US20070060932A1 - Devices and methods for retaining a gastro-esophageal implant - Google Patents

Abstract

Various methods and devices are described for retaining a medical implant within a body cavity. According to one aspect, one or more plications are formed and the medical device is coupled to or seated against the plication(s). A patch may be positioned between tissue layers forming the plication so as to reinforce the tissue adhesion forming between the tissue layers.

Description

• This application is a divisional of U.S. patent application Ser. No. 10/898,036, filed Jul. 23, 2004, which is a continuation in part of U.S. patent application Ser. No. 10/843,702, filed May 11, 2004 and claims the benefit of U.S. Provisional Application No. 60/510,268, filed Oct. 10, 2003.
FIELD OF THE INVENTION
• The present invention relates generally to the field of gastro-esophageal implant devices, and specifically to devices and methods for retaining such implants within the gastro-esophageal junction region or stomach of a patient.
BACKGROUND OF THE INVENTION
• An anatomical view of a human stomach S and associated features is shown inFIG. 1A. The esophagus E delivers food from the mouth to the proximal portion of the stomach S. The z-line or gastro-esophageal junction Z is the irregularly-shaped border between the thin tissue of the esophagus and the thicker tissue of the stomach wall. The gastro-esophageal junction region G is the region encompassing the distal portion of the esophagus E, the z-line, and the proximal portion of the stomach S.
• Stomach S includes a fundus F at its proximal end and an antrum A at its distal end. Antrum A feeds into the pylorus P which attaches to the duodenum D, the proximal region of the small intestine. Within the pylorus P is a sphincter that prevents backflow of food from the duodenum D into the stomach. The middle region of the small intestine, positioned distally of the duodenum D, is the jejunum J.
• FIG. 1B illustrates the tissue layers forming the stomach wall. The outermost layer is the serosal layer or “serosa” S and the innermost layer, lining the stomach interior, is the mucosal layer or “mucosa” MUC. The submucosa SM and the multi-layer muscularis M lie between the mucosa and the serosa.
• Various types of implants are positionable within the esophagus or stomach. These include prosthetic valves implanted for treatment of gastro-esophageal reflux disease. Another category of stomach implants includes prosthetic implants for controlling obesity. These include space-occupying devices such as inflatable balloons tethered to the stomach interior. Other obesity-controlling implants are shown and described in U.S. application Ser. No. 09/940,110, filed Aug. 27, 2001 and U.S. application Ser. No. 10/118,211006 filed Apr. 8, 2002, and U.S. Provisional Application No. 60/379,306 filed May 10, 2002, U.S. application Ser. Nos. 10/345,666 and 10/345,1104 filed Jan. 16, 2003. These applications are owned by the assignee of the present application, and the disclosures of these applications are incorporated herein by reference. Certain forms of these devices involve positioning a restrictive device in the proximal stomach. For example, aprosthetic pouch2 of the type shown inFIG. 2A may be positioned in the proximal stomach or at the gastro-esophageal junction region as shown inFIG. 2B. The pouch may act as a restrictor, limiting the amount of food intake by restricting passage of food from the esophagus into the stomach.
• This type ofpouch2 may include aproximal opening4 and a smallerdistal opening6 and forms a small reservoir that collects masticated food from the esophagus-thereby limiting the amount of food that can be consumed at one time. Because of its small volume (which may be on the order of approximately 2 cc-300 cc in volume, but is preferably in the range of 10-30 cc), the pouch functions to limit the amount of food that can be consumed at one time. Over time the food within this reservoir descends into the stomach through the distal opening.
• As the pouch fills with food, it may distend, imparting pressure against the upper stomach and lower esophageal sphincter causing the patient to experience sensations of fullness. Other types of restrictive devices are disclosed in the above-identified prior applications as well as in this application.
• Thepouch2 or other restrictive implant may be formed of a flexible material. Examples of such materials include, but are not limited to polyesters (e.g. Dacron® polyester), ePTFE fabric (e.g. GoreTex® fabric or others), a polyurethane such as ChronoFlex® polyurethane, nylon fabrics, silicone, other polymeric materials, and bio-absorbable materials (e.g. PLLA, PGA, PCL, poly-amhydride etc). In the case of thepouch2, it is optimal but not mandatory that the material prevents passage of food through the sides of the pouch. The material may be a composite of compliant, semi-compliant and/or non-compliant materials that give different regions of the pouch different degrees of compliance so as to allow/limit expansion of the pouch in various locations. For example, it may be desirable to provide a pouch with a fairly elastic exit port to as to prevent occlusion in the event a large piece of food is ingested and/or to control the exit pressure of food from the pouch, whereas the proximal end of the pouch may be stiffer to prevent bulging. Varying degrees of compliance may also be built into the pouch by varying the cross-sectional thickness in different regions of the pouch. The material may be coated with a lubricious, bio-compatible, chemically inert material, such as paraleyne, to reduce friction on the base material's surface which will help prevent sticking and food build up on the device.
