reversiblesutureless attachment mechanism172 for temporary implantation of the device. A reversiblesutureless attachment mechanism172 may have two modes of attachment, a temporary mode and a permanent mode. Thus, astoma device170 can be implanted in a patient's stomach for a trial period using the temporary attachment mode. After the trial period, if the therapy has been ineffective or if the implant was not well tolerated by the patient, thestoma device170 can be removed. On the other hand, if the therapy has been effective and the implant is well tolerated by the patient, thestoma device170 can be permanently attached by actuating the permanent attachment mode or simply leaving the implant in place to allow permanent attachment and tissue ingrowth to take place.
• Preferably, the stoma device is constructed with radiopaque and/or sonoreflective materials and/or includes one or more radiopaque and/or sonoreflective markers for enhanced imaging by X-ray, fluoroscopy and/or ultrasonic imaging so that the position and functional state of the implanted stoma device can be verified noninvasively in addition to endoscopic direct visualization.
• In another aspect, the system may include an internalgastric sleeve200 that may be used separately or used with, attached to or integrated with theartificial stoma component100.FIG. 11 shows agastric sleeve device200 with anartificial stoma device100 implanted within a patient's stomach. Optionally the sleeve can be attached to the outlet of a surgically created stoma or pouch that does not include an artificial implanted stoma. Thegastric sleeve device200 may include apyloric sleeve anchor202 for anchoring the distal end of thesleeve200 in the region of the pylorus. Thepyloric sleeve anchor202 can be configured withopenings214 to allow digestive secretions to pass through the pylorus into the small intestine. The internalgastric sleeve200 effectively reduces the volume of the stomach because the flow of solid food is limited to the lumen of thesleeve200. The entiregastric sleeve200 or a portion of it can be porous or semipermeable to allow the flow of digestive secretions into the sleeve and to allow the flow of nutrients and/or fluids out through the wall of thegastric sleeve200. Porosity can be achieved for example by forming holes in the sleeve using a laser or mechanical means. Semipermeable areas of the sleeve can be formed, for example, from silicone or materials used for hemodialysis membranes.
• Pyloric anchors can be fixed to a predetermined location on the sleeve or be mobile. For example, a pyloric anchor could be slidable and slid into place before it is fixed to a structure on the sleeve. Structures for anchor fixation could include reinforcement and/or structures such as snaps, loops and/or holes to facilitate attachment of the anchor to the sleeve. Slidable or other structures that allow positing of an anchor can be used to set the distance between the attachment of the sleeve near the GEJ and the support or strain relief provided by the anchor at the pylorus. This distance can be set prior to placement of the device, based upon fluoroscopic or other measurements or in vivo. If the distance is set in vivo, structure could be provided to allow fixation using commercially available tools such as ENDOCINCH (Bard), ENDOSCOPIC SUTURING DEVICE (Wilson-Cook Medical) or PLICATOR (NDO Surgical Inc.) or an endoscopic grasper. Alternately, a structure that requires a special attachment device, such as the riveters described herein could be used.
• In some clinical situations it could be beneficial to have an anchor designed to allow motion. This could include some means to bias the anchor to return to a predetermined location relative to a set position on the sleeve. This could be accomplished by incorporation of a spring, elastomeric structure or other such biasing structure.
• FIGS. 12A-12E are detail drawings showing additional features of a gastric or intestinal sleeve device.FIG. 12A shows a detail drawing of a gastric and/or intestinal sleeve device withopenings204 through the sleeve wall.Valves206 may be provided in the wall of the gastric sleeve to allow digestive secretions to enter the sleeve, but to prevent solid food and/or nutrients from flowing out through the wall of the sleeve.FIG. 12B shows a detail drawing of a gastric and/or intestinal sleeve device withvalved openings206 through the sleeve wall. Examples of valves for this application include slit and flap type valves. Alternatively, the entiregastric sleeve200 or a portion of it can be nonporous or impermeable to act as an internal gastric bypass.FIG. 12C shows a detail drawing of a gastric and/or intestinal sleeve device withporous sections216 in the wall of the sleeve.
• FIG. 12D shows a detail drawing of a gastric and/or intestinal sleeve device withslits218 in the wall of the sleeve.FIG. 12E shows a detail drawing of a gastric or intestinal sleeve device withartificial cilia230 on the interior of the sleeve wall. Theartificial cilia230 facilitate the flow of food through the sleeve. Artificial cilia could be created by brushing or abrading the interior surface of the sleeve in the direction of food flow. This can raise a nap in the surface of the material biased to the direction of the abrasion. Alternatively, for example, the cilia could be molded into the surface of the sleeve. Alternatively or in addition, a hydrogel coating (for example polyvinyl pyrrolidone, hydromer) or other lubricious coating (for example PHOTOLINK LUBRICIOUS COATING, Surmodics Inc.) may be used to facilitate the flow of food through the sleeve.
• The proximal (food entry) opening of the gastric sleeve is dimensioned to correspond to the opening of the esophagus, pouch outlet or artificial stoma. The outlet of the esophagus is generally free of restrictions to food passage while pouch outlets and stomas which are in some cases configured to restrict the passage of food. These outlets or stoma are generally less than 10-40 mm in diameter and, if restricted, are typically 15 mm or less. This distal end of the sleeve is reinforced and/or configured for attachment to the gastric wall, surgical or artificial stoma opening. This opening for attachment is preferably slightly larger than the diameter of the restricted opening. Past the attachment to the opening the sleeve itself is typically 20-40 mm in diameter with a smooth transition from the opening diameter to the main diameter. If the sleeve continues past the pylorus, at the pylorus this diameter may remain the same, or may reduce to a smaller diameter on the order of 10-20 mm. The sleeve should not be in sealing contact with the stomach wall or the pylorus to allow free passage of gastric secretions along the outside of the sleeve as described herein.
• In certain embodiments, the wall of thegastric sleeve200 is flexible to allow the peristaltic motions of the stomach to effect movement of food through thegastric sleeve200. For example, blow molded 90A durometer polyurethane of a wall thickness on the order of 0.005″ will work in this manner. Other suitable materials for construction of thegastric sleeve device200 can include fluoropolymers, silicone and polyurethane. Some fluoropolymers can be thermoformed (e.g. PFA and FEP) while others such as PTFE can be expanded in a similar manner to the formation of a vascular graft as well known in that art. Silicone (e.g. Dow Silastic or similar material from Nusil Technologies) or polyurethane (e.g. Dow Pellethane) can be dip molded or cast. Polyurethane can also be blow molded. In some embodiments the wall of the sleeve may be reinforced with rings or a spiral made of wire and/or plastic to hold the sleeve open.FIG. 13 shows a detail drawing of a gastric and/or intestinal sleeve device with reinforcement rings208. The reinforcement rings208 are spaced apart at intervals along the length of the sleeve and the sleeve may include one or morelongitudinal ribs210 linking the reinforcement rings together along the length of the sleeve.FIG. 14 shows a detail drawing of a gastric and/or intestinal sleeve device with aspiral reinforcement212. The reinforcement rings208 orspiral reinforcement212 should be resilient enough that peristaltic motions of the stomach and/or intestines can be transmitted through the wall of the sleeve with the sleeve springing back to its full diameter after the peristaltic contractions. The resiliency of the reinforcement rings208 orspiral reinforcement212 also allows the sleeve to be collapsed to facilitate endoscopic placement of the device. The reinforcement rings208 orspiral reinforcement212 may be made of or supported with stainless steel or a superelastic or shape-memory NiTi alloy. The reinforcement rings208 orspiral reinforcement212 can also be plastic. The reinforcement rings208 orspiral reinforcement212 may be sized to fit loosely within the stomach or intestines or to provide a little bit of contact force to create a seal with the intestinal walls. As described herein in relation to the intestinal sleeve, it is important to control the coupling of forces that are transmitted by the action of the stomach (in this case) to the sleeve. Transmission of excessive force to the stomach attachment can be contraindicated in many clinical situations and in this case the coupling should be minimized. This can be accomplished, for example, through the use of low friction coatings on the sleeve exterior, using soft compliant (e.g <70A durometer non-metal reinforced) reinforcing rings and/or by not using reinforcing rings.
• The interior and exterior of the sleeve can optionally be coated with a low friction material as described herein (e.g. a hydrogel) to reduce friction of food passage (interior) and reduce gastric irritation (exterior). The interior of the sleeve can optionally include flexible prongs angled toward the direction of food flow to act as artificial cilia and resist food moving retrograde along the sleeve, as shown inFIG. 12E. Optionally the distal end of the gastric sleeve can incorporate an enlarged reservoir portion proximal to the pylorus. Optionally the sleeve can include coatings on its interior and/or exterior to enhance the surface properties of the sleeve in clinically relevant manners. Coating examples include: 1) parylene coatings to increase the chemical resistance of a sleeve material, 2) coating with an antimicrobial agent to resist infection and/or 3) coating with an anti-inflammatory agent to reduce tissue inflammatory response, as described herein.
• In conjunction with thegastric sleeve200, the volume of the stomach can be reduced by suturing, stapling or banding using open, transesophageal or laparoscopic techniques. In the example shown inFIG. 10, a vertical line of gastroplasty sutures orstaples104 parallel to thesleeve200 has been used to reduce gastric volume. Alternatively or in addition, a horizontal line of gastroplasty sutures or staples may be used to form a reduced volume gastric pouch. The sutures or staples may or may not be in a continuous line and may or may not be reversible. The stomach can also optionally be divided at the gastroplasty. These adjunctive techniques may assist in enhancing the effect of peristaltic motions of the stomach for moving food through the gastric sleeve.
• Alternatively or in addition, a gastric balloon or other volume displacement device may be used in conjunction with the gastric sleeve to provide a feeling of satiety.
• Preferably, portions of the gastric sleeve are constructed with radiopaque and/or sonoreflective materials and/or includes one or more radiopaque and/or sonoreflective markers for enhanced imaging by X-ray, fluoroscopy and/or ultrasonic imaging so that the position and functional state of the implanted gastric sleeve can be verified noninvasively. However, the sleeve should not be completely radiopaque to allow visualization of the passage of ingested radioopaque contrast as in a “swallow” study.
• In another aspect, the system may include an internalintestinal sleeve300 that may be used separately or used with, attached to or integrated with the internalgastric sleeve200 andartificial stoma component100.FIG. 15 shows a combined gastric200 and intestinal300 sleeve device with anartificial stoma device100 implanted within a patient's stomach with a line of gastroplasty sutures or staples parallel to thesleeve104. The entireintestinal sleeve300 or a portion of it can be porous or semipermeable to allow the flow of digestive secretions into the sleeve and to allow the flow of nutrients and/or fluids out through the wall of the sleeve. Suitable materials for construction of theintestinal sleeve device300 include fluoropolymers, silicone (e.g. Dow Silastic or similar material from Nusil Technologies) and polyurethane (e.g. Pellethane). For example, in one embodiment theintestinal sleeve device300 may be constructed of blow molded 90A durometer polyurethane with a wall thickness on the order of 0.005″. Some fluoropolymers can be thermoformed (e.g. PFA and FEP) while others such as PTFE can be expanded in a similar manner to the formation of a vascular graft as well known in that art.Openings204 may be provided through the wall of the sleeve, as shown inFIG. 12A.Valves206 may be provided in the wall of the intestinal sleeve to allow digestive secretions to enter the sleeve, but to prevent solid food and/or nutrients from flowing out through the wall of the sleeve, as shown inFIG. 12B. Alternatively, the entire intestinal sleeve or a portion of it can be nonporous or impermeable to act as an internal intestinal bypass. Valve and porosity structures to allow flow such as those described herein in relationship to the gastric sleeve can also be applied to the intestinal sleeve. In certain embodiments, the wall of theintestinal sleeve300 is flexible to allow the peristaltic motions of the intestinal wall to effect movement of food through the intestinal sleeve. The interior and exterior of the sleeve can optionally be coated with a low friction material (e.g. a hydrogel) to reduce friction of food passage (interior) and reduce intestinal irritation (exterior). Other coatings such as those described herein in relationship to the gastric sleeve can also be applied to the intestinal sleeve. The interior of the sleeve can optionally include flexible prongs angled toward the direction of food flow to act as artificial cilia and resist food moving retrograde along the sleeve, as shown inFIG. 12E. The wall of the sleeve may be reinforced withrings208 or aspiral212 made of wire and/or plastic, as shown inFIGS. 13 and 14. Optionally the intestinal sleeve can include means for stabilization at the distal end such as a brush (as described by Berry), weight or inflatable balloon.
• The intestinal sleeve diameter can be 10-40 mm, but it is typically 15-30 mm with an optional smaller diameter at the point the sleeve passes through the pylorus (if the sleeve passes through the pylorus). The diameter of the sleeve is optionally selected to be smaller that the diameter of the intestine. The sleeve should not be in permanent sealing contact with the intestinal wall or the pylorus if it is intended to control or allow passage of gastric, biliary, pancreatic and intestinal secretions along the outside of the sleeve.
• Optionally, theintestinal sleeve300 may have a proximal end with a reinforced anchoring segment or other anchoring mechanism for attachment in the region of the pylorus or the proximal end of theintestinal sleeve300 may be attached to a stoma device or surgically created stoma at the outlet of a reduced stomach. Alternatively, theintestinal sleeve300 may be attached to or continuous with the internalgastric sleeve200. Optionally, the distal end of theintestinal sleeve300 may include an anchoring mechanism.FIG. 16 shows a combined gastric200 and intestinal300 sleeve device with anartificial stoma device100 located within asleeve entry180 with a reinforcedsuture area182. Thesleeve entry180 creates a reduced-volume pouch within the patient's stomach that functions similarly to a surgically created gastroplasty pouch.
• Theintestinal sleeve300 is typically approximately 60-180 cm in length, whereby partially digested or undigested nutrients exit from the sleeve into the jejunum where they can elicit a hormonal, neural and/or osmotic reaction in the jejunum and/or ileum. However, sleeve length can be either shorter or longer depending on clinical needs. Increasing the length of the sleeve can increase the degree of response in the ileum while reducing the length of the sleeve can have the opposite effect.
• In relation to the example of the placement of astoma100 implanted into a surgically formed pouch described above, thegastric sleeve200 and/orintestinal sleeve300 may be implanted according to the following method:
• Sleeve Placement
• At any point in the procedure for stoma implantation described above, preferably prior to suturing of the gastric pouch (step8), a gastric and/or intestinal sleeve device may be placed in the stomach and/or intestines. The distal end of the intestinal sleeve is placed endoscopically approximately 100 cm distal to the pylorus (for an intestinal sleeve with a nominal length to be 100 cm past the pylorus as defined by the relative position of the end of the gastric sleeve200). The proximal end of the sleeve is attached, then the gastric pouch is sutured or stapled and the stoma placement procedure is resumed at step9. Alternatively, the gastric and/or intestinal sleeve device may be placed after a pouch is formed and the stoma is placed, provided the stoma opening is sufficiently large to allow passage and manipulation of the sleeve and visualization apparatus. In the case of an intestinal sleeve, the proximal end would optionally be attached at the outlet of the stomach or at the pylorus. In the case of a gastric sleeve or combined gastric and intestinal sleeve, the proximal end would preferably be attached to a stoma device or surgically created stoma. Alternatively, the sleeve can be attached to the stomach or esophageal wall. In situations where it is desirable for the distal end of the sleeve to be placed further than 100 cm distal to the pylorus, or as an alternative means of placement, the sleeve will be inserted in a collapsed configuration through the pylorus and restrained in the collapsed configuration by a bioabsorbable/dissolvable means and passed through the intestines by the normal peristaltic action of the intestine. Optionally a balloon, ring or other means of increasing the coupling of the peristaltic action to the sleeve may be attached at the distal end of the sleeve. This is similar to the use of peristaltic action for passage of a Baker, or other long intestinal, tube as know in the art. Rings and/or other means of increasing the coupling of the peristaltic action may be placed at other locations along the length of the intestinal sleeve if clinically appropriate. In some clinical situations a method of use whereby the resiliency of the peristalsis rings can be selected to allow the intestines to use the rings in the manner of a ladder. In this case the intestine essentially crawls up the sleeve and takes on a pleated bellows like configuration. This can have the result of effectively lengthening the sleeve as food would now exit the sleeve at a more distal location within the intestine.
• In an alternative method, the gastric and/or intestinal sleeve device may be used with a stoma device placed using standard surgical techniques, with a surgically created stoma, with surgical gastric banding or it may be used alone with no stoma device at all.
• Preferably, portions of the intestinal sleeve are constructed with radiopaque and/or sonoreflective materials and/or includes one or more radiopaque and/or sonoreflective markers for enhanced imaging by X-ray, fluoroscopy and/or ultrasonic imaging so that the position and functional state of the implanted intestinal sleeve can be verified noninvasively. However, the sleeve should not be completely radiopaque to allow visualization of the passage of ingested radioopaque contrast as in a “swallow” study.
• FIG. 17 shows anartificial stoma device100 implanted within a patient's stomach with a line of gastroplasty sutures orstaples104 to reduce the gastric volume. Also shown is a line of sutures orstaples304 longitudinally dividing the small intestine to create a bile/pancreatic channel308 separate from theintestinal lumen310. Thebiliopancreatic channel308 serves to prevent the patient's bile from mixing with the food in theintestinal lumen310, thus reducing the digestion and absorption of fat.
• FIG. 18 shows a cross section of the patient's small intestine showing the bile/pancreatic channel308.
• FIG. 19 shows anartificial stoma device100 implanted within a patient's stomach with a line of gastroplasty sutures orstaples104 to reduce the gastric volume and a line of sutures orstaples304 longitudinally dividing the small intestine to create abiliopancreatic channel308 separate from theintestinal lumen310 with anoptional stent306 to keep the bile/pancreatic channel308 open and prevents collapse of the channel.
• FIG. 20 shows a cross section of the patient's small intestine showing thebiliopancreatic channel308 with anoptional stent306.
• FIG. 21 shows a combined gastric200 and intestinal300 sleeve device implanted within a patient's stomach with agastric balloon220 to reduce the gastric volume.
• In summary, one aspect of the invention provides a method and system for treatment of morbid obesity that has three components, an artificial stoma device, an internal gastric sleeve and an internal intestinal sleeve, which can be used separately or in combination. The artificial stoma device is implanted into a patient's stomach or lower esophagus and then can optionally be used to restrict food intake. The artificial stoma device may have a fixed aperture, an adjustable aperture or an aperture that varies in response to changing stomach conditions. The artificial stoma device may be implanted using sutures, staples, a reinforced anchoring segment, a sutureless or other attachment mechanism as described herein. A restriction can optionally be placed within the lumen of the gastric sleeve. The internal gastric sleeve may be separate from or integrated with the artificial stoma device. The internal gastric sleeve effectively reduces the patient's gastric volume and restricts the absorption of nutrients and calories from the food that passes through the stomach. The internal intestinal sleeve may be separate from or integrated with the internal gastric sleeve and/or the artificial stoma device. The wall of the internal gastric sleeve and/or internal intestinal sleeve may be constructed with reinforcing rings or a spiral reinforcement. The wall of the internal gastric sleeve and/or internal intestinal sleeve may have openings or valves to allow or restrict the digestive secretions and nutrients through the wall of the sleeve. Along with these components, the treatment system may also include an attachment system that uses wire fasteners for performing a gastrostomy and a stent for supporting a bile/pancreatic channel in the patient's small intestine.
• The method provided by this invention has the capacity to combine these various components, as well as other components described herein, into a system that treats obesity by creating a pouch with an outlet restriction which can be optionally controlled or operable, placing means by which the food exiting the pouch is transferred via gastric and intestinal sleeves to a point in the intestine while being substantially isolated from (or allowed to contact a controlled amount) gastric, biliary, pancreatic and intestinal secretions, whereby this location in the intestine can be optionally selected to induce various reactions of the intestinal tissue which may include dumping syndrome, hormonal secretion and/or nervous stimulation.