• The restrictive implant may be reinforced with, constructed of, or supported by supporting members, such as a soft mesh, a cage structure, ribs, rings etc. The supporting members may be formed of stainless steel, polymer, shape memory materials such as nitinol, shape memory alloys, or shape memory polymers, or thickened regions of material. The implant may be constructed so as to be self-expanding, so that it will spring radially open into an expanded condition upon ejection from a deployment device or catheter.
• Thepouch2 or other implant in the stomach/esophagus may be fixed inplace using sutures8a,8bor other means such as clips or suitable adhesives at anchor points around the perimeter of theproximal opening4. The implant may include a reinforced section such as rim section9 onpouch2 for receiving thesutures8a,8bor other anchoring means. As illustrated inFIG. 2B, where anchoring means such as clips or sutures are used, the anchoring means may be passed completely through the wall of the stomach as withsuture8a(called a “full thickness” suture or clip), or partially through the wall of the stomach as withsuture8b(called a “partial thickness” suture or clip). One suture attachment device found useful for applying sutures between the pouch and tissue is the “Sew-Right” suturing device available from LSI Solutions of Victor, New York. Although the pouch may be secured to the esophageal tissue, it is more preferable to apply sutures/clips below the Z-line to allow for attachment to the thicker tissue of the stomach wall.
• Once secured within the stomach, the implant and associated anchoring means are subjected to significant forces caused by stomach motility and by forces imparted against the pouch by ingested food. Such forces may be imparted against restrictive devices such aspouch2 as well as other forms of gastro-esophageal implants, such as prosthetic valves implanted within the esophagus for treatment of gastro-esophageal reflux disease or space-occupying implants for hunger control. Over time, such forces could cause the implant to become detached from the wall of the stomach or esophagus due to erosion of the stomach/esophageal tissue at the anchoring points. It is thus desirable to provide an anchoring mechanism that will retain an implant within the stomach and/or esophagus over an extended period of time.
SUMMARY
• Various methods and devices are described for retaining a medical implant within a body cavity. According to one aspect, one or more plications are formed and the medical device is coupled to or seated against the plication(s). A patch may be positioned between tissue layers forming the plication so as to reinforce the tissue adhesion forming between the tissue layers.
BRIEF DESCRIPTION OF THE DRAWINGS
• FIG. 1A is a schematic illustration of a human stomach and a portion of the small intestine.
• FIG. 1B is a cross-sectional perspective view of a portion of a stomach wall, illustrating the layers of tissue forming the wall.
• FIG. 2A is a perspective view of a restrictive device of a type that may be used to promote weight loss.
• FIG. 2B is a cross-sectional elevation view of an esophagus and proximal stomach, showing the restrictive device ofFIG. 2A implanted in the gastro-esophageal junction region.
• FIG. 3 is a perspective view illustrating a restrictive device retained by tissue structures in the proximal portion of a human stomach.
• FIGS. 4A and 4B are perspective views of alternate embodiments of restrictive implant utilizing a ring as a restrictive element.
• FIG. 4C is a perspective view illustrating an alternate embodiment of a restrictive implant utilizing a notched disk as a restrictive element. The implant is shown positioned at the gastro-esophageal junction region.FIG. 4D is a cross-sectional front view showing the implant positioned within the gastro-esophageal junction region.
• FIG. 4E is a perspective view similar toFIG. 3 showing an inflatable restrictive implant retained within the gastro-esophageal junction region. Also shown are an inflation tube and an endoscope.FIG. 4F is similar toFIG. 4E but shows the implant following inflation, with the inflation tube still attached to the restrictive implant.
• FIG. 5A is a front perspective view of a stomach wall illustrating formation of a vertical tissue pocket formed using plications in the wall.
• FIG. 5B is a perspective view looking downwardly into the interior of a stomach, illustrating placement of the implant ofFIG. 4A into pockets formed by plications of the type shown inFIG. 5A.
• FIG. 6A is a front schematic illustration of an esophagus and stomach, illustrating formation of tissue pockets using a surgical stapler.
• FIG. 6B is a cross-section view of a tissue pocket, taken along the plane designated6B-6B inFIG. 6A.
• FIG. 6C is a cross-sectional side view of a proximal stomach.