• In contrast to previous devices, the present inventors have found that in many cases an effective gastrointestinal sleeve device will preferably have the characteristics of each section of the device tailored to the function of the section of the gastrointestinal tract in which it resides. For example, in some clinical situations a potential issue with gastric pouch or sleeve systems could be a lack of physiological signals causing opening of the pylorus. If the pylorus were to remain tightly closed over a sleeve passing through, it could be problematic for the patient. In these clinical situations, one desirable characteristic of an effective gastrointestinal sleeve device could be for it to have sufficient volume and/or compliance in the area of the stomach immediately upstream of the pylorus to create enough pressure or wall tension in that area to trigger the opening of the pylorus to empty the stomach contents.
• In addition, when normal functioning of the pylorus is clinically desired, the section of the sleeve device that passes through the pylorus must have enough wall flexibility or compliance to allow normal opening and closing of the pylorus and to allow drainage of stomach secretions around the outside of the sleeve. For example blow molded 90A durometer polyurethane of a wall thickness on the order of 0.005″ or less will work in this manner. Other sections of the gastrointestinal sleeve device will also be tailored to the section of the gastrointestinal tract in which it resides.
• The configuration of the gastrointestinal sleeve device enables a method of treatment for morbid obesity that includes isolating ingested food from the digestive secretions of the stomach and intestines as the food passes through the stomach, the duodenum and the upper part of the jejunum.
• FIG. 22 illustrates an example of agastrointestinal sleeve device400 constructed in accordance with the present invention. Thegastrointestinal sleeve device400 is shown deployed within a patient's gastrointestinal tract for treating morbid obesity. The characteristics of each portion or section of thegastrointestinal sleeve device400 may be tailored to the function of the section of the gastrointestinal tract in which it resides.
• Theproximal opening402 of thegastrointestinal sleeve device400 is primarily designed to facilitate attachment of the sleeve within the patient's stomach. Depending on the clinical needs of the individual patient and the judgement of the physician, locations for attachment of theproximal opening402 of the sleeve may include the gastroesophageal junction and the cardia or cardiofundal border. The gastroesophageal junction is advantageous as a possible attachment site because the tissue wall is relatively thick at this location and it is relatively easy to access via a per oral route. Attachment at the gastroesophageal junction excludes all gastric secretions from the interior of thegastrointestinal sleeve device400. The cardiofundal border is also advantageous as a possible attachment site because it provides the ability to create a gastric pouch from the cardia of the stomach and the tissue wall is relatively thick at this location compared to the fundus. Attachment at the cardia or cardiofundal border allows the secretions of the cardia, which are primarily lubricious mucous, to enter the interior of thegastrointestinal sleeve device400 and excludes the fundal secretions, which are high in acid content, from the interior of the sleeve. The lubricious mucous secretions from the cardia will help to lubricate the interior surface of thegastrointestinal sleeve device400 and will facilitate passage of ingested food through the sleeve.
• By way of example, the embodiment ofFIG. 22 shows theproximal opening402 of thegastrointestinal sleeve device400 attached at the gastroesophageal junction. In this configuration, it can be preferred that theproximal opening402 be sized to have a diameter approximately equal to, or slightly larger than the diameter of the esophagus at the gastroesophageal junction. In adult humans, the esophagus at this point typically has a diameter of approximately 1.5-2.0 cm.
• Attachment of theproximal opening402 of thegastrointestinal sleeve device400 within the stomach can be accomplished using open, laparoscopic or endoscopic surgical techniques e.g. sutures, wires or staples or using any of the attachment methods described herein. Attachment is preferably optimized to distribute stress over an enlarged area and minimize stress or strain transmitted to the tissue where it is attached in order to minimize tissue erosion. During ingestion of food, the sleeve and the attachment must withstand the pressure created by swallowing as the food is forced into the sleeve. This is particularly true if there is a restriction downstream of the proximal sleeve opening. The sleeve and the attachment must also withstand any tensile forces created as a result of swallowing food and the presence of any food or liquid within the sleeve or pouch, as well as forces due to peristaltic action of the intestines or stomach.
• In one embodiment shown inFIGS. 23A and 23B, theproximal opening402 of thegastrointestinal sleeve device400 is attached to the stomach wall with an optionally removable,healable fixation system430. Thefixation system430 is configured with two components: ananchor ring422 and an attachment means424 for connecting thegastrointestinal sleeve device400 to theanchor ring422. The attachment means424 could be configured as part of theanchor ring422 or thegastrointestinal sleeve device400 or as one more separate components. Thefixation system430 is configured to operate in three different modes. It can provide a permanent or long-term attachment of thegastrointestinal sleeve device400 to the stomach wall; it can allow replacement or revision of thegastrointestinal sleeve device400 without removal of theanchor ring422; and it can be removed completely to allow the stomach wall to heal where theanchor ring422 had been attached.
• Theanchor ring422, shown inFIG. 23A, may be configured as a continuous wire, polymer or wire-reinforced polymer ring with an exterior or coating that resists ingrowth and adhesion. The wire could be NiTi or SS. Suitable polymers would include silicone, Teflon (PTFE) and other fluoropolymers. Possible coatings include hydrophilic coatings, hydromers, hydrogels and fluoropolymers. Portions of theanchor ring422 can be enclosed with a material428 that encourages ingrowth of tissue. Between the portions ofingrowth material428, theanchor ring422 can be bare to discourage ingrowth and to provide attachment points for thegastrointestinal sleeve device400. Theingrowth material428 in this embodiment is preferably a biodegradable or resorbable material such as polyglecaprone (Monocryl, Ethicon), polyglactin (Vycril, Ethicon), or other known biodegradable or resorbable material. Theingrowth material428 is configured so ingrowth results in a partial and intermittent encapsulation of theanchor ring422. Areas of encapsulation would be interspaced with areas where ring was exposed.
• In one example of thefixation system430 shown inFIG. 23A, the attachment means424 is configured with a plurality of clip rings426 mounted around the exterior of thegastrointestinal sleeve device400 near theproximal opening402. The clip rings426 are configured with gaps in the rings that allow the rings to clip onto the exposed bare portions of theanchor ring422 to hold thegastrointestinal sleeve device400 in position.
• In other embodiments, the attachment means424 may comprise magnets, clips, hooks, staples, sutures or other known fasteners.
• In one method, theanchor ring422 would be implanted and allowed to heal before another device, such as thegastrointestinal sleeve device400, would be attached to it. After sufficient healing has taken place, the device could be attached to the anchor ring at areas where ingrowth did not occur, as shown inFIG. 23B. In this method/structure a biodegradable ingrowth material is used and since the ingrowth material is biodegradable, it will eventually disappear after providing a scaffold for ingrowth resulting in intermittent encapsulation of the anchor ring.
• FIG. 23B also shows no restriction at the attachment stoma and no restriction in the sleeve thereby showing the pylorus acting as a naturally controlled restriction as described herein.
• In another example of an alternate embodiment the sleeve ofFIG. 23B could use an attachment ring and ring interface as shown inFIGS. 77-84 which are attached to the stomach using T-tag fasteners or T-pledgets as described herein.
• The anchor ring and thegastrointestinal sleeve device400 can be left in place permanently. Alternatively, thegastrointestinal sleeve device400 can be removed at a later date and replaced or revised. If and when it is desirable to remove the anchor ring, one or more or areas with no ingrowth can be used as access to sever or cut the ring. Since the ring exterior resists ingrowth and is nonadherent, it can be pulled out of the tissue without damaging the tissue. After removal of the anchor ring, the tunnel through the tissue formed by the encapsulation can heal.
• As an alternative to a biodegradable material, a nondegradable scaffold material can be used. These materials become incorporated into tissue and are often made of naturally occurring or biological components, such as processed bovine tissue.
• FIG. 24A shows another way of attaching theproximal opening402 of thegastrointestinal sleeve device400 within the patient's stomach. A combined attachment/stoma device432 is implanted into the patient's stomach to create a restriction and thegastrointestinal sleeve device400 is attached to the stoma device. Thestoma device432 and thegastrointestinal sleeve device400 may be implanted in a single procedure or they may be implanted in two sequential procedures as described above, leaving enough time for healing of the gastric wall in between the two procedures. Thestoma device432 may be attached at the gastroesophageal junction or it may be attached at the cardiofundal border to create a reduced volume reservoir upstream of the restriction (gastric pouch) using the tissue of the cardia, as shown inFIG. 24A. Thegastrointestinal sleeve device400 may be attached using any one of the stoma devices described herein. By way of example, thegastrointestinal sleeve device400 ofFIG. 24A is shown attached using astoma device432 in the form of a stomal ring clip.
• In general, the proximal end of thegastrointestinal sleeve device400 may be secured in the vicinity of the lower esophageal sphincter or z-line, using astoma device432 having any of a variety of configurations including those illustrated in FIGS.24A-D. As used herein, the term “stoma device” includes devices which define an opening, without limitation to the relative size of the opening compared to the surrounding anatomy unless otherwise described.
• Referring toFIGS. 24A and 24B, thestoma device432 includes at least onetissue contacting surface420 for contacting tissue such as illustrated inFIG. 24A. Thetissue contacting surface420 may be carried by ananchor support421 such as atransverse flange422. In the illustrated embodiment, thetransverse flange422 comprises a continuous radially outwardly extending annular support. However, theanchor support421 may comprise a plurality of radially outwardly extending connection tabs such as two or four or six or eight or more, which may be circumferentially symmetrically positioned about the longitudinal axis of thegastrointestinal sleeve400. As is described elsewhere herein, thegastrointestinal sleeve400 may be either permanently or detachably connected to theanchor support421. Theanchor support421 may be provided with a plurality ofapertures427 such as to receive a “T” fastener or other tissue connector as is discussed elsewhere herein.
• Alternatively, theanchor support421 may be pierceable by the deployment of the “T” fastener or other tissue connector.
• In a modification of the anchor support421 (seeFIG. 24C), the at least onetissue contacting surface420 faces radially outwardly from the longitudinal axis of thegastrointestinal sleeve400. In this configuration, the “T” fastener or other tissue anchor may extend radially outwardly into adjacent tissue, as may be desirable depending upon the tissue anchor configuration. Thetissue contacting surface420 may also be inclined with respect to the longitudinal axis of thegastrointestinal sleeve400.
• Referring toFIG. 24D, at least a firsttissue contacting surface420 is carried by afirst anchor support421 and at least a secondtissue contacting surface423 is carried by at least asecond anchor support424. In the illustrated embodiment, each of thefirst anchor support421 andsecond anchor support424 is illustrated as an annular flange. However, the anchor supports may take any of a variety of configurations as has been discussed. In addition, thefirst anchor support421 andsecond anchor support424 are spaced axially apart, to allowtissue425 to be drawn therebetween.Tissue425 may be drawn between the first and second anchor supports using vacuum, supplied by the deployment catheter. This configuration enables the advance of afixation device426 between thefirst anchor support421, through thetissue425 and into or through thesecond anchor support424 as illustrated inFIG. 24D. The device shown inFIG. 24D can optionally be configured to enable full thickness plication and serosa-to-serosa contact at thefixation device426 as described herein. Thefixation device426 may comprise a “T” fastener, a pin, or other structures disclosed herein. In the annular construction illustrated inFIG. 24D, two or four ormore tissue extensions425 may be drawn radially inwardly, for attachment to thestoma device432.
• The attachment described inFIG. 24A can also be used where the attachment is dimensioned so as not to create a restriction. In this case, a restriction can optionally be placed downstream within the gastric sleeve. It is generally clinically preferable for devices placed at the gastroesophageal junction to have the stoma downstream, while devices placed at the cardiofundal border may combine the restriction with the attachment to allow a smaller food reservoir upstream of the restriction.
• Downstream of theproximal opening402, thegastrointestinal sleeve device400 hassleeve portions404,406 that reside in the fundus and the antrum of the stomach, respectively. In the example ofFIG. 22, thegastrointestinal sleeve device400 has an approximately constant diameter from theproximal opening402 to theupstream end408 of the pylorus, including thefundus portion404 and theantrum portion406 of the sleeve. In this embodiment, the sleeve through the fundus andantrum portions404,406 preferably has a diameter approximately equal to or slightly larger than the diameter of the esophagus at the gastroesophageal junction, which in adult humans is approximately 1.5-2.0 cm. Alternatively, thegastrointestinal sleeve device400 may gradually taper outward or open immediately downstream of theproximal opening402, as shown inFIG. 24A. In this embodiment, thegastrointestinal sleeve device400 preferably has aproximal opening402 with a diameter of approximately 1.0-1.5 cm where it is attached to thestoma device432. Downstream of theproximal opening402, the fundus andantrum portions404,406 of the sleeve have a diameter of approximately 1.5-2.0 cm.
• The example illustrated inFIG. 24A may utilize any of a variety of dimensions, materials, attachment structures and other features disclosed elsewhere herein. In general, the example ofFIG. 24A is provided with a substantially uniform inside diameter throughout its axial length. Axial lengths between theproximal opening402 and a distal end of the device are generally in excess of 50 cm, often at least about 75 cm to 125 cm or more, depending upon the desired clinical performance as has been described elsewhere herein. In one implementation of the invention, the tubular wall of thegastrointestinal sleeve400 is sufficiently flexible that the natural operation of the pylorus operates as an adjustable stoma on material traveling through thesleeve400.
• Thesleeve400 may be attached in the vicinity of the gastroesophageal junction, such as by attachment to a ring or cuff or directly attached to the cardia of the stomach adjacent the gastroesophageal junction. Attachment may be accomplished in any of a variety of ways including those disclosed elsewhere herein, such as “T” fasteners including T tags such as illustrated inFIG. 91A or T pledgets such as illustrated inFIG. 91B. Such anchors may be positioned utilizing the placement techniques illustrated, for example, inFIG. 94A through 94C.
• Thesleeve400 may comprise a homogenous material throughout. At least the gastric section may comprise a sufficient length to extend through the gastroesophageal junction, past the pylorus and into the duodenum. Materials such as a blow molded polyurethane, having a wall thickness of approximately 0.005″ and a durometer of about 90A may be used. Thesleeve400 may additionally be provided with a lubricious coating on one or more of the interior and exterior surfaces. Diameters on the order of about 2.0 cm, ±50% or more may be utilized. Other dimensions and materials may be optimized by those of skill in the art in view of the disclosure herein.
• The intestinal section of thesleeve400 is dimensioned to start in the duodenum and extend at least about 50, often about 75 or 100 cm or more, to imitate a gastric bypass. The intestinal section of thesleeve400 may be the same diameter as the gastric portion of the sleeve, or may be no more than about 90% or 80% or less of the diameter of the gastric sleeve portion. Delivery and retrieval techniques for the implementation of the invention illustrated inFIG. 24A have been disclosed elsewhere herein.
• The function of thesleeve portion404 located in the zone of the fundus is to transmit food through thegastrointestinal sleeve device400. Accordingly, this portion of thegastrointestinal sleeve device400 may be configured to resist kinking and provide a lubricious inner surface. Saliva and mucous secreted in the esophagus and/or cardia could facilitate passage of food. The zone of the fundus and/or the area of the cardiofundal border could be a possible location for a restriction if one is used. Location of the restriction is clinically relevant in that the volume between the restriction and the gastroesophageal junction effectively defines a restricted stomach volume.
• The antrum of the stomach has muscular action to grind food and this muscular action can manifest as peristalsis. Based upon clinical requirements, thesleeve portion406 in the antral zone could include stiffeningmembers410 or other means to prevent motion and/or kinking of the sleeve. The stiffeningmembers410, which may be made of a metal and/or polymer, may be oriented axially, as shown inFIG. 22, or they may be in a helical configuration or other geometry. This reinforcing should be configured so as to provide little or no interface for peristaltic motion to capture the sleeve and move it toward the pylorus. The sleeve should also be configured to resist or avoid forces that could be applied in a retrograde direction. Note that the retrograde force is caused by fluid flow. As the antrum undergoes peristalsis, food and secretions can flow retrograde. A slippery hydrophilic or other coating, as described herein, on the exterior of the sleeve in theantrum portion406 may be preferred.
• In an alternate construction illustrated inFIG. 25, thefundus portion404 and/or theantrum portion406 of thegastrointestinal sleeve device400 may be stiffened using a coaxialinflatable balloon440 that surrounds the sleeve. Thecoaxial balloon440 may be inflated within the patient's stomach using a detachable tether and a self-sealing valve as described in the prior art (e.g. Pevsner). With proper selection of inflation media (compressible air or incompressible liquid) inflation pressure and inner and outer wall compliance, thecoaxial balloon440 can optionally provide axial stiffening, and can optionally serve to transmit peristaltic motion to the interior of thegastrointestinal sleeve device400 to help ingested food transit through the sleeve.
• Downstream of theantrum portion406, thegastrointestinal sleeve device400 may optionally include apyloric anchor414 at theupstream end408 of the pylorus, as shown inFIG. 22. In one embodiment, thepyloric anchor414 is configured as a perforated collar slidable along the exterior of the sleeve for custom fit to the patient. The outer circumference of thepyloric anchor414 is optionally attached to the stomach lining at theupstream end408 of the pylorus, then the slidable collar is cinched around or otherwise attached to the sleeve to anchor it in position. Perforations or channels in the collar allow gastric secretions to pass from the stomach into the pylorus without obstruction. Thepyloric anchor414 can be constructed from a variety of biocompatible materials with different properties. For example, fluoropolymers such as Teflon (Dupont) can be used to avoid ingrowth or, alternatively, polyester cuff materials (e.g. Dupont Dacron) can be used to encourage ingrowth if desired. As an alternative to attaching the pyloric anchor top the stomach wall, it can be constructed with sufficient stiffness and sized to be retained in the antrum of the stomach by being too large to pass through the pylorus.
• An anchor placed in the antrum can also be used as a platform to support devices placed in the stomach. For example, combining such an anchor located in the antrum with the reinforced sleeve or coaxial balloon as described herein can be used to support an attachment ring and reduce the forces transmitted to the attachment at the stomach wall.
• Structures that are not a part of the gastric sleeve such as self-expanding wire meshes of NiTi or stainless steel could also be used where clinically indicated. Antral support structures could also be independent, as a sleeve anchor and could optionally be used to support other devices as described herein.
• In certain embodiments, the sleeve is configured to open and to collapse as it passes through the pylorus to facilitate internal passage of food and external passage of gastric secretions and to minimize irritation and/or damage to the pylorus. Additionally, thegastrointestinal sleeve device400 may optionally narrow slightly in diameter as it passes through the pylorus so that it facilitates passage of gastric secretions along the exterior of the sleeve through the pylorus when it is opened. This diameter may be on the order of 0.75-2.5 cm. Thepylorus section412 of thegastrointestinal sleeve device400 must have enough wall flexibility or compliance to allow normal opening and closing of the pylorus and to avoid irritation of the pylorus. For example blow molded 90A durometer polyurethane of a wall thickness on the order of 0.005″ or less will work in this manner. With this configuration one can optionally use the pylorus as a natural stoma by allowing the sleeve to be closed by the pylorus and then opened to allow passage of food when the muscles of the pylorus relax.
• Conversely, in some patients it may be desirable to hold open the pylorus. In such cases where the device is configured for holding open the pylorus, it should also include means of draining gastric secretions, e.g. tubes or channels, along the exterior of the sleeve.
• A collapsible or collapsed tubular gastrointestinal sleeve device can allow gastric and intestinal secretions to pass along its outer surface. Spiral reinforcing can facilitate passage of the secretions if the sleeve between the reinforcing is configured to form channels where secretions can flow between the reinforced sleeve and the wall of the intestine or pylorus with which it may be in contact. This could be of particular use in the pylorus where food in the sleeve could be competing with gastric secretions to pass through the pylorus outside the sleeve. In the case of a flaccid sleeve, whichever of the food or secretions has the higher pressure would pass through the pylorus. In the case of a spiral reinforced sleeve with channels or other means (e.g. tubular lumens passing through the pylorus and with openings both proximal and distal to the pylorus) of enabling passage of secretions along the pylorus, the food and secretions could pass at the same time.
• Thegastrointestinal sleeve device400 continues below the pylorus and passes through the duodenum and into the jejunum. Theduodenum portion416 and thejejunum portion418 may have a total length of approximately 50-200 cm, depending on the clinical needs of the individual patient and the judgement of the physician. Shorter lengths may be used if it is desirable for the sleeve to empty into the duodenum or proximal jejunum. Longer lengths can be used if it is desirable to have the sleeve empty in the distal jejunum or ileum. In certain embodiments, thesleeve400 may be configured with a length of 100 cm as this is a standard length of the roux limb in a Roux-en-Y gastric bypass. Asleeve400 with a length of approximately 500 cm or more can be used to perform a nonsurgical biliopancreatic diversion for achieving results similar to a Scopinaro procedure. In one configuration, thegastrointestinal sleeve device400 has an approximately constant diameter of approximately 0.75-2.5 cm through theduodenum portion416 and thejejunum portion418. This diameter is less than the internal diameter of the small intestine through these sections to allow free flow of gastric, biliary, pancreatic and intestinal secretions along the outside of the sleeve. This diameter can be optimized for individual patients where a smaller diameter may be tolerated better and a larger diameter may be superior regarding the passage of food. Collapsibility may allow use of larger diameter sleeves, while sleeves of smaller diameter and greater resilience may be clinically indicated to minimize irritation.
• Past the pylorus and past the duodenum, thegastrointestinal sleeve device400 may include means to couple peristaltic muscular action of the intestine and use it to apply antegrade tension to the sleeve. One ormore rings420 in the sleeve may provide this coupling. Therings420 may include a metallic spring to return the ring to its circular shape if collapsed by either the installation procedure or by peristaltic action of the intestine. Therings420 may be positioned in the jejunum, as the duodenum exhibits little or no peristalsis. Alternatively, the exterior of the sleeve may be configured with small bumps or other features to provide a small amount of friction for coupling with the peristaltic muscular action of the intestine. A balance can be struck between friction and lubricity on the exterior of the sleeve.
• There should be enough friction so that peristalsis will act to straighten the sleeve and apply a small amount of tension to keep it in place. Too much friction, however, will allow the intestinal wall to “climb” up the exterior of the sleeve due to peristalsis, which would generally not be desirable. For example, this balance can be achieved using a smooth polyurethane sleeve with PHOTOLINK LUBRICIOUS COATING (Surmodics Inc.) or other**. However, in some clinical situations it may be desirable to achieve this end result. This can be achieved by using rings or other means of mechanically coupling the sleeve with the intestinal peristaltic action. In this case the intestine essentially crawls up the sleeve and takes on a pleated bellows like configuration. This can have the result of effectively lengthening the sleeve, as food would now exit the sleeve at a more distal location within the intestine.
• It may be desirable in some clinical circumstances to provide a temporary peristalsis coupling that can straighten the sleeve for a period of time after insertion and not couple with the peristaltic action after this period. This will tend to reduce the climbing of the intestine and can allow any previous change in the position of the intestine to return to normal. This can be accomplished by using a biodegradable coupling means such as a dissolvable peristalsis ring or a high friction coating that comes off, leaving a lubricious surface. A balloon that detaches or deflates could be another means of accomplishing this end. For example, the balloons and other features inFIGS. 32A, 32B and32C can be configured for this application. Such balloons can be made self-deflating by the inclusion of a dissolvable portion or by inflation with a hypo-osmolar fluid combined with use of osmotically active balloon membrane. In this event the inflation fluid will escape the balloon through the membrane due to the osmotic imbalance between the inflation fluid and the contents of the intestine.
• Optionally, thegastrointestinal sleeve device400, along some or all of its length, may be configured by means of controlled wall thickness or reinforcing so that, if the sleeve is folded or kinked,open channels442 will be maintained, as shown inFIGS. 26A, 26B and26C. In this case locally increased wall rigidity may also be used to control the fold preferences of the sleeve.
• Alternatively, thegastrointestinal sleeve device400, along some or all of its length, may includeaxial channels444, as shown inFIGS. 27A and 27B. The axial channels would be configured so that, in the event of a fold or kink in the sleeve, the lumen of the sleeve remains patent and open. These channels can also be formed by peaks and valleys in a constant thickness sleeve wall in addition to the manner diagrammed.
• In one embodiment of thegastrointestinal sleeve device400, the gastric and intestinal portions of the sleeve are constructed to be normally collapsed to a somewhat flattened configuration when in a rest position, such as is shown inFIGS. 26B, 26C or27B. This can minimize the potential for irritation of the mucosa in the stomach, the pylorus and the intestine and other structures such as the ampula of Veder. The sleeve may open or expand to a circular cross section, as shown inFIG. 26A or27A, for the passage of ingested food. Thus the stomach and intestinal walls would not be constantly subjected to stimulation, which could result in increased secretion and/or peristaltic action. Alternatively, some or all of the gastric and intestinal portions of the sleeve may be constructed to remain in an open or expanded configuration when in a rest position and to easily collapse when subjected to external pressure, for example to allow passage of digestive secretions along the exterior or the sleeve. This second option may also include diametric sizing based upon the clinical desirability of stimulating the passage wall (similar diameter to passage) or not (smaller diameter than passage).
• Thegastrointestinal sleeve device400 is generally impermeable along its entire length to isolate ingested food from digestive secretions. However, it may be desirable to have thegastrointestinal sleeve device400 having semipermeable or controlled permeability properties along some or all of its length to allow absorption of certain nutrients at the appropriate location in the stomach or intestine in order to avoid malabsorption complications while still limiting caloric absorption. For example, in the duodenal portion it would be beneficial to allow Iron and B-12 to exit the sleeve so that it can be absorbed through the intestinal wall.
• FIG. 28 illustrates an optional one-way valve450 feature of the gastrointestinal sleeve device. Positioning of valves may be patient dependent. One clinically significant location could be at or near the transition from the duodenum, where there is little or no peristaltic action and the jejunum where peristalsis occurs. Other significant locations include the distal opening of the device (to prevent flow into the sleeve), the proximal opening of the device (to prevent reflux into the esophagus) and at or near the pylorus (to help ingested food pass through the pylorus and duodenum). A valve upstream of a restriction may also help, in combination with contractions or peristalsis of the stomach, to force ingested food through the restriction.
• FIG. 29 illustrates another example of agastrointestinal sleeve device400 deployed within a patient's gastrointestinal tract for treating morbid obesity. In this embodiment, theproximal opening402 of thegastrointestinal sleeve device400 has a flared opening that is configured for attachment at the cardiofundal border. Attachment at the cardiofundal border confers different advantages to thegastrointestinal sleeve device400, as described above. Attachment can be made using any of the methods described herein. Theproximal opening402 has a diameter of approximately 2-10 cm, which smoothly tapers down to a diameter of approximately 1.5-4.0 cm through thefundus portion404 and theantrum portion406 of the sleeve. The remainder of thegastrointestinal sleeve device400 may be configured similarly to the embodiment described in connection withFIG. 22.
• FIG. 30 illustrates another example of agastrointestinal sleeve device400 having areservoir452 located above the patient's pyloric sphincter. Thereservoir452 allows ingested food to accumulate in the antrum of the stomach and to apply pressure against the pylorus, which may contribute to periodic opening of the pyloric sphincter for proper emptying of the stomach contents. Alternatively or in addition, areservoir452 may be positioned elsewhere in the gastrointestinal system, for example just below the GEJ, to provide a sensation of fullness and satiety.FIG. 30 also illustrates the optional feature of arestriction454 in thegastrointestinal sleeve device400 between theproximal opening402 and theupstream end408 of the pylorus. Therestriction454 can be provided by a simple narrowing of thesleeve400 or, as illustrated in this embodiment, can be provided by astoma device454 positioned within the lumen of thesleeve400. Thestoma device454 can be an adjustable stoma device, a smart stoma or any of the stoma devices described herein. Positioning of the stoma device relative to the proximal sleeve opening can be selected as clinically indicated to provide a reservoir for food proximal to a restriction**that is appropriate for the desired weight loss. In other embodiments of thegastrointestinal sleeve device400, sufficient reduced volume or resistance to ingestion of food for encouraging weight loss may be provided by the length and diameter of the gastric portion of thesleeve400 without the need for a stoma device or other restriction other than the use of the pylorus as a natural restriction as described above.
• When the pylorus is used as a natural stoma to control food flow, an electrical stimulation system can optionally be used to control the opening and closing of the pylorus. This system could include one or more electrodes for stimulating the pylorus, a stimulator (including power source and controlling electronics) and one or more optional sensing electrodes.
• FIG. 31 illustrates another example of agastrointestinal sleeve device400 having an inflatablegastric balloon460 to enhance satiation by taking up volume in the stomach. Thegastric balloon460 may be arranged coaxially around the sleeve or it may be configured to inflate preferentially toward the greater curvature of the stomach, as shown inFIG. 31. Thegastric balloon460 may be inflated within the patient's stomach using a detachable tether and a self-sealing valve. Alternatively, thegastric balloon460 may be made self-inflating by having a hyperosmolar material within thegastric balloon460 and an osmotically active balloon membrane (complete or partial). Thegastric balloon460 can be configured to transmit peristaltic motion to the interior of thegastrointestinal sleeve device400 to help ingested food transit through the sleeve as described above. Optionally, the sleeve under and around thegastric balloon460 may be combined with one or more one-way valves450 positioned upstream and/or downstream of the gastric balloon to assist peristaltic action to urge ingested food through the sleeve.
• FIGS. 32A, 32B,32C and32D illustrate optional features to assist in the deployment of the gastrointestinal sleeve device within a patient's gastrointestinal tract.FIG. 32A illustrates agastrointestinal sleeve device400 having aninflatable balloon462 on its distal end. Theballoon462 is inflated via aninflation lumen464 that extends through thegastrointestinal sleeve device400. Theinflation lumen464 can be incorporated into the wall ofsleeve400 or it can be in a coaxial tubular tether that can be separated from thesleeve400 to deflate theballoon462 once the sleeve is fully deployed within the patient's intestine. Theballoon462 is inflated after the distal end of thesleeve400 is past the pylorus and the inflated balloon is carried distally by peristaltic action of the intestines. Once the sleeve is fully deployed within the patient's intestine, theballoon462 can be deflated. The balloon can alternately be inflated prior to insertion into the body, thereby not requiring an inflation lumen the length of the device, and can either deflate naturally or have an active means of deflation as described herein. In an alternate embodiment the means to attach the balloon to the distal sleeve would be biodegradable and after the degradation of the attachment means the balloon would pass through the digestive tract naturally.
• FIG. 32B illustrates agastrointestinal sleeve device400 having a sponge orfoam member466 on its distal end. The use of afoam member466 simplifies thegastrointestinal sleeve device400 in that an inflation lumen is unnecessary to expand thefoam member466. Thefoam member466 is allowed to expand after the distal end of thesleeve400 is past the pylorus and the expandedfoam member466 is carried distally by peristaltic action of the intestines. Thefoam member466 can be biodegradably attached, as described above, or made of a dissolvable or digestible material so that it disappears after it has served its purpose.
• FIG. 32C illustrates a variation of thegastrointestinal sleeve device400 ofFIG. 32A, wherein theinflatable balloon462 is mounted on aflexible tail468 formed on or attached to the distal end of the sleeve.
• FIG. 32D illustrates a variation of thegastrointestinal sleeve device400 ofFIG. 32C, wherein the inflatable balloon is replaced with amagnet470. Thismagnet470 can be used in conjunction with other magnets, to guide the deployment of the intestinal sleeve. Matching guide magnets of opposing polarity can be used internal to the intestine in conjunction with an endoscope, within the abdomen external to the intestine in conjunction with a laparoscope or external to the body in a manner similar to that described by Gabriel in U.S. Pat. No. 5,431,640. In an alternate embodiment the means to attach the magnet to the distal sleeve would be biodegradable and after the degradation of the attachment the magnet would pass through the digestive tract naturally.
• In summary, the present invention provides a gastrointestinal sleeve device which allows separation of ingested foods and liquids from digestive secretions through the stomach and past the duodenum and optionally into the jejunum or ileum. This is of particular significance because gastric acids are neutralized by bile and duodenal secretions. This prevents digestion from gastric acid taking place even if the food and gastric secretions are allowed to mix at a later point in the intestines.
• FIG. 33 shows a cutaway view of a portion of a human digestive system, with an embodiment of thebiliopancreatic diverter tube500 in situ. The biliopancreatic diverter tube is comprised of a tube that diverts bile salts released from thegallbladder508 and pancreatic juices from the pancreas (shown with dotted lines) from being discharged into the duodenum at theduodenal papilla512, and instead allows for discharge of these fluids farther downstream within thesmall intestine510 from the distal tip502 of the device.
• The proximal end of the embodiment ofFIG. 33 is bifurcated, so that the proximal end of the device has two branches, abile duct branch504 that extends into thecommon bile duct514, and apancreatic duct branch506 that extends into thepancreatic duct516.
• FIG. 34 shows an alternative embodiment of thebiliopancreatic diverter tube520 where the proximal end is not bifurcated. Instead, theproximal tip524 extends into the common bile duct as shown, and the proximal end has an array ofinlet ports526, or a single larger inlet port, for collecting pancreatic juices from the pancreatic duct. The pancreatic juices and bile salts collected at theproximal tip524 and the array ofinlet ports526 flow through a common lumen connecting to thedistal tip522 of thediverter tube520. The pancreatic juices and bile salts are prevented from avoiding the diverter tube by anannular stop member528 that forms a seal between thedevice520 and the surrounding duct. Alternatively, the tube may be sized for a tight fit in the duct, obviating the need for the annular stop member.
• In addition to the two embodiments shown, other configurations may be necessitated by anatomical variations.
• In an alternative embodiment, thedevice520 could have a dual lumen aligned coaxially, so that an inner lumen would collect bile salts from theproximal tip524, perhaps tapered so that only the inner lumen's proximal orifice is exposed at the proximal tip, and the outer lumen would collect pancreatic juices from the array ofinlet ports526 or single inlet port. Alternatively, thedevice520 could have a dual lumen aligned side-by-side, or in some other arrangement.
• Alternatively, theproximal tip524 of the device could be placed within the pancreatic duct, and the array ofinlet ports526 or single inlet port would collect bile salts.
• The portion of the device in the intestine may be semipermeable, allowing certain materials from the intestine to pass into the tube, such as acids. Alternatively, the portion of the device in the intestine may only allow certain materials from inside the device to permeate out, such as bases to neutralize stomach acids. It should be noted that the duodenum also excretes bases to neutralize stomach acids.
• The lumen of the diverter tube is preferably of a diameter to allow flow of bile and pancreatic secretions the tube. Optionally, the diverter tube may be constructed with flexible walls to allow peristaltic motions of the intestinal wall to effect movement of bile and pancreatic juices through the diverter tube.
• The interior and/or exterior of the diverter tube can optionally be formed from a relatively inert material such as a polyolefin (e.g. polyethelene) or a fluoropolyment (e.g FEP or PFA) or coated with a low friction material (e.g. a hydrogel) to reduce friction of bile and pancreatic juices (interior) and reduce native luminal irritation (exterior).
• The interior of the diverter tube can optionally include a coating to resist crystallizing and/or deposition of bile and pancreatic secretions which could obstruct flow through the tube.
• The wall of the diverter tube may be reinforced with rings or a spiral made of wire and/or plastic. Optionally the diverter tube can include means for stabilization at the distal end such as a brush (as described by Berry, U.S. Pat. No. 5,306,300), weight, or inflatable balloon.
• FIG. 35 shows an embodiment of thebiliopancreatic diverter tube530 being delivered using a transesophageal approach under visualization with aflexible endoscope532. Theendoscope532 is passed through a patient's mouth, down the esophagus, into thestomach534, past thepyloric sphincter536, and into theduodenum544. Thedistal end538 of the endoscope is positioned adjacent to the duodenal papilla. A guidewire is then passed through the endoscope and out of itsdistal end538, into the opening of the biliopancreatic duct at the duodenal papilla, and advanced within the duct or ducts where an embodiment of the biliopancreatic diverter tube will eventually be positioned. An embodiment of thebiliopancreatic diverter tube540 is then passed over the guidewire. The guidewire is then removed.
• Optionally, laparoscopic or open surgical techniques may be used to assist in or complete the implantation of the device.
• The proximal end of the device may be anchored in place with a variety of means. One means of anchoring the device is with anannular stop member542, as shown, that may be inflated to make contact with the surrounding walls of the duct. Other means for anchoring an embodiment of the biliopancreatic diverter tube include integrating a self-expanding stent-type anchor on the proximal end of the device. Such a stent may be coated with a dissolving material to delay expansion of the stent portion of the device until it is properly seated. Alternatively, a balloon expandable stent-type anchor may be used, or the proximal end of the device may be barbed or toggled, or the tube itself could be self-expanding, or the proximal end may be formed with a pigtail curve, or the proximal end could be manufactured of a material that swells up with moisture, for example a hydrogel, hydromer or other materials as described herein. In addition, the outer surface of the proximal end of the device may be covered with a fabric to facilitate ingrowth of tissue to secure the device in place. Some of these attachment means will require the proximal tip of the device to be placed in the gallbladder while others will attach within the bile duct. Stent-type anchors can also be configured for use as inlet ports to allow entry of pancreatic secretions into the tube.
• Once anchored in place, the distal end of the device may be deployed from the endoscope. The endoscope could be pushed downstream within the small intestine as an embodiment of the biliopancreatic diverter tube is pushed out of the distal end of the endoscope. Alternatively, the endoscope could remain stationary, or even be retracted as an embodiment of the biliopancreatic diverter tube is pushed out the distal end of the endoscope, allowing peristalsis to then carry the distal end of the device downstream.
• Typically, the device will be 50-510 cm in length and have an inner diameter of 1.0-7.5 mm. The device could be made from a silicone, polyurethane, polyethylene or a fluoropolymer such as PFA. Device coatings could include hydrogels such as PVP (polyvinylpyrolidone or other coating such as parylene as described herein. Stent-type retention components could be stainless steel or NiTi.
• Preferably, the diverter tube is constructed with radiopaque and/or sonoreflective materials and/or includes one or more radiopaque and/or sonoreflective markers for enhanced imaging by X-ray, fluoroscopy and/or ultrasonic imaging so that the position and functional state of the implanted intestinal sleeve can be verified noninvasively.
• Thebiliopancreatic diverter tube500 is an alternative to dividing intestine as described inFIGS. 17-20. It should be noted that the biliopancreatic diverter tube does not isolate ingested food from the gastric juices, but neutralization of acid and action of biliopancreatic secretions is delayed.
• The biliopancreatic diverter tube is intended for use in conjunction with other surgical and/or interventional procedures for a combined treatment, for example using any of the devices and methods for treatment of morbid obesity described herein.
• In one aspect, the invention describes a number of fastener systems that can be used in situations where it is desirable to replace a portion of the fastening system, and any device or devices held in place by the fastener, while other portions of the system remain in place.
• In particular, these systems are useful in attaching devices to the inside of hollow organs such as the stomach. Though these fastening systems generally consist of two or three components at each attachment point, various components can be combined or connected. Some of the fastener systems can be applied to attachment ring systems and stomal ring clip systems as described herein.
• FIG. 36 illustrates afastener system600 withseveral fastener segments602, each segment having gripping fingers for attachment of a surgical appliance. As shown inFIG. 36, sixindividual segments602 are positioned within a passageway of the body along a plane that lies approximately perpendicular to the passageway, such that collectively they form an annular mounting surface along the perimeter of the passageway with graspingfingers604 extending away from the perimeter of the passageway, for attachment with another device. Thefasteners segments602 and the graspingfingers604 are preferably constructed of a biocompatible metal or polymer or a composite or combination thereof. Suitable materials include, but are not limited to, stainless steel, titanium, NiTi alloys, cobalt alloys such as Elgiloy or MP35, elastomers such as silicone or polyurethane and other rigid or flexible plastics. In some embodiments, it may be desirable to construct a part or all of the fastener of a biodegradable or bioresorbable material. In certain applications, it may be advantageous to have individual fastener segments rather that one integrated device as shown inFIG. 38. That decision may be informed by the following characteristic, the fastener segments ofFIG. 36 may be more flexible than the device ofFIG. 38 because they can move more independently of one another, and thus do not transmit forces to one another.
• FIG. 37 illustrates asleeve member606 that has been attached to the annular mounting surface created by thefastener system600. When used within the stomach, thesleeve member606 and related components and features function as a conduit for food within the gastrointestinal tract that essentially restricts the flow of food downstream with a narrow opening. These devices encourage weight loss by limiting the rate at which food can be consumed, and by contributing to the feeling of being full, or satiated and other mechanisms. It should be noted that although the sleeve member restricts the flow of food, the flow of food is not substantially inhibited by the fastener segments. Thefastener segments602 do remain attached to the perimeter of the passageway, and only slightly protrude into the passageway. In addition, thefastener segments602 do not rely on folded tissue for anchoring purposes, and this allows the inner diameter of the passageway to retain its original diameter. In some situations it is clinically preferable that this diameter is the same as the resting diameter of the hollow organ so as to transmit minimal force and result in little or no deformation of the wall from its resting position.
• An example of a method of use that may be used with any embodiment of the fastener system of the present invention as described herein, the fastener or fasteners may be implanted into the stomach or another hollow organ and allowed to heal for a period of days or weeks. After sufficient healing time, a surgical appliance, such as a gastrointestinal sleeve device, may be installed by attaching it to the fastener system. Alternatively, the surgical appliance may be installed at the same time as the implantation of the fasteners. In another exemplary method, a first surgical appliance, such as a gastrointestinal sleeve device, may be initially installed (either immediately or after a period of healing as described above.) Subsequently, the first surgical appliance may be removed and, if desired, replaced with a second surgical appliance. For example, a first gastrointestinal sleeve device with an initial stoma size may be replaced with a second gastrointestinal sleeve device with a larger or smaller stoma size. This could be used to modify the treatment regimen as the patient gradually becomes accustomed to consuming less food or it may be used to modify a treatment regiment to obtain better effective weight loss. Alternatively, gastrointestinal sleeve devices with incrementally larger restrictive stoma sizes may be installed at the end of a successful treatment regimen to wean the patient back to normal dietary guidelines for maintaining the weight loss.
• The fastener system of the present invention may also be used for attachment and subsequent removal or replacement of a valve or restriction at the gastroesophageal junction for treatment of gastroesophageal reflux disease. In the alternative, the fastener system may be used in other hollow organs for attachment and subsequent removal or replacement of other surgical appliances, as described above.
• AlthoughFIG. 36 shows sixindividual fastener segments602, it should be noted that as few as two segments could be used, more than six could be used, and that between four and six segments can be preferred. Eachsegment602 is shown having threegripping fingers604, each oriented approximately perpendicular to the surface of the passageway, with two opposed relative to the third so that another device can be snapped between opposing fingers. Thefingers604 are flexible, yet rigid enough to hold adevice606 in place, such as shown inFIG. 37, while also allowing that device to be removed at some later time, perhaps to be replaced by another device.
• Theindividual fastener segments602 ofFIG. 36 can be attached to the body passageway in several ways. As shown, eachsegment602 can be attached with sutures that pass throughholes608 positioned in each corner of each fastener segment. Alternative to sutures, wire, a staple, rivet or other type of fastener may be passed through each hole. In addition, the surface of each segment adjacent to the body's tissues may be coated with tissue growth promoting materials, such as Dacron felt or mesh, to improve the attachment of the device to the body. Tissue growth promoting materials may be used in conjunction with all embodiments herein to improve attachment. The embodiment shown inFIG. 36 is preferably configured so that its installation does not narrow the passageway of the organ.
• One skilled in the art can envision a corresponding insertion tool, which will temporarily deform theannular ring610 or other attachment surface of thedevice606 to allow facilitated passage of thedevice606 over the graspingfingers604 ofFIG. 36. One can also imagine that by cutting theannular ring610 of the dependingdevice606 it could easily be removed.
• FIG. 38 shows an alternative embodiment of afastener system612 comprising an annular shapedmember614 havinggripping fingers616 for attachment of asurgical appliance606 within a hollow organ in a patient's body. Theannular member614 and the graspingfingers616 are preferably constructed of a biocompatible metal or polymer or a composite or combination thereof. Suitable materials include, but are not limited to, stainless steel, titanium, NiTi alloys, cobalt alloys such as Elgiloy or MP35, elastomers such as silicone or polyurethane and other rigid or flexible plastics (e.g. polyolefins or fluoropolymers). In some embodiments, it may be desirable to construct a part or all of the fastener of a biodegradable or bioresorbable material. The fastener shown here may be configured as a single component, and this feature means that it is more rigid within the body compared to an embodiment comprising two or more fastener segments. This feature may be desirable in certain applications, such as for use within the circulatory system. However, when the device has portions made of a highly flexible material, such as a low durometer silicone material, it can be made stretchable or deformable so that it can move with motion of the wall of the passageway, yet still maintain a grasp on any attached device with its fingers which are preferably made from a less elastic or rigid material such as a higher durometer silicone, a rigid plastic or metal such as stainless steel or titanium.
• In an alternative embodiment, the fastener system shown inFIG. 38 may be designed so that it is essentially the fastener system ofFIG. 36 held together by bioresorbable material as polyglecaprone (Monocryl, Ethicon), polygalactyn (Vycril, Ethicon) or other known in the art, thus facilitating installation. In this configuration, the one piece device ofFIG. 38 could be installed relatively easily compared to the multi-piece device shown inFIG. 36, and also enjoy the flexibility of the device ofFIG. 36 once the bioresorbable material has dissipated.
• The embodiment shown inFIG. 38 is preferably configured so that its installation does not narrow the passageway of the organ. The annular dimension is sized so that when the device is attached to the hollow organ it essentially fits into the organ with little or no stress on the organ walls. The passageway of the organ substantially retains its original diameter.
• FIG. 39 shows thefastener system612 ofFIG. 38 with asurgical appliance606 attached. The means of attachment shown inFIG. 39 with the use offingers616 is just one of many possible means of attachment. For example, the device ofFIG. 38 could be reconfigured so that it can accommodate a bayonet mount (a fitting engaged by being pushed into a socket and twisted), wherein the sleeve member could be pushed into a socket formed by the annular shaped member and then twisted. Also, an interference type of fit could be used wherein the sleeve member, for example, could be attached to the annular member by simply resting over the annular member because the sleeve member has a larger inner diameter at its proximal opening than the inner diameter of the annular member. The fitting may not alter the original diameter of the passageway. The engagement means would be configured to secure the depending device to an attachment device that could be flexible, deformable and with a variable opening diameter. In addition to these types of attachment means, magnets and barbs may also be employed.
• FIG. 40A shows analternative fastener system618 comprising an annular shapedmember620 wherein the surface of the annular shaped member alternates between having tissuegrowth promoting materials619 such as Dacron felt or mesh, and non-tissuegrowth promoting materials621 such as a fluoropolymer. The tissuegrowth promoting materials619 are illustrated as having a rough surface, and are intended to become assimilated with the adjacent body tissue to supplement other attachment means such as sutures, staples, clips or other means known in the art. Thesurface621 of the annular shaped member that lacks tissue growth promoting materials may be used for attaching another appliance or device.FIG. 40A illustrates this surface as having a hole or void617 that can be used for attaching a hooking device, or the functional device itself.
• FIG. 40B shows afastener system622 comprisingfastener segments623 connected with segments of abioresorbable material625, as discussed herein, to ease installation. Thefastener segments623, illustrated with a rough surface to indicate that they are also coated with a tissue growth promoting material, are surgically attached to the adjacent tissue wall. Each segment is also shown as having a hole or void624 that can be used for attaching a hooking device, or another device. Thebioresorbable segments625, shown having a smooth surface, would dissipate over time, leaving thefastener segments623 in place to support a load. This device would be simple to install, and once the bioresorbable material has dissipated, it would haveindividual segments623 that could move independently of one another, and not transmit these forces to other segments. The embodiments shown inFIGS. 40A and 40B are preferably configured so that installation does not narrow the passageway of the organ.
• FIG. 41A shows analternative fastener system626 comprising an annular shapedmember627 wherein the surface of the annular shaped member alternates between having tissuegrowth promoting materials628 and non-tissuegrowth promoting materials629. This embodiment shows thesurface629 of the annular shaped member that lacks tissue growth promoting materials shaped to form a hanging or attachment platform for another device by extending away from and then back into the tissue growth promoting surfaces628.
• This attachment platform can be used for various items such as sutures, clips, rings, hooks, hangers, etc., that can depend form the attachment platform.
• FIG. 41B shows analternative fastener system630 comprising an annular shapedmember631 wherein the surface of the annular shaped member alternates between having tissuegrowth promoting materials632 and non-tissuegrowth promoting materials633. In this embodiment, thesegments632 of the device having the rough surface would be the segments attached to the adjacent tissue wall. The coupledsmooth segments633 are made from an elastic material that can be stretched, as illustrated with onesegment634 drawn tight. This configuration allows the attachedrough segments632 to move almost independently of one another, and also provides a platform from which a load can be supported, that platform being the entire annular shapedmember631. Whatever device is eventually coupled to the annular shapedmember631 could be coupled using any or all portions of the annular shaped member for support. The embodiments shown inFIGS. 41A and 41B are preferably configured so that installation does not narrow the passageway of the organ.
• FIG. 42A shows analternative fastener system635 comprising an annular shapedmember636 wherein the surface of the annular shaped member alternates between having tissuegrowth promoting materials637 and non-tissuegrowth promoting materials638. This embodiment shows thesurface638 of the annular shaped member that lacks tissue growth promoting materials to havehooks639 extending from the plane of the annular shapedmember636. Thesehooks639 can be used for attaching another device or appliance.
• Also shown areholes640 in this embodiment which may be used to pass a suture or other attachment structure, as described herein, through to help secure the device in place. Thehooks639 can be curled to retain other devices, or could have specific mating couplings for example wherein a quarter turn will lock the coupling to thehooks639.
• FIG. 42B shows analternative fastener system641 comprising anannular member642 ofrough segments643 havinghooks644 coupled tosmooth segments645 that are made of a bioresorbable material. Therough segments643 are coupled to the adjacent tissue wall and remain in place to support a load after thebioresorbable segments645 have dissipated. This embodiment is thus simple to install, and enables eachsegment643 to move independently of one another once the bioresorbablesmooth segments645 have dissipated.
• The embodiment shown inFIGS. 42A and 42B are optionally configured so that installation does not narrow the passageway of the organ.
• FIGS. 43-45 show various embodiments of a fastener system that can optionally function to create a stoma within a passageway that is more narrow than the original passageway. The stoma can be created by plicating or pinching the tissue of the passageway such that it is folded in the manner shown inFIGS. 43-46A. The folds are held in place with the fasteners which pass through both tissue layers and hold them together. In addition, these fasteners also function as attachment surfaces for another device or devices, such as a clip supported by a fastener, and a device supported from the clip.
• The use of plications (folds) is often useful in overcoming the difficulties of coupling a fastener device to a hollow walled organ because the folds give the added strength of a double layer attachment point, and also protect against leaks because the hole passes from the inside of the organ and back to the inside of the organ. Another advantage is that the outermost wall of the gastrointestinal tract, the serosa, appears to heal well because when it is in contact with itself, such as within a fold, it tends to heal together. This will further serve to prevent leaks by sealing the channel formed by the placement of the fastener through the fold. Plications can be formed by a fastener system or can be formed by standard techniques such as sutures with a fastener attached either to the suture or directly to the plication after it is formed. Alternately, plications can be formed and fasteners inserted that the fasteners pass through the muscularis layer of the gastrointestinal wall but do not pass through the serosa. This may be clinically preferred as a means to prevent leaks as the serosa provides a sealing layer. This also applies to the fasteners shown in FIGS.47A-F and48.
• FIG. 43 shows a fastener system comprising ahollow plication element646 that may be used to hold tissue together, as well as anattachment element647 that is shown capable of passing through thehollow plication element646 and snapping into place. Theattachment element647 thus provides a platform for attaching other devices or hooks. Alternatively, a device may clip in directly to thehollow plication element646, thus obviating the need for anattachment element647. Thehollow plication element646 could have a cone shaped end that is able to pierce through the tissue layers, and this cone shaped end would then expand to remain in place.
• FIG. 44 shows an alternative embodiment of a device similar to the device ofFIG. 43, wherein theattachment element648 differs. Theattachment element648 is in the form of a wire clip that attaches to thehollow plication element646.
• FIG. 45 shows an alternative embodiment of a device for both holding two layers of tissue together and providing a platform from which another device or hanger can be attached. In this embodiment, the device comprises two components, apost649 having an attachment platform, as well as asnap cap650 to hold the tissue layers together. This embodiment has a solid, rather than hollow element for connecting the tissue layers which may be advantageous in certain applications, especially where less tissue is available for folding, or where it may be desirable to have the original diameter of the passageway kept as wide as possible. Note that though all fasteners inFIGS. 43-45 are shown passing through the serosa of both layers of the plications, this is not a requirement of the devices or methods.
• FIG. 46A shows an alternative embodiment of a fastener system. This embodiment includes afastener651 that can be made from a metal having superelastic or shape memory characteristics such as Nitinol, so that the device can be loaded within a delivery device, such as a hypodermic tube. Once the tissue has been folded, thefastener651 can optionally be sent through both tissue layers to hold them together to create a stoma, and also optionally function to provide a platform for attaching another device or hanging element. The curledportion652 of the device can be straightened out and stored so that it lies essentially parallel to thepost653 that is positioned between the tissue layers. When the curledportion652 of the device is released from the delivery device and allowed to expand, it then forms a cone shaped spring to hold the tissue layers together. The relative dimensions of the cone shaped spring are exaggerated for illustration purposes. The cone shaped spring distributes force onto adjacent tissue over a relatively large area, and centers that force onto the post. The cone also prevents the fastener from being pulled through the hole. This particular geometry is intended to be exemplary and other geometries which increase the area of the portion of the fastener which bears the weight (force) of the dependent device and thereby helps resist pull-through.
• FIG. 46B shows thefastener device651 ofFIG. 46A being driven through a single tissue layer, with the attachment means654 on the end of thepost653 positioned within the passageway, and the cone shaped spring positioned652 on the opposite side. The embodiment shown inFIG. 46B is preferably configured so that its installation does not narrow the passageway of the organ. Delivery of fastener embodiments communicating with the exterior of a hollow organ as shown inFIG. 46B (also FIGS.6B-D) may incorporate means to control capture of other structures. Though it may be clinically desirable to capture other structures as in the case of capturing the diaphragm by fasteners placed in the cardia of the stomach it is more likely that this would be undesirable. Fastening means could incorporate shielding means and/or means to invaginate the organ wall as the fastener is advanced through the organ wall.
• FIG. 47A shows aclip655 that can be used to plicate tissue, and also provide a platform for attaching another device or hanger. Theclip655 is shown being used with one embodiment for aplication tool656. Theplication tool656 is capable of folding tissue in a desired way and then delivering aclip655 to hold the tissue in a folded configuration. This is accomplished by grabbing the wall of a tissue at two points, and then pinching the wall (either with the tool itself or the fastener) and delivering aclip655 to hold the fold together. Various means may be employed to ensure that the fold occurs properly, such as suction, or pushing thetool656 into the tissue wall as it pinches.
• FIGS. 47B-47D show the sequence of steps used to deliver theclip655 ofFIG. 47A. This process may be repeated to collectively form a support structure for another device. Theplication tool656 may include suction or other mechanical means such as hooks or barbs to encourage the tissue to fold as shown in the figures.
• FIG. 47B shows a side view of theplication tool656 loaded with aclip655. Theclip655 is positioned adjacent to a tissue wall, as shown.
• FIG. 47C shows theclip655 being compressed. The clips distal ends pierce the adjacent tissue, and then fold it as theclip655 is compressed with theplication tool656.
• FIG. 47D shows theclip655 being compressed further. The direction arrows above theplication tool656 indicate that theplication tool656 could be biased towards the closed position with a spring mechanism, or that some type of direct mechanical force could operate the tool.
• Theclip655 may be designed so that it is normally closed or normally open. If theclip655 is designed normally open, it will need to be compressed and remain compressed. Therefore, theclip655 is preferably made of a deformable or malleable material, such as an annealed metal, that can be deformed by theapplication tool656 such that the clip will retain the deformed position. Thetool656 used to compress the clip transmits force to close theclip655, using for example, a wire or rod that is optimized to transmit a push force to compress the clip. However, if theclip655 is designed to be normally closed, it is preferable that theclip655 be made of an elastic material that can be opened up, and then close on its own or with the assistance of aplication tool656. Theplication tool656 would need to be able to hold aclip655 that is normally closed in the open position, and should be designed to do such a task with an appropriately designed clip. The normally closedclip655 may be preferred in some circumstances because it easier to hold tension in a tool and then release it than to transmit force through a tool. The normally closedclip655 will be easier to pass into the body when closed and mechanisms to open the clip in vivo can be accomplished using pull wire actuators as well known in the art.
• FIG. 47E shows anotherdevice606 that is positioned to hang fromseveral clips655 positioned within a passageway. The embodiment shown inFIG. 47E is preferably configured so that its installation does not narrow the passageway of the organ. The vertical lines indicate that this device has been positioned within an organ, such as the stomach, such that the inner diameter of the device is not more narrow than the inner diameter of the tissue upstream of it, in this case the esophagus.
• FIG. 47F shows analternative clip embodiment659 having twoseparate attachment platforms657,658. Oneplatform657 is positioned at the hinge portion of theclip659, and asecond platform658 is positioned along the bottom half of theclip659, as shown inFIG. 47F. One or bothplatforms657,658 may be used, and thesecond platform658 can be easily repositioned on the clip, if desired. Note that if thesleeve device606 ofFIG. 47E were supported by thesecond platform658 of theclip659 ofFIG. 47F, a larger diameter sleeve device can be employed.
• FIG. 48 shows another embodiment of afastener660 comprising ahanger661 that also functions to hold two layers of folded tissue together. This fastener has atoggle662 that pivots on ahinge663 so that is can be aligned with thepost664 as it is passed through tissue layers, and can then be pivoted to hold the tissue layers together.
• Thetoggle662 helps to distribute forces that hold thefastener660 in place over the length of thetoggle662, and also prevents thefastener660 from being pulled through the hole. Alternative to thetoggle662, a similar functioning apparatus such as a multi-arm umbrella could also be used to distribute forces on the adjacent tissues while preventing thefastener660 from passing through the hole. This fastener functions similarly to the T-tag fasteners described herein.
• In summary the fastener system can include:
• • an implantable surface for mounting a functional element that may attach to the tissue itself with a suture, staple, clip, T-tag or pass through one or more layers of tissue including a fold of tissue.
• The fastener system, optionally including:
• • an interface element, and
  • a functional element, wherein the interface element couples the implantable surface for mounting a functional element to the functional element.
• The fastener system, optionally including:
• • a functional element, wherein the functional element couples to the implantable surface for mounting a functional element.
• The fastener system, optionally including:
• • a plication tool for folding a tissue wall such that the tissue wall is pinched and pulled toward the tool and the interior of a body organ, and
  • an implantable surface for mounting a functional element delivered by the plication tool for maintaining the fold, and that also provides a platform for attachment of another element.
• The fastener system, optionally including:
• • a removal tool that can be used to remove a functional element by, for example, unhooking it, cutting it, turning it, unlocking it.
• A method for positioning the fastener system and using it can include:
• • attaching an implantable surface for mounting a functional element that may attach to the tissue itself with a suture, staple, clip, T-tag or pass through a fold of tissue,
  • optionally attaching one or more interface elements to interface between the implantable surface for mounting a functional element and a removable functional element, and
  • attaching a removable functional element that attaches either to implantable surface for mounting a functional element itself, or to the interface element.
• A method for removing the functional element can include:
• • using a removal tool to remove the functional element by, for example, unhooking it, cutting it, turning it, unlocking it.
• In the case of an attachment ring the ring does not necessarily create a restriction. In many embodiments, a second element generally creates a restriction using a restricting device (for example stoma100). The restriction may or may not be co-located with the attachment ring. In the case of the stomal ring clip (SCR) the ring clip creates the restriction by positioning natural tissue to create the restriction. Therefore they differ in that the SRC: 1) preferably uses tissue to create the restriction and 2) always has the restriction at its location. This is the case even where a sleeve is passed through the stoma created by an SRC. Please note that many apparatus (including fastening systems) can be applied to either use and some could be applied interchangeably. Please also note that the structures described as an SRC can generally be used as components of an attachment ring system in which case the restriction is not necessarily collocated.
• One aspect of present invention provides apparatus and methods for performing gastric and esophageal surgery. The apparatus of the invention includes a surgical instrument for creating a stoma or restriction in a patient's stomach or esophagus using minimally invasive surgical techniques. This apparatus can also be used to create a plication or fold in the stomach or esophagus and furthermore can then be used to attach other devices including those described herein, to the fold thereby created. The apparatus can also include stomal ring clip devices implantable within the patient's stomach for forming and maintaining the stoma or restriction. The surgical instruments and the implantable stomal ring clip devices may be used separately or in combination depending on the needs of the individual patient. Methods are described using the surgical instruments and the implantable stomal ring clip devices separately and in combination for creating a stoma or restriction in a patient's stomach or esophagus. The apparatus and methods are useful for treatment of morbid obesity and can be combined with other surgical techniques or devices as part of a complete treatment regimen. The apparatus and methods are useful for treatment of gastroesophageal reflux disease (GERD) by creating a restriction or a valve-like structure at the gastroesophageal junction to prevent reflux of the stomach contents.
• FIGS. 49-51 illustrate asurgical instrument700 constructed in accordance with the present invention. Theinstrument700 has an optionally flexibleelongated body702 with ahandle704 on its proximal end. At the distal end of the flexibleelongated body702, thesurgical instrument700 includes afastener delivery mechanism708 and an articulatedarm706 with means for grasping and plicating a portion of tissue, such as the stomach wall, and for fastening the tissue with rivets orsimilar fasteners710. Optionally, as shown inFIG. 53, the device is sized to pass through the working channel of an endoscope. The articulatedarm706 is pivotally mounted on anextension arm720 extending from the distal end of the flexibleelongated body702. Optionally, theextension arm720 may be extendable and retractable from the flexibleelongated body702. This option allows the articulatedarm706 to capture varying sizes of tissue folds including those that can optionally result in the fastener passing through layers of serosa. The articulatedarm706 has ananvil722 for heading therivets710 and may have one or more spikes orteeth724 for securely grasping the tissue.FIG. 49 shows thesurgical instrument700 with the articulatedarm706 pivoted outward.FIG. 50 shows thesurgical instrument700 with the articulatedarm706 pivoted inward toward thefastener delivery mechanism708.FIG. 51 shows thesurgical instrument700 with the articulatedarm706 heading or expanding arivet710. The articulatedarm706 may be actuated from acontrol button718 on thehandle704 by cables, rods or other actuation mechanism within the flexibleelongated body702. Optionally, the articulatedarm706 may be normally in the position shown inFIGS. 2 and 3 and require actuation to open to the position shown inFIG. 49.
• Thefasteners710 may take one of several possible forms. Thefasteners710 may be in the form of double-ended rivets with an expandable head on the leading and trailing ends, as shown inFIGS. 49-51 and55-57. Thefastener710 is pushed through the tissue, then the expandable head on the leading and trailing ends is expanded by the force of theanvil722. Alternatively, thefasteners710 may have a fixed head on the trailing end of the fastener and an expandable head on the leading end. In another alternative configuration, thefasteners710 may be in the form of blind fasteners, of the type commonly known as pop rivets. Additionally, thefasteners710 could be self-expanding so that once passed through the tissue of the stomach, they expand to hold the plicated stomach tissue together. Thesefasteners710 may be biased, or spring loaded, so that minimal contact with the anvil causes the fastener to expand below the plicated tissue. In this embodiment,fasteners710 could include a trailing end that self expands as it exits lumen114 ofFIG. 52 thereby capturing the tissue in a plication. Also, the fasteners could have a self-expanding end, and a non self-expanding end. Perhaps the non self-expanding end is already expanded, or could be made to expand with additional force.
• Thefasteners710 can be permanent or biodegradable. Thefasteners710 may be constructed of a biocompatible metal or polymer or a combination or composite thereof. Alternatively, theentire fastener710 or a portion of it may be constructed of a bioresorable material. Additionally, thefasteners710 can include enhanced scar forming means such as a coating of lower that normal pH or a material such as polyglactin (Vycril, Ethicon).
• The articulatedarm706 section of the device can be configured to capture varying sizes of tissue folds, with some embodiments enabling capture of folds of greater dimension than the width of the device. This may involve use of curvilinear, bendable and/or multiple articulated arms106. In another embodiment the rivet lumen exit can be angled to cooperate with a larger articulatingarm706 to capture a larger fold of tissue.
• Thesurgical instrument700 is preferably configured for performing surgery on the stomach or esophagus via a peroral endoscopic approach. As such, the flexibleelongated body702 may be sized and configured to fit through the instrument channel of a gastroscope or to fit through the patient's esophagus alongside a gastroscope. Otherwise, the flexibleelongated body702 may be configured with a lumen or channel to accept a gastroscope or other endoscope or imaging device through thesurgical instrument700. Alternatively, thesurgical instrument700 may be reversibly attached to or integrated with a gastroscope or imaging device.
• FIG. 52 shows a cross section of one possible configuration of thesurgical instrument700 shown inFIGS. 49-51. The flexibleelongated body702 has a first lumen orchannel712 for the articulatedarm706, a second lumen orchannel714 for thefastener delivery mechanism708 and a third lumen orchannel716 for passage of an endoscope or other instrument. Thechannel714 for thefastener delivery mechanism708 may include a protrusion (not shown) that extends from the distal end of thechannel714 to capture the holes in the stomal ring clip (described below) to hold it in place, and assure that a fastener is delivered accurately through a stomal ring clip. In other embodiments, such as that ofFIG. 53, the articulatedarm706, andfastener delivery mechanism708, can be passed down the lumen of anendoscope702.
• FIG. 53 shows a surgical instrument comprised of afastener delivery mechanism708, and an anvil attached to anextension arm720 with a hinge or hinge-like structure, used for creation of a stoma or restriction in a patient's stomach that is sized for passage through an endoscope. Theextension arm720 in this embodiment is shown to curve away from thefastener delivery mechanism708 so that the surgical instrument can plicate a greater amount of stomach tissue. This allows the fastener to gain the advantage of passing through two complete layers of stomach tissue because the fastener is no longer near the edge of the fold. The surgical instrument is inserted within anendoscope730. The endoscope has been introduced into the patient's mouth and down through the esophagus into the patient's stomach. The surgical instrument is then passed through theendoscope730. The articulatedarm706 is pivoted outward, as shown inFIG. 49, to grasp a portion of the stomach wall using thespike724. The articulatedarm706 is then pivoted toward thefastener delivery mechanism708, as shown inFIG. 50, to plicate or fold the stomach wall. The rivet orfastener710 is driven through the fold in the stomach wall, and theanvil722 on the articulatedarm706 heads or expands the rivet orfastener710 to secure the tissue fold as shown inFIG. 53. Thesurgical instrument700 is rotated, independently or with the endoscope, and the process is repeated to place a series offasteners710 in a circular pattern to form a stoma or restriction in the patient's stomach as shown inFIG. 54, perhaps moving to the opposite side of the stomach from the previous fastener, rather than to an adjacent position, to create a uniform stoma. In the example shown, when the stoma forms a restriction, the stoma is typically sized between one half and two centimeters in diameter, to restrict food intake into the stomach for treatment of morbid obesity. Alternatively, thesurgical instrument700 may be used to create a valve-like flap at the gastroesophageal junction for treatment of gastroesophageal reflux disease.
• FIGS. 55-57 show the sequence of steps for inserting afastener710 in greater detail. These figures also illustrate one embodiment of afastener710 having a pointed cone-shaped distal end to allow it to be easily passed though stomach tissue, and perhaps a stomal ring clip (as discussed below).
• FIG. 55 shows thespike724 positioned on the terminal end of theanvil722. The articulatedarm706 is initially extended parallel to theextension arm720. Thespike724 is then moved toward the stomach tissue. Once thespike724 has gotten hold of the stomach tissue, theanvil722 is rotated toward thefastener delivery mechanism708, as shown inFIG. 56.
• FIG. 56 shows the distal end of thefastener710 in the expanded position. As previously discussed, thisfastener710 could be self-expanding, whereupon contact with theanvil722 forces thefastener710 to expand. In this figure, thespike724 is shown to engage the biased spring of the fastener, which then expands with the impetus provided by the force of pushing thefastener710 over thespike424. In this embodiment, the proximal end of thefastener710 is self-expanding and expands as soon as it exits thedelivery lumen708. Alternatively, a trigger (not shown) may be provided within thefastener710 that allows the distal end of the fastener to expand. This same trigger mechanism may then encourage the proximal end of thefastener710 to expand once released from the fastener delivery lumen.
• FIG. 56 also shows thecurved extension arm720 in proximity to the stomach tissue. If necessary, thecurved extension arm720 could prevent the stomach tissue from expanding back over the distal end of the fastener prior to the fastener's release from the fastener delivery lumen.
• FIG. 57 shows thefastener710 in situ. Thefastener delivery lumen708 is retracted, as is theanvil724. The process is repeated in a circular pattern to create a stoma as inFIG. 54.
• FIG. 58 shows an example of a stomalring clip device740 with only anupper ring742 implanted in a patient's stomach, held in place withfasteners746. It should be noted that a ring can be used either above or below the tissue plication. The stomalring clip device740 helps to maintain the dimensions of the stoma that is formed by resisting inadvertent or deliberate stretching of the stomal opening, adding to the overall success of the treatment. The stomal ring clip is constructed from a material that will resist the forces that could stretch the stomal opening beyond its intended dimension. Alternatively, the material can be elastic and be selected to resist most stresses and if stretched return the stomal opening to its original size.
• FIG. 58 also illustrates the placement of a stomal ring clip device relative to the plicated stomach tissue, showing that the plicated stomach tissue diameter is actually narrower than the stomal ring clip's inner diameter, in some embodiments. This type of placement has the added advantage of allowing for a variable stomal diameter. For example, the plicated stomach tissue may have a diameter of 1 cm, and the inner diameter of the stomal ring clip may be 2 cm. The plicated stomach tissue's diameter can expand if necessary, up to the diameter of the stomal ring clip. This allows a patient who inadvertently swallows a large piece of food to have a larger stomal opening to accommodate that larger piece of food. The inner diameter of the stomal ring clip could be made large enough to accommodate anything that makes it down the esophagus, while the plicated stomach tissue's diameter could be made small enough to slow the rate of consumption and increase the feeling of satiation, leading to a decrease in the amount of overall food consumption for the patient, and thus resulting in weight loss. Alternatively, the diameter of this tissue can be sized to create little or no restriction to food flow as discussed herein.
• FIGS. 59-64 show a sequence of steps for using asurgical instrument700 to implant a stomalring clip device740 similar to the stomal ring clip device ofFIG. 58.
• In one method of application, thering742 of the stomalring clip device740 is rolled or folded and passed into the patient's stomach through the patient's esophagus or through a sleeve temporarily placed in the esophagus to protect the esophagus or through the instrument channel of an endoscope orsurgical instrument700. Thering742 is then allowed to return to its flat state within the patient's stomach, as shown inFIG. 59.FIG. 59 also shows an embodiment of asurgical instrument700 for attaching the stomal ring clip positioned at the top of the stomach. In this embodiment, thesurgical instrument700 has an additional feature for retrieving the stomal ring clip. It is comprised of threeprongs743 that can be used to grasp a stomal ring clip. Twoprongs743 grasp the stomal ring clip's inner surface, preferably grasping the clip on either side of a lobe. Thethird prong743 grasps the outside surface of the stomal ring clip and opposes the grasping force from the inner two prongs. Also, thethird prong743 is shown to have aspike745 on it. Thespike745 may be used to oppose the force created by the upwardly moving articulated arm706 (refer toFIG. 62). Theprongs743 may also curve at their terminal ends to improve their grip on the stomal ring clip. Theprongs743 can be retracted and extended within their respective lumens, and also can be moved inward and outward to grasp and release thestomal ring clip742. In some embodiments, only the inner or outer prongs may be moved inwardly or outwardly.
• FIG. 60 shows asurgical instrument700 holding astomal ring clip742. In this embodiment, thesurgical instrument700 is shown to grasp astomal ring clip742 having lobes. The lobes may be useful for increasing the surface area around the preformed holes in a stomal ring clip, or for increasing the surface area for a fastener to make contact with in embodiments of a stomal ring clip not having preformed holes (in these embodiments, the stomal ring clip is made from a material that may be pierced by the fastener as it is being deployed). Another use for the lobes is to aid in the orientation of the stomal ring clip relative to the fastener delivery mechanism. In this embodiment, the fastener delivery mechanism would be aligned over the lobe area for placement of a fastener.
• FIG. 61 shows the next step of the process in which the stomach tissue is folded. Theextension arm720 andanvil722 are deployed, extending through the interior of thestomal ring clip742. The anvil is able to pivot so that it moves away from the stomal ring clip to avoid catching the spike, and then pivot in the opposite direction to engage the stomach tissue. It should be noted that the spike is shown relatively large in this embodiment for illustration purposes. It should also be noted that a spike may be positioned elsewhere on the device relative to the anvil, such as is shown inFIG. 49.
• FIGS. 59-64 show an embodiment of thesurgical instrument700 for attaching the stomal ring clip positioned at the top of the stomach above a plication. Alternatively, if it is desirable to attach a stomal ring clip below the plication, grasping prongs could be placed on the articulating arm. In this case, secondary grasping means can be used to assist in positioning stomach tissue to form the plication prior to fastening.
• FIG. 62 shows theanvil722, with thespike724 engaging adjacent stomach tissue, and beginning to be rotated toward thestomal clip742, thus folding the stomach tissue.
• FIG. 63 shows the next step of the procedure, comprising the delivery of afastener710. Note that thespike724, or additional spikes, may be positioned elsewhere along theanvil722 or articulatedarm706 to facilitate the formation of the plication.
• FIG. 64 shows a close-up view of asingle fastener710 in place.
• The device is then used to plicate additional stomach tissues and insertfasteners710 as described before, perhaps moving to the opposite lobe rather than to an adjacent lobe on thestomal ring clip742, to create a uniform stoma.
• FIG. 65 is an exploded view of a stomalring clip device740 having upper742 and lower744 rings for forming a stoma or a restriction in a patient's stomach.FIG. 65 shows an alternate embodiment of therivets746 in which the rivets are blind fasteners of a “pop rivet” type configuration where instead of the distal head of the rivet being expanded by pressing against an anvil, the rivets include an internal expander which is drawn proximally into the rivet to expand its distal end. In this configuration, therivet delivery lumen714 can include grasping and articulating means to deploy the rivet expander, hold the rivet in place as the expander is drawn proximally, and then remove the undesired portion of the expander after deployment. The undesired portion of the expander could be caught with a magnet or some other means, and then retracted. As previously stated, other types of fasteners could also be used, for example double-ended rivets, single-ended rivets or rivets designed to expand with anvils without spikes.
• FIG. 66 shows an assembled view of the stomalring clip device740 ofFIG. 65 implanted in a patient's stomach. The stomalring clip device740 is configured to be implantable within the patient's stomach using a peroral endoscopic approach with thesurgical instrument700 ofFIGS. 49-51, or one of the other embodiments discussed.
• Alternatively, the stomalring clip device740 may be implanted with standard endoscopic instruments or it may be implanted via alaparoscopic approach or a combined endoscopic and laparoscopic approach. The stomal ring clip can be fastened in place using open surgery, laparoscopic techniques, standard endoscopic suturing techniques or use specialized sewing devices such as the ENDOCINCH″ (CR Bard Inc.) or others described herein. The stomalring clip device740 includes anupper ring742, a plurality offasteners746 and, optionally, alower ring744. Theupper ring742 and thelower ring744 are generally flat and have an inner diameter and an outer diameter. The inner diameter is preferably larger than the diameter of the desired stoma opening such that the folded tissue rather than the stomal ring clip material form the actual stoma opening. This would result in an inner diameter of approximately one to three centimeters. The width of the stomal ring clip is dimensioned to allow placement of attachment means and may include ribs or ridges to restrain the tissue captured in the folds between the rings. In one embodiment, both theupper ring742 and thelower ring744 are made of a flexible, resilient material that can be folded or rolled to a diameter small enough to be delivered easily through the patient's esophagus or through the instrument channel of an endoscope or surgical instrument and which will return to its flat state for deployment in the patient's stomach. Suitable materials for theupper ring742 and thelower ring744 include resilient metals, such as spring-tempered stainless steel and superelastic NiTi alloys, and resilient polymers (fluoropolymers, polypropylene, polyethylene, nylon or Pebax), elastomers (silicone, polyurethane) or composites or reinforced versions thereof. Commercially available materials such as Goretex (Gore) or Marlex (Davol) mesh could also be configured for use as a stomal ring clip. Materials can be permanent or biodissolvable. Though it is preferable for the rings to be resilient and have the ability to be folded or rolled, the rings could be made of rigid material (e.g. titanium or rigid plastic such as polyester) and be designed with hinges or articulations to allow passage through the esophagus after which, upon entering the stomach, they could be opened to their full size prior to attachment. Alternatively, the stomal ring clip may be constructed of sections made of rigid materials connected by sections of flexible material.
• FIG. 67 shows an example of a stomalring clip device740 with anupper ring742 and alower ring744 implanted in a patient's stomach. In this example, the stomalring clip device740 has a diameter smaller than the diameter of the opening formed by the plicated tissue.
• Theupper ring742 and thelower ring744 optionally have a plurality of preformed holes sized to accept the plurality offasteners746. In one embodiment, the plurality offasteners746 are in the form of rivets or similar fasteners that are deliverable using thesurgical instrument700 ofFIGS. 49-51. Alternatively, thefasteners746 can be integrated into one or both of therings742,744 so that the two can be fastened together without separate fasteners. Alternately fasteners and holes can be designed so the fasteners secure themselves to the rings as they are placed through the ring material. This can obviate the need for an expandable distal head on the fastener. Similarly, the proximal head of a fastener can be dimensioned larger than the shaft of the fastener and the hole through which the shaft passes in the upper ring thereby obviating the need for an expandable proximal head. Alternately constructing therings742 and/or744 of a pierceable material, such as Goretex or Marlex or materials commonly used for vascular grafts or other materials described herein, would allow a fastener of an appropriate piercing design would allow implantation without requiring the lining up of preformed holes.
• In a variation of the method for placing a single ring, alower ring744 may be passed into the patient's stomach prior to theupper ring742. A surgical instrument, which may be inserted laparoscopically, holds thelower ring744 from below, while another instrument, inserted endoscopically, holds theupper ring742. The stomach wall is plicated or invaginated between theupper ring742 and thelower ring744 and thefasteners746 are driven through both rings, effectively sandwiching a fold of the stomach wall tissue between the two rings.FIG. 67 shows an example of a stomalring clip device740 with anupper ring742 and alower ring744 implanted in a patient's stomach.
• These apparatus and methods can be combined with other surgical techniques or devices described above as part of a complete treatment regimen for treatment of morbid obesity. By way of example,FIGS. 68 and 70 show two embodiments ofgastrointestinal sleeve devices750 attached by stomalring clip devices740. Thesesleeve devices750 interrupt the digestion process by delaying various digestive juices from interacting with ingested food until the food reaches a desired location in the intestine.
• FIG. 69 shows the device ofFIG. 68 in situ. Thesleeve portion750 of the device is attached to a lowerstomal ring clip744. Thesleeve750 is flexible as described herein, allowing it to conform to the various curves involved with the gastro-intestinal (GI) tract. Thesleeve portion750 of the device may also be compressible, collapsible or foldable, allowing the pyloric sphincter to open and close, as well as expandable for larger pieces of food. In this embodiment thesleeve750 is attached to the outer diameter of the lowerstomal ring clip744 thereby allowing the suturing or fastening device access to thestomal ring clip740 for fastening without damaging or piercing thesleeve750. This type ofsleeve750 is generally placed at the same time as the stoma, however thesleeve750 andstomal ring clip740 can be constructed with removable and replaceable connections for the exchange of sleeves on a previously implanted stomal ring clip.
• FIG. 70 shows an embodiment for asleeve device750 that may be used with an existing stoma orstomal ring clip740. Thesleeve device750 is made of a flexible material like the device ofFIGS. 68 and 69, and is attached to a ring orconnector751 constructed to have a rigidity greater than that of thesleeve750 and having a diameter that is larger relative to the stoma and preferably larger than the inner diameter of the upperstomal ring clip742, thus preventing thesleeve device750 from slipping through the stoma and moving downstream within the GI tract. Thesesleeve devices750 provide for a variable stomal diameter. For example, the devices shown are in a non-stressed state, and the sleeve can be made of a flexible or elastomeric material, and in this case the diameter of the stoma can actually increase if stretched by a large piece of food. This type ofsleeve750 is generally placed after the stoma orstomal ring clip740 is positioned. This can facilitate exchange of sleeves, for example, if a longer sleeve is considered desirable. In some embodiments thering connector751 on thesleeve750 will attach and secure to the upperstomal ring clip740.
• FIG. 71 shows the device ofFIG. 70 in situ. Thesleeve device750 shown inFIG. 70 can be used with a stoma (either created with fasteners alone, or created with fasteners and a stomal ring clip device740) to pass food from the mouth to someplace downstream within the GI tract, thus preventing the digestion.
• An added benefit of the device ofFIG. 70 is that when positioned in the stomach, as shown inFIG. 71, thesleeve device750 can completely cover astoma ring clip740, and thus prevent food from getting stuck and caught up in the ring and fasteners, thus improving the flow of food through the stoma.
• The devices may be positioned as follows, after the stoma is created (as previously discussed), a sleeve device is then passed through the mouth and into the stomach (as previously discussed for a stomal ring clip), and then the distal portion of the sleeve device is passed through the stoma and preferably past the pylorus and duodenum and the distal end is carried downstream within the GI tract (either pushed or via peristalsis), and the proximal end is eventually left to sit atop the stoma. The sleeve can be dimensioned, as described herein, to locate the restriction to food flow at the stomal ring clip or at some other more distal location. In other embodiments the sleeve diameter will not create the restriction and the restriction will use the pylorus as a natural restriction or the restriction will be created at the stoma ring clip. For additional security, the proximal end may be attached to the stoma by some means, perhaps clicking into place on a stomal ring clip designed to accept the proximal end of a sleeve device, sutured into place or attached using one of the other structures described herein.
• FIG. 72 illustrates another embodiment of asurgical instrument760 for fastening tissue. In one embodiment, thesurgical instrument760 is mounted on the exterior of a gastroscope or otherflexible endoscope730 with a mounting ring or clamp762. Thesurgical instrument760 has an articulatedarm764 with a plicator/riveter support766 having a pair of spaced apart supportfingers768 mounted to it. Aflexible control cable772, which extends to the proximal end of thegastroscope730, allows the operator to move the articulatedarm764 and plicator/riveter support766 axially and radially with respect to thegastroscope730. In certain embodiments, thesupport fingers768 include one or moreretractable tines770 for grasping and manipulating the tissue. Rivet-likesurgical fasteners780 are delivered with aninsertion pusher tube774 through the workingchannel732 of thegastroscope730.
• FIG. 73 is an exploded view of a rivet-likesurgical fastener780 for use with the surgical instrument ofFIG. 72. Thesurgical fastener780 has two components arivet tube782 and arivet cap wire788. Therivet tube782 can be made of a biocompatible polymer or metal. Therivet tube782 has a tapereddistal end786 aninternal lumen784 sized to allow passage of therivet cap wire788 in a straightened condition. In its deployed condition, therivet cap wire788 has astraight piercing section796 on its distal end, followed by thedistal button792, which is a section of the wire formed into a circle or spiral. Next, is a straightcentral section790 that connects thedistal button792 to theproximal button794, which is another section of the wire formed into a circle or spiral. In certain embodiments, therivet cap wire788 is made of a highly resilient material, for example a superelastic NiTi alloy, which can be preformed into this geometry by cold working and/or heat treatment, and which will return to this geometry after being straightened out for insertion through theinternal lumen784 of therivet tube782.Rivet tube782 can be constructed of a relatively bioinert material such as304 or316 SS or Ti unless the clinical situation suggests that a material that encourages a scar forming healing response as discussed earlier is desirable.
• Rivet tube782 will typically have an outer diameter of approximately 0.25-1.5 mm with the inner diameter large enough to provide for passage of a pre-formed NiTi wire of approximately 2×-6× the diameter of the wire. The tapered tip will preferably have a minimum clearance to allow free passage between its inner diameter and the outer diameter of the NiTi wire. Wall thickness oftube782 will typically be on the order of 0.002-0.005″.
• FIG. 74 shows thesurgical fastener780 ofFIG. 73 in a deployed condition. The straightcentral section790 of therivet cap wire788 extends through theinternal lumen784 of therivet tube782, and thedistal button792 andproximal button794 are formed into a substantially planar tissue-retaining geometry approximately perpendicular to therivet tube782 at the proximal and distal ends of therivet tube782. Thestraight piercing section796 may be bent inward slightly so that thedistal button792 protects it from inadvertently piercing any adjacent tissue structures when in the deployed condition.
• FIGS. 75A-75F show a sequence of steps for deploying thesurgical fastener780 ofFIGS. 73 and 74. Thetines770 of the plicator/riveter support766 grasp the tissue to be fastened, for example the stomach wall, and the articulatedarm764 draws it toward thegastroscope730 to plicate the tissue. Thesupport fingers768 of the plicator/riveter support766 are positioned astride the workingchannel732 of thegastroscope730. Asurgical fastener780 is advanced through the workingchannel732 of thegastroscope730 by theinsertion pusher tube774. Thesurgical fastener780 is positioned with the tapereddistal end786 of therivet tube782 facing distally and therivet cap wire788 straightened out and inserted through theinsertion pusher tube774 and through theinternal lumen784 of therivet tube782 with the straight piercingsection796 extending slightly beyond the distal end of therivet tube782.
• Thestraight piercing section796 of therivet cap wire788 pierces the plicated tissue, as shown inFIG. 75A. Then theinsertion pusher tube774 pushes the tapereddistal end786 of therivet tube782 through the tissue, as shown inFIG. 75B, until therivet tube782 has passed all the way through the tissue, as shown inFIG. 75C. Next, therivet cap wire788 is advanced until thedistal button792 reforms to retain the plicated tissue the distal end of therivet tube782, as shown inFIG. 75D. Theinsertion pusher tube774 is then withdrawn, as shown inFIG. 75E, allowing theproximal button794 to reform to retain the plicated tissue the distal end of therivet tube782. The fully deployedsurgical fastener780 holding the plicated tissue is shown inFIG. 75F.
• The construction of thesurgical fastener780 allows it to be removed if it is desired to reverse or revise the surgical procedure.FIG. 76 shows thesurgical fastener780 ofFIG. 73 being removed. A grasping tool or other rivettube retaining tool752 engages the proximal end of therivet tube782 and agrasper756 grasps therivet cap wire788 near its proximal and withdraws it from therivet tube782 to release the fastened tissue.
• The attachment device and fasteners described inFIGS. 72-76 share many attributes with the attachment device and fasteners described inFIGS. 49-65. With appropriate design adjustment features of the attachment devices and fasteners can be combined and/or interchanged.
• FIGS. 89A-89D shows analternate rivet design870 in which therivet tube872 is provided with an attached or formed in placeproximal rivet cap874. Theproximal rivet cap874 can be formed as described earlier or formed as shown inFIG. 89A.FIG. 89B shows a multi fingereddistal cap876 that can be deployed by an axial advancement of the fingers, as shown inFIG. 89C. With a design that includes a proximal eye or other means of coupling, the fingers could also be retracted back into therivet body872 if so desired. Thefingers876 of this rivet do not require the degree of superelasticity of the rivets described inFIGS. 72-79 and could optionally be made from 304, 316 or other stainless steels in addition to NiTi alloys, as well as other metals.FIG. 89D shows anexemplary apparatus878 for deploying this type of rivet.
• FIG. 77 shows a top view of anattachment ring device800 for attaching a gastrointestinal sleeve device within a patient's stomach.FIG. 78 shows a cross section of theattachment ring800 ofFIG. 77 attached at a plication formed in a stomach wall of a patient. Theattachment ring device800 provides strain relief to distribute the stress of attachment to a substantial area of the stomach wall. Theattachment ring device800 has a first,outer ring802 that engages and seals against the stomach wall. A second, slightlysmaller diameter ring804 is connected to thefirst ring802 by a first annular sheet ofmaterial806 that can support and seal to the sleeve interface. Thefirst ring802 and thesecond ring804 are preferably wire-reinforced plastic rings. Suitable materials for the first annular sheet ofmaterial806 include, but are not limited to, polyurethane, silicone and Teflon. Inside of thesecond ring804 is a second annular sheet ofmaterial808 that is easily pierced with a surgical fastener, such as thesurgical fastener780 previously described, or other surgical rivet, staple or suture. Suitable materials for the second annular sheet ofmaterial808 include, but are not limited to, Teflon fabric, Goretex or Marlex or materials commonly used for vascular grafts. The second annular sheet ofmaterial808 may be slit or perforated to enhance the flexibility of the fabric.
• FIG. 79 shows a cross section of theattachment ring device800 ofFIG. 77 with agastrointestinal sleeve device400 installed. Thegastrointestinal sleeve device400 has asleeve ring810 that is sized to have a diameter slightly smaller than or the same size as thefirst ring802 and slightly larger than the diameter of thesecond ring804. Thesleeve ring810 is preferably a wire-reinforced plastic ring that may be somewhat more rigid thanfirst ring802 and thesecond ring804. For installation, thesleeve ring810 is compressed slightly so that it can slip past thefirst ring802, then it is allowed to expand so that it engages and seals against the first annular sheet ofmaterial806 between thefirst ring802 and thesecond ring804.
• Some configurations of attachment rings, such as the one illustrated inFIG. 79, could be placed with a stapling device similar to circular anastomotic staplers. In this method, the stapling device would be placed via a peroral route with the attachment ring preferably pre-positioned on the stapling device. The device would then use suction, stay sutures or other mechanical means to draw gastric wall into the gap between the anvils of the stapling device in a manner that forms a plication adjacent to the attachment ring. Dimensioning of the device can be selected to obtain stapling within the muscularis or a full thickness plication that also goes through the serosa as indicated by the clinical situation. Firing of the stapling device would then result in an attachment similar to that shown inFIG. 78 with the substitution of the rivet as shown with one or more rows of staples. One embodiment of the stapling device would include a tilting or collapsible distal anvil that could be withdrawn through the stapled in-place attachment ring after the completion of the stapling procedure. Buttressing of the staples with bovine or porcine tissue, Teflon pledges or other buttressing material, may be indicated in some clinical situations.
• A leak shield may be used with any of the gastrointestinal sleeve devices described herein to help assure an adequate seal between the sleeve and the stomach wall at the proximal end of the device. The leak shield may be a separate component or it may be integral to the gastrointestinal sleeve device or to the attachment device.FIG. 80 shows a cross section of theattachment device800 and thegastrointestinal sleeve device400 ofFIG. 79 with anoptional leak shield812 installed. Theleak shield812 in this example is constructed integrally with thegastrointestinal sleeve device400. Theleak shield812 is a tubular extension of thegastrointestinal sleeve device400 that has a resilientleak shield ring814 at its proximal end. Theleak shield ring814 is preferably a wire-reinforced plastic ring. Theleak shield812 may be made of the same material as thegastrointestinal sleeve device400 or, more preferably, it may be made of a material chosen for its ability to provide a reliable seal against the stomach wall such as silicone, polyurethane or other flexible film. It would be expected that the material of the leak shield would generally be of equal or greater flexibility and equal or lower durometer than the sleeve due to the desire for it to conform and seal as well as the lower forces it would be expected to withstand without failure.
• FIG. 81 shows a top view of another embodiment of anattachment ring device820 for attaching a gastrointestinal sleeve device within a patient's stomach.FIG. 82 shows a side view of theattachment ring device820 ofFIG. 81, which, by way of example, is shown attached between two plications formed in a stomach wall of a patient. Theattachment ring device820 could alternately be attached to a single plication. Theattachment ring device820 has a first,outer ring822 that engages and seals against the stomach wall. A second, slightlysmaller diameter ring824 is connected to thefirst ring802 by a first annular sheet ofmaterial826 that is easily pierced with a surgical fastener, such as thesurgical fastener780 previously described, or other surgical rivet, staple or suture. Athird ring830 is connected to thefirst ring802 by a second annular sheet ofmaterial828 that can support and seal to the sleeve interface. Thefirst ring822,second ring824 andthird ring830 are preferably wire-reinforced plastic rings.
• The double plication illustrated inFIG. 82 as a structure and method of attaching a device can be a preferred embodiment in certain clinical situations. As mentioned previously in relation toFIGS. 43-45 the use of a plication can confer certain advantages to an attachment structure and method. All of these advantages also exist with a device attached between a double plication. The geometry created by the capture of a device in a double plication is analogous to the placement of an o-ring in a grove. Though not 100% encapsulation, tissue would be in contact with the implanted ring on three sides that would improve the leak resistance of the attachment. The use of the double plications would also serve to stabilize the attachment and result in a favorable distribution of forces that might be transmitted to the ring as a result of its connection to a sleeve and/or stoma. A further advantage of the double plication attachment would be the doubling of the tissue attachment area. This would serve to distribute the forces transmitted to the ring over double the area resulting in a lowering of the pressure applied to the tissue. Clinically, suture and other attachment failure can often be attributed to localized ischemia and ischemia can be related to the pressure applied to the tissue by the suture or fastener. Therefore, if a double plication may reduce the pressure transmitted to the tissue by the attachment means, attachment failure will be reduced.
• In a related aspect of an embodiment that could be clinically preferred, one should consider that when suturing or otherwise securing an attachment ring or other device in place it is beneficial to reduce the pressure transmitted to the tissue. This has been discussed previously related to the use of force distributing pledgets, fastener structures and rivet end caps. These previously discussed structures and methods relate to reducing pressure along the axis of the fastener system. The double plication addresses pressures that are perpendicular or radial to the axis of the fastener. Increased fastener diameter would serve to reduce pressures in this direction however one can imagine that this would eventually have diminishing returns, as the area of tissue available to resist these forces would eventually be reduced below an optimum level. With single and double plications and a fastener system that uses thin wires or sutures approximately between 0.2 and 0.5 mm in diameter or less, a simple method and structure to reduce pressure would be use of an increased fastener density. In particular, use of paired parallel fasteners is well suited to this end. One method would apply a single continuous suture or wire that passed through all layers to be fastened and then secured at one point. Of course two separate sutures or wires could then be secured to each other on either side of the layers to be attached. Alternately, the two separate sutures or wires could be secured by, and/or to, a common end cap. A pair of thin rivets could also use a common end cap to achieve this end.
• In another aspect the embodiment ofFIGS. 81 and 82 can be modified to include two or more easily pierced material faces826 and their associated rings822. For example, using a 3 faced ring in the double plication attachment ofFIG. 82 where the material faces are sandwiched around both plications such thatrivets780 would pierce3 layers of the face material in addition to 4 layers of stomach wall. InFIG. 91B a 2 faced ring is shown attached with a T-pledget fastener as described herein. In an alternate variation the attachment ring shown inFIGS. 77 and 78, the easily piercedmaterial808 can be lengthened to a sufficient length to fold over the plication and be in a position to buttress therivet780 inFIG. 78 on both sides of the plication. Other structures can accomplish the same result.
• In an additional aspect of the method of using the attachment ring shown820 inFIGS. 81 and 82,FIG. 91A shows how this type of attachment ring could be attached using a transmural T-Tag918. In some clinical situations it may be desirable to have additional attachment in which case one method to achieve this result would be to use two rows of T-tags918 in a variation of what is shown inFIG. 91A. In this example the material face826 (betweenrings822 and824) can have an increased width to provide additional room for the attachment of the additional row of T-Tags.
• FIG. 83 shows a cross section of theattachment ring device820 ofFIG. 81 with agastrointestinal sleeve device400 installed. Thegastrointestinal sleeve device400 has asleeve ring810 that is sized to have a diameter slightly smaller than or the same size as thesecond ring824 and slightly larger than the diameter of thethird ring830. For installation, thesleeve ring810 is compressed slightly so that it can slip past thesecond ring824, then it is allowed to expand so that it engages and seals against the second annular sheet ofmaterial828 between thesecond ring824 and thethird ring830. Optionally, an integral or separate leak shield may be used with this embodiment of theattachment ring device820.
• Optionally, magnets can be used to facilitate alignment of theattachment ring device820 and thegastrointestinal sleeve device400. One or more magnets would be positioned in theattachment ring device820 and an equal number of magnets, arranged with opposite poles facing, would be positioned in thegastrointestinal sleeve device400, When theattachment ring device820 and thegastrointestinal sleeve device400 are moved into proximity with one another, the magnets cause the two components to align automatically. The magnets will also help to create and maintain a seal between the two components.
• The structures and methods associated withFIGS. 77-83 can also be applied to other attachment methods and structures as described herein. Examples include 1) incorporating the structure ofFIG. 77 or81 could be incorporated into a stoma ring clip; 2) attaching these rings with T-tags in place of rivets and 3) use of multiple rows of attachment in place of a single row as shown.
• FIGS. 84A-84C show agastrointestinal sleeve device400 with anintegral leak shield812 similar to that shown inFIG. 80.FIG. 84A shows a cross section of the proximal end of thegastrointestinal sleeve device400 with theleak shield812 in a deployed position. In some clinical situations, theleak shield ring814 has a diameter slightly larger than the diameter of thesleeve ring810. For installation, theleak shield ring814 is compressed slightly and stuffed past thesleeve ring810 into the proximal end of thegastrointestinal sleeve device400, as shown inFIG. 84B so that it will not interfere with the installation of thesleeve ring810. Once thesleeve ring810 has been installed in the chosen attachment ring device, agrasper734 is inserted through the workingchannel732 of thegastroscope730 to grasp theleak shield ring814 and pull it out of thegastrointestinal sleeve device400 to the deployed position, as shown inFIG. 84C.
• FIG. 85 illustrates the components of a kit for delivering and deploying a gastrointestinal sleeve device. In one embodiment, the kit includes anoptional guidewire840, a pyloric/duodenal introducer850, and either adistal pusher catheter852 or adistal balloon seal856 andpusher catheter854. Aballoon catheter860 for removal of the gastrointestinal sleeve device may be included as part of the kit or supplied as a separate item. For example this balloon catheter can be used for retrieval as described in step12 of the method outlined below. As an alternative to the use of a balloon catheter for retrieval, an endoscopic grasper such as those in the MAXUM line (Wilson-Cook) can be passed coaxially down the sleeve or delivered externally to the sleeve through the working channel of an endoscope then clamped onto the sleeve at some distal location and then used to retract the distal sleeve.
• The pyloric/duodenal introducer850 has atubular body844 with anintroducer lumen846 sized to pass through the gastrointestinal sleeve device. Thetubular body844 has a length sufficient to reach past the patient's pylorus into the duodenum via a peroral route. In certain embodiments, thetubular body844 has a slit floweringdistal end848 for atraumatic crossing of the pylorus. An optionaldistal infusion lumen842 parallels theintroducer lumen846 and allows infusion of fluids near the distal end of theintroducer850. For example, the introducer can be used as described in step10 g of the method outlined below.
• FIGS. 86A-86C illustrate three options for preloading agastrointestinal sleeve device400 for delivery and deployment.FIG. 86A shows agastrointestinal sleeve device400 in a straight configuration. This configuration is the simplest for construction and loading of thegastrointestinal sleeve device400, however it poses some challenges for delivery and deployment within the patient's gastrointestinal system. The straightgastrointestinal sleeve device400 would have to be inserted full-length into the patient's small intestines, which would be challenging because of the torturous path of the small intestines. Another strategy is to invert thegastrointestinal sleeve device400 so that it would only have to be directly inserted past the patient's pylorus, with peristaltic action assisting the deployment of the device within the patient's small intestines by eversion of the inverted sections.FIG. 86B shows agastrointestinal sleeve device400 loaded in a fully inverted configuration.FIG. 86C shows agastrointestinal sleeve device400 loaded in a double-inverted configuration. This simplifies the delivery and deployment of the device, but it adds some additional constraints to the configuration of the device. The inverting segments can have very thin walls and inverting interfaces can be highly lubricious for easy and reliable deployment. For example blow molded 90A durometer polyurethane of a wall thickness on the order of 0.005″ or less, most preferably about 0.002″, with a lubricious coating will work in this manner. The double inverted configuration has the advantage of having the option to use a distal balloon, or other structure as described earlier, to assist the peristalsis working on its distal end to evert the sleeve. This may avoid the need to use internal pressure to accomplish the eversion.
• Thegastrointestinal sleeve device400 inFIGS. 86B and 86C could be optionally everted using the method of internal pressurization that is well known in the everting catheter art. To maintain the internal fluid pressure used to assist in everting the invertedgastrointestinal sleeve device400, the distal end of the device may be temporarily sealed during deployment.FIGS. 87A-87D illustrate four options for sealing the distal end of a gastrointestinal sleeve device during delivery and deployment.FIG. 87A shows the inverted distal end of thegastrointestinal sleeve device400 sealed with abiodegradable tie900 that is formulated to dissolve within approximately 24 hours in the intestines. Dissolution of thebiodegradable tie900 can be aided by a solvent or active agent that is ingested or placed in the optional everting fluid.FIG. 87B shows the noninverted distal end of thegastrointestinal sleeve device400 sealed with abiodegradable tie900 that is formulated to dissolve within approximately 24 hours in the intestines.FIG. 87C shows aninflatable balloon902 that extends past the distal end of thegastrointestinal sleeve device400. Thegastrointestinal sleeve device400 can be attached and/or sealed with abiodegradable tie900 proximal to theballoon902. Theballoon902 is carried along through the intestine by peristalsis to deploy thegastrointestinal sleeve device400 by eversion of the inverted section. When thebiodegradable tie900 dissolves, theballoon902 detaches and deflates and is carried harmlessly out through the intestines. Theinflatable balloon902 may also be made of a biodegradable material.FIG. 87D shows aballoon catheter904 with aninflatable balloon906 that is inflated within thegastrointestinal sleeve device400 to form a seal. Once thegastrointestinal sleeve device400 is fully deployed, theballoon906 is deflated and theballoon catheter904 is withdrawn. Please note that the aforementioned 24 hour dissolution time is an example and, depending on the clinical situation, this time period could range from a few hours to many weeks.
• FIGS. 88A-88B illustrate a method of delivering and deploying agastrointestinal sleeve device400. First, anattachment ring device800 or the like is installed in the patient's stomach using any of the devices and methods previously describe, as shown inFIG. 88A. Subsequently, the pyloric/duodenal introducer850 with thegastrointestinal sleeve device400 loaded into it is inserted through the patient's pylorus via a peroral route, as shown inFIG. 88B. In this example, the proximal portion of thegastrointestinal sleeve device400 is external to the pyloric/duodenal introducer850 and the distal portion of the sleeve is double inverted inside of theintroducer850 similar to the sleeve shown inFIG. 87C. Thesleeve ring810 is installed in theattachment ring device800 and the pyloric/duodenal introducer850 is withdrawn. Then, using a combination of fluid pressure, a push rod orcatheter854 inside of thegastrointestinal sleeve device400 and/or peristalsis of the intestines, optionally assisted by an inflatable balloon on the catheter or a biodegradably attacheddistal peristalsis balloon902, thegastrointestinal sleeve device400 everts to a fully deployed position.
• Attachment devices and fasteners are described inFIGS. 49-65,72-76 etc. These attachment devices include means and structures to facilitate attachment using a purely peroral approach. An alternate method for employing these devices could include assistance via a laparoscopic approach. This could be indicated in certain clinical situations to facilitate location of a ring of other structure for attachment as well as invaginating tissue to form a plication and stabilizing the tissue and ring for attachment. This can be particularly useful in the case of double plications
• FIG. 90A illustrates an example of a laparoscopically introduced device that works from the outside of the stomach to assist in the formation of a double plication and the stabilization and attachment of aring device820.Laparoscope880 is used to guide one or more laparoscopic tools. Onesuch tool882 is shown capturing aring device820 between a fold of tissue that folds mucosa-to-mucosa rather than serosa-to-serosa. Positioning offastener delivery device760 folds the gastric wall to form two serosa-to-serosa plications. A fastener can then follow a path through both the plications and thering820, which may be configured similar to the ring inFIGS. 81 and 82.FIG. 90B shows the distal structure of atool884 which includes an upperbifurcated fork886 and lowerbifurcated fork888. The two forks can move relative to each other to capture tissue and/or apparatus while the use of a bifurcated fork allows their withdrawal after placement of one or more fasteners.
• FIG. 95 illustrates a method for placing some configurations ofattachment ring820, such as the one illustrated inFIG. 81, using laparoscopic and standard stapling techniques. In this embodiment and method thedevice820 is captured within a single plication that is formed by folding the stomach wall over the device so that mucosa is in contact with the attachment area821 of the device. This attachment portion821 of the device can optionally be porous or have open area to allow mucosa to mucosa contact. This area could be made from a PTFE graft material, a polyester (Marlex) mesh or other material with natural or formed openings if tissue contact is desired. In this method a laparoscope, external to the stomach, can be used to guide attachment of the device through the gastric wall. Standardlaparoscopic stapling devices890 can be used for this application, as can sutures or other attachment means. Buttressing of the attachment as described herein may be indicated in some clinical situations.
• The following outline gives a more detailed description of one example of a method for delivering and deploying an embodiment of a gastrointestinal sleeve device.
• This procedure assumes a specific device configuration. Many other device configurations are possible and therefore some aspects of this procedure may have to be modified to accommodate other configurations. Device details are as follows:
• • 1 Ring
    • a Initially parachuted into place on stay sutures
    • b Definitively attached with rivets and riveter, rivet position is not preset by holes
  • 2 Sleeve (mating rings with or without magnet)
    • a Lock sleeve into place
    • b Leak shield attached to sleeve with self-expanding ring
    • c A distal delivery balloon that deflates/detaches/dissolves in 2-5 days
  • 3 Sleeve delivery using
    • a Gastroscopic placement of a guide wire in the duodenum
    • b An over the guidewire sleeve and duodenal introducer
    • c Everting mid-sleeve deployment as it extends distally
    • d A RO distal balloon to advance the distal sleeve by peristalsis
  • 4 Sleeve removal using
    • a A “swallowable” retrieval balloon catheter
    • b Balloon advances to the distal sleeve by swallowing water for propulsion
    • c Balloon is inflated to wedge against the walls of the sleeve
    • d Balloon catheter is withdrawn as the proximal sleeve is withdrawn
  • 5 Sleeve replacement by repeating3
  • 6 Ring removal by
    • a Unravelling rivet heads
    • b Retrieving the ring with a gastroscope and grasper
      Peroral Gastric Bypass Procedure:
  • 1 Patient sees physician for referral or self-refers to an interventionist
    • a. Open surgeon (present)
    • b. Laparoscopic surgeon (present)
    • c. Endoscopist (future)
  • 2 Patient is referred to Surgeon/Endoscopist
  • 3 Work up is done by support staff
  • 4 Patient must qualify
    • a. Psychologically
      • i. Relaxed requirements (compared to current gastric surgery procedures)
    • b. Medically
      • i. Relaxed requirements (compared to current gastric surgery procedures)
        • 1. Marginal BMI's (e.g. <35)
        • 2. Super obese
    • c. Financially (for reimbursement or self-pay)
      • i. Should cost less that surgery
  • 5 Patient is seen by Doc performing procedure
  • 6 Pre-op counseling
  • 7 Pre-op regime for weight loss prior to surgery
    • a. Nothing, not needed for peroral procedure
  • 8 Implant sleeve mounting ring
    • a. Check vitals etc.
    • b. Sedation
    • c. IV
    • d. Anesthesia
      • i. May be required for ring attachment
      • ii. Should not be required for most patients for sleeve procedures
    • e. Prep.
    • f. Place esophageal tube
    • g. Place endoscope in stomach
    • h. Place stay suture
      • i. Identify locations by anatomical land marks
      • ii. Pass suturing device through scope or tube
      • iii. Take bite(s) at location1, bring suture ends out of mouth
      • iv. Repeat h (ii & iii) forlocations2,3 &4
    • i. Position ring
      • i. Attach stay sutures to ring
      • ii. Fold ring for passage through sleeve
      • iii. Pass ring through sleeve under direct vision using gastroscope
      • iv. Secure stay sutures to position ring along gastric wall by GEJ
        • 1. Ring design will facilitate forming plications in the gastric wall
        • 2. Ring design will place gastric wall in position for riveting
        • 3. Stay sutures can be tied and trimmed in place
    • j. Attach ring
      • i. Pass riveting device through or along scope through tube
        • 1. Scope to include channel for grasper or other device
        • 2. Position riveter for attaching rivet
        • 3. If necessary use grasper to position gastric wall at rivet site
        • 4. Fire riveter
        • 5. Repeat j(i)2-4 as required
    • k. Leak test
      • i. Place mock sleeve in ring (to seal ring opening)
      • ii. Pressurize to leak test
      • iii. Remove mock sleeve
    • l. Remove scope & instruments
    • m. Remove tube
  • 9 Wait approximately one month for the ring attachment to heal
  • 10 Hang sleeve
    • a. Check vitals etc.
    • b. Sedation (no anesthesia)
    • c. IV
    • d. Prep. Place esophageal tube
    • e. Insert gastroscope to check ring
    • f. Advance gastroscope to duodenum
      • i. Place guidewire in duodenum
      • ii. Remove and replace scope (alongside the guidewire)
    • g. Insert sleeve (sleeve comes pre-positioned on duodenal introducer)
      • i. Inflate distal balloon
      • ii. Thread system over guidewire
      • iii. Advance through esophageal tube
      • iv. Advance to system to duodenum under direct vision
      • v. Pull back gastroscope proximal to ring
      • vi. Advance system into duodenum (˜2-5 cm) to seat sleeve in ring
        • 1. Manipulate sleeve to mate with ring using grasper as required
      • vii. Advance distal and mid sleeves to jejunum (I)
        • 1. Pressurize duodenal introducer
        • 2. Mid-sleeve everts under pressure (maybe 20-40 cm)
        • 3. Advancement of mid-sleeve advances distal sleeve
        • 4. Remove duodenal introducer and guidewire
        • 5. Allow peristalsis to advance distal sleeve balloon
    • OR
      • v. Advance distal and mid sleeves to jejunum (II)
        • 1. Use pusher to advance distal sleeve under fluoro (balloon acts as bumper)
        • 2. Remove duodenal introducer, guidewire & pusher
        • 3. Allow peristalsis to advance distal sleeve
    • h. Deploy leak shield
      • i. Manipulate leak shield out of sleeve using grasper as required
      • ii. Uniformly position leak shield using grasper as required
    • i. Leak test
      • i. Place balloon catheter in proximal sleeve
      • ii. Inflate balloon to seal sleeve opening
      • iii. Pressurize to leak test
      • iv. Deflate and remove balloon catheter
    • j. Remove scope & instruments
    • k. Wait 2-4 days
      • i. Balloon dissolves/detaches/deflates
    • l. Wait approximately 2 weeks and observe for complication
      • i. Adjust stoma by one of the methods described herein (if the device is configured to include an adjustable restrictive stoma)
  • 11 Remove sleeve (e.g. to be performed after a therapeutic period)
    • a. Check vitals etc.
    • b. Sedation (no anesthesia)
    • c. IV
    • d. Swallow removable balloon catheter
    • e. Drink copious amounts of water
    • f. Check balloon position fluoroscopically
    • g. Position gastroscope (with retrieval tool)
    • h. Grasp sleeve at leak shield ring or mating ring
    • i. Inflate removal balloon
    • j. Pull out scope, sleeve and removal balloon simultaneously
  • 13 Replace sleeve
    • a.Repeat 10, 11 and 12 as required
  • 14 Remove ring
    • a. Check vitals etc.
    • b. Sedation (anesthesia should not be required)
    • c. IV
    • d. Prep.
    • e. Place esophageal tube
    • f. Place endoscope in stomach
    • g. Pass rivet removal tool through tube
    • h. Locate rivets and remove heads
    • i. Using grasper pull ring away from gastric wall
    • j. Pull ring into tube (it should fold as it enters the tube)
    • k. Visually examine stomach at site of ring
    • l. Remove scope, instruments and tube
• In an alternate embodiment, all or part of the sleeve device could be constructed from a biodegradable polymer as described herein. This would obviate the need for removal of the sleeve device at the end of the treatment period. Material selection and/or selective coatings of the exterior of the biodegradable sleeve could control the rate of dissolution/degradation of the sleeve in the presence of the differing chemical environments found at different locations along the alimentary tract. For example a Parylene coating in the sleeve in the stomach, pylorus and duodenum could inhibit the effects of the stomach acids. This would be less of an issue after these acids mix with the basic secretions of bile in the duodenum an beyond in the jejunum.
• Morbid obesity endoscopic transgastric diaphragmatic attachment, a.k.a. Gastropexy attachment, and apparatus are described for attaching devices and/or securing tissue at or near the gastroesophageal junction and cardia of the stomach. The method and apparatus allow attachment to include securing the tissue and/or device to the diaphragm and/or connecting the diaphragm to the esophagus via a peroral endoscopic approach. Attaching tissue to the diaphragm is common in Nissen fundoplication surgery using conventional methods.
• A fastener or other attachment structure can be passed through the gastric wall and through the diaphragm while manipulating surrounding tissue, including the esophagus and the lungs, to avoid damage to these tissues.
• FIG. 92 illustrates agastropexy apparatus910. The apparatus can include anendoscope911 with a distraction means912, transillumination means913, and securingmeans914 slidably mounted on the endoscope with acontrol tail915 to control the position of these components along theendoscope911. A fastener delivery/deployment device916 is insertable through working channel ofendoscope911. The transillumination means913 may be an LED or optical fiber. The optical fiber can be plastic or glass. The wavelength of light used for transillumination can be a visible wavelength selected for penetration of tissue.
• The embodiment ofFIG. 92 shows a balloon as the distraction means912, suction as the securing means914 and an LED as the transillumination means913 for aiming the fastener delivery/deployment device916. The combination of distraction and securing the esophageal wall creates a pocket into which afastener918 can be safely deployed. Transillumination through the tissue structures, i.e. the esophageal wall, diaphragm and gastric wall, is a preferred, though not required, method to aim the fastener delivery/deployment device916. Alternatively of in addition, an ultrasound imaging or location device can be mounted on the device or externally.
• A standard flexible endoscope may be used with the distraction means, securing means and optional transillumination means being incorporated into a device that can be removably attached to the endoscope. Alternatively, these features can be incorporated into a combined endoscope device.
• Various types of fasteners, including those described elsewhere in this specification, can be used in this method. T-type or other expanding-head or deployable fasteners are preferable. Fasteners can include features that allow: 1) placement of the fastener, 2) removal of the delivery/deployment device, 3) positioning or actuation of a fastener attachment means, and 4) if necessary, removal of excess material from the fastener.
• After delivery/deployment of the distal T of thefastener918 in the safe zone above the diaphragm, the delivery/deployment device916 can then be removed. An attachment means can be advanced into position over the proximal tail of thefastener918, which extends through theendoscope911. The fastener attachment means can screw, crimp, snap or otherwise attach to the attachment zone of the fastener. An additional device may or may not be required for delivering and attaching the fastener attachment means, depending on the attachment mechanism utilized. Excess material, including the proximal tail, can then be cut otherwise detached and removed.
• The method of use could involve the steps of: 1) advancing the distal tip of the endoscope into contact with the gastric wall, 2) continuing to advance the endoscope until the gastric wall contacts the diaphragm, 3) manipulating the endoscope to visualize the transillumination means, and 4) actuating the fastener. The method may also involve the use of stay sutures to preposition a device for attachment. These stay sutures could be used optionally to parachute the device into position through the esophagus.
• One possible method for gastropexy attachment would be performed as follows:
• • 1. Position endoscope overtube
  • 2. Attach gastropexy protector (GP) to exterior of endoscopy and attach required accessories (suction, light source, inflation syringe). Calibrate delivery device advancement stop.
  • 3. Insert endoscope (1-channel) with mounted GP
  • 4. Turn on transillumination (TI) light to transmit light through an optical fiber, or bundle.
  • 5. Position scope so GP is positioned just above the diaphragm. Position scope for T-tag gastropexy. View TI light to assist in positioning.
  • 6. Apply suction to esophagus
  • 7. Inflate GP protection balloon
  • 8. Confirm scope position with TI light and advance T-tag deployment device with its integrated tissue protector to the gastric wall. Continue advancing device until exterior of the gastric wall contacts the diaphragm
  • 9. Reconfirm scope position with TI light, retract tissue protector, pass T-tag delivery cannula through the diaphragm until the advancing stop is reached and using T-tag device, deploy T-tag in safe zone above diaphragm
  • 10. Retract T-tag deployment device out through diaphragm
  • 11. Release vacuum
  • 12. Deflate balloon
  • 13. Remove scope and position tails externally
  • a. Repeat steps 5-13 6 times
  • 14. Pre-thread T-tag tails sleeve ring
  • 15. Prepare to parachute sleeve ring through over tube and pass sleeve ring through overtube.
  • 16. Snug T-tag tails to position device(s) and ready for final attachment
  • 17. Using tails, guide the T-tag securement caps (crimp, snap or screw) into position and secure in place (Repeat 6 times)
  • 18. Trim tails and remove all instrumentation
• Optionally, the gastropexy apparatus may also include a delivery device tip protector. The delivery device tip protector can be a removable obturator that is coaxial with an exemplary hollow needle introducer. The obdurator is removed after the delivery cannula is in place and replaced with a T-tag deployment mechanism and its associated T-tag(s)
• Additionally, the gastropexy apparatus may include a delivery device advancement stop. The stop can be a structure that can be adjustably fixed to a position on the proximal portion of the T-tag delivery device that is connected to and thereby controls the position of the degree to which the T-tag delivery cannula extends from the distal end of the endoscope. This could be a collar with a thumbscrew lock
• Description of the calibration of the advancement stop procedure—Attach the GP to the endoscope; bend the endoscope so that the distal tip of the scope aligns with the transillumination light; extend the T-tag delivery cannula until it is a set distance from the transillumination light (on the order of 0.25″ or 6 mm); position advancement stop against the working channel proximal port; then secure advancement stop. Confirm calibration of advancement stop by straightening and re-bending the scope then adjusting the position of the stop if necessary.
• While the present invention has been described herein with respect to the exemplary embodiments and the best mode for practicing the invention, it will be apparent to one of ordinary skill in the art that many modifications, improvements and subcombinations of the various embodiments, adaptations and variations can be made to the invention without departing from the spirit and scope thereof.

Claims (42)

1. A method of treating a patient, comprising the steps of:

providing an elongate tubular body, having a proximal end, a distal end, and a flow restrictor; and

positioning the tubular body in the patient such that the distal end is in the intestine, and the flow restrictor is in the stomach, spaced apart from the pylorus.

2. A method of treating a patient as inclaim 1, wherein the flow restrictor comprises a narrowing in the tubular body.

3. A method of treating a patient as inclaim 1, wherein the flow restrictor comprises an orifice.

4. A method of treating a patient as inclaim 1, wherein the flow restrictor is adjustable.

5. A method of treating a patient as inclaim 1, wherein at least a portion of the tubular body is releasably coupled to the flow restrictor.

6. A method of treating a patient as inclaim 1, further comprising the step of attaching the tubular body to the wall of the stomach.

7. A method of treating as inclaim 6, wherein the attaching step comprises using a suture.

8. A method of treating a patient as inclaim 7, wherein the attaching step comprises suturing the tubular body to the wall of the stomach.

9. A method of treating a patient as inclaim 7, wherein the attaching step comprises attaching the tubular body to a tissue anchor with the suture.

10. A method of treating a patient, comprising the steps of:

establishing a flow restriction within the stomach, in between the LES and pylorus; and

positioning a tube between the flow restriction and the intestine.

11. A method of treating a patient as inclaim 10, wherein the positioning step comprises positioning the tube such that it extends from the flow restriction and into the intestine at least as far as the ligament of Treitz.

12. A method of treating a patient as inclaim 10, wherein the establishing a flow restriction step comprises inserting a prosthetic stoma.

13. A method of treating a patient as inclaim 10, wherein the establishing a flow restriction step comprises creating a stoma from adjacent tissue.

14. A method of treating a patient, comprising the steps of:

providing a tube, having a proximal end, a distal end and a lumen extending therethrough;

positioning the proximal end in the stomach and the distal end in the intestine; and

preventing gastric juices expressed from the wall of the stomach distally of the proximal end from entering the lumen.

15. A method of treating a patient as inclaim 14, wherein the positioning step comprises positioning the distal end in the jejunum.

16. An endolumenal bypass method for treating obesity in a mammal, comprising the steps of:

establishing a pseudo stomach within the mammal, having a restricted distal opening;

establishing a flow path between the restricted opening and a point in the intestine distal to the duodenum.

17. An endolumenal bypass method as inclaim 16, wherein the establishing a flow path step comprises deploying a tubular sleeve within the intestine.

18. An endolumenal bypass method as inclaim 16, wherein the establishing a flow path step comprises securing opposing tissue surfaces together.

19. An upper gastrointestinal implant, comprising:

an elongate, tubular body, having a proximal end and a distal end;

a funnel opening on the proximal end; and

a support structure, spaced distally apart from the proximal end;

wherein the implant is dimensioned such that the proximal end is positioned in between the antrum and the lower esophageal sphincter when the support structure is positioned in the antrum.

20. An upper gastrointestinal implant as inclaim 19, wherein the support structure comprises a self expandable ring.

21. An upper gastrointestinal implant as inclaim 19, wherein the support structure comprises a longitudinally oriented stiffening member.

22. An upper gastrointestinal implant as inclaim 19 further comprising an intestinal extension.

23. An upper gastrointestinal implant as inclaim 22, wherein the column strength of the implant is greater in between the support structure and the proximal end than it is in the intestinal extension.

24. A method of treating a patient, comprising the steps of:

providing an elongate tubular body, having a proximal end and a distal end:

positioning the tubular body such that the proximal end is within the stomach and the distal end is in the intestine; and

retaining the tubular body in position by engaging an anchor on the tubular body with adjacent tissue;

wherein the anchor is spaced distally apart from the proximal end of the tubular body.

25. A method of treating a patient as inclaim 24, wherein the providing step comprises providing a tubular body having a flow restrictor.

26. A method of treating a patient as inclaim 25, wherein the flow restrictor comprises a narrowing in the tubular body.

27. A method of treating a patient as inclaim 25, wherein the flow restrictor comprises an orifice.

28. A method of treating a patient as inclaim 25, wherein the flow restrictor is adjustable.

29. A method of treating a patient as inclaim 25, wherein at least a portion of the tubular body is releasably coupled to the flow restrictor.

30. A method of treating a patient as inclaim 25, further comprising the step of attaching the tubular body to the wall of the stomach.

31. A method of treating as inclaim 30, wherein the attaching step comprises using a suture.

32. A method of treating a patient as inclaim 31, wherein the attaching step comprises suturing the tubular body to the wall of the stomach.

33. A method of treating a patient as inclaim 31, wherein the attaching step comprises attaching the tubular body to a tissue anchor with the suture.

34. A method of treating a patient as inclaim 24, wherein the retaining step comprises engaging the anchor within the antrum.

35. A method of treating a patient as inclaim 24, wherein the retaining step comprises engaging the anchor within the pylorus.

36. A method of transesophageally deploying a tubular implant within a patient, comprising the steps of:

providing a tubular implant, having a proximal end, a distal end, and a central lumen; the distal end initially positioned within the central lumen such that the distal most aspect of the implant is initially an intermediate portion of the implant;

transesophageally advancing the implant, intermediate portion first, through the stomach at least as far as the antrum; and

everting the distal end of the implant from the central lumen and into the intestine.

37. A method of increasing the effective length of an endolumenal intestinal bypass, comprising the steps of:

positioning an endolumenal bypass tube within an intestine such that a distal end of the bypass tube is initially positioned at a first point in the intestine;

anchoring the tube against distal migration with respect to the stomach; and

permitting peristalsis to draw the intestine proximally with respect to the tube, thereby locating the distal end at a position within the intestine which is distal to the first point.

38. A method of positioning a tubular implant within an intestine of a patient, comprising the steps of:

providing an elongate, tubular body, having a proximal end, a distal end, and a first magnet secured to the distal end;

transesophageally introducing the distal end into the stomach;

advancing the distal end into the pylorus; and

advancing the distal end from the pylorus into the intestine;

wherein at least the advancing the distal end from the pylorus into the intestine step is accomplished using a second magnet, external to the patient.

39. A method of treating a patient, comprising the steps of:

providing a gastrointestinal sleeve, having a proximal end, a distal end and a length of at least about 50 cm;

positioning the sleeve with the proximal end adjacent an attachment site in the vicinity of the lower esophageal sphincter, with the distal end extending transluminally at least as far as the jejunum;

forming at least one plication at the attachment site; and

securing the sleeve to the plication.

40. A method of treating a patient as inclaim 39, comprising the step of forming at least three plications and securing the sleeve to the plications.

41. A method of treating a patient as inclaim 39, comprising the step of extending the distal end into the intestine at least as far as the ligament of Treitz.

42. A method of treating a patient as inclaim 39, wherein the providing step comprises providing a sleeve having a substantially constant diameter throughout its length.

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