• FIG. 6D is cross-section view taken along the plane designated6D-6D inFIG. 6C, illustrating one form of plication formed in the stomach wall to create tissue pockets.
• FIG. 7 is a cross-section view of a portion of a stomach wall, showing a modification to theFIG. 6A-6B arrangement in which the tissue pocket is formed from within the stomach.
• FIGS. 8A and 8B are a cross-sectional side view of a stomach wall illustrating methods for drawing tissue together to form plications in the stomach wall.
• FIGS. 8C and 8D are similar toFIGS. 8A and 8B further illustrate methods of attaching the folds of tissue that have been drawn together to form a tissue pocket.
• FIGS. 8E through 8G are cross-sectional top views of a portion of a stomach wall, illustrating various configurations of plications that may be formed to create tissue pockets.
• FIG. 9B is a cross-section view of a stomach similar toFIG. 6D, illustrating an alternate form of plication used to create tissue pockets. A more detailed view of one of the pockets ofFIG. 9B is shown inFIG. 9A.FIG. 9C is a cross-sectional top view of a portion of a stomach wall showing yet another plication arrangement for forming a tissue pocket.
• FIG. 11A is a cross-sectional perspective view of a portion of stomach wall, showing yet another type of plication that may be used.FIG. 10B is a cross-sectional top view of a stomach, similar toFIG. 6D, showing three such plications in the wall of a stomach.
• FIGS. 11A through 11D are a sequence of cross-sectional perspective views of a portion of stomach wall, showing yet another plication method for forming tissue pockets.
• FIGS. 12A through G are a sequence of cross-sectional perspective views of a proximal portion of a stomach, illustrating another method for forming plications to create tissue pockets.
• FIG. 13A is a side elevation view of suturing device for modifying a tissue surface and for forming a plication in tissue.FIG. 13B is a cross-section view of the distal portion of the device ofFIG. 13A.FIGS. 13C-13G illustrate use of the device ofFIGS. 13A-13B to form tissue pockets, andFIG. 13H illustrates positioning portions of a restrictive implant within the tissue pockets.
• FIG. 14A is a cross-sectional side view of a distal portion of an alternative embodiment of a tissue modification device which uses an ablative wire loop.FIG. 14B is a cross-sectional side view of a distal portion of yet another alternative embodiment of a tissue modification device which uses an ablative contact plate.
• FIGS. 15A and 15B schematically illustrate implantation of a restrictive device of the type shown inFIG. 3.
• FIGS. 16A and 16B schematically illustrate an endoscopic method for threading portions of a restrictive device into tissue pockets within the stomach.
• FIGS. 17-19 are cross-sectional plan views of a portion of a stomach and esophagus, showing restrictive devices and arrangements of components for retaining the restrictive devices in position.
• FIG. 20A is a top perspective view looking down into a stomach and illustrating the use of plications for retaining a ring within the stomach.
• FIG. 20B is a cross-section view of a plication and ring taken along the plane designated20B-20B inFIG. 20A.
• FIG. 20C is a top perspective view similar toFIG. 20A illustrating the use of plications for retaining an alternative ring within the stomach.
• FIG. 20D is a top perspective view looking down into a stomach and illustrating the use of plications for retaining multiple members within the stomach.
• FIG. 21A is a cross-sectional top view of a stomach, illustrating plications formed in the stomach.
• FIG. 21B is a cross-sectional elevation view of a plication illustrating use of the plications to support a liner within the stomach.
• FIGS. 22A-24 are cross-sectional front views of an esophagus and stomach illustrating the use of rings to shape the stomach wall for retaining an implant.
• FIG. 25 is a cross-sectional front view of a proximal stomach illustrating a method of forming an anchoring structure within the stomach.
• FIG. 26A is a schematic illustration of a portion of an exterior stomach wall, showing a pledget anchored to the wall as an external reinforcement to an internally positioned restrictive device.
• FIG. 26B is a schematic illustration similar toFIG. 26A, showing a T-bar anchored to the wall as an external reinforcement to an internally positioned restrictive device.
• FIG. 27A is a schematic illustration of the exterior of a lower esophagus and proximal stomach, showing “moly bolt” type external reinforcements used to facilitate anchoring of an internally positioned restrictive device.FIGS. 27B and 27C are cross-sectional side views showing introduction of the external reinforcement device through the stomach wall and its subsequent expansion to anchor a restrictive device in place
• FIGS. 28A through 28C are schematic illustrations of the exteriors of a lower esophagus and proximal stomach, each showing four additional embodiments of external reinforcements used to facilitate anchoring of an internally positioned restrictive device.
• FIG. 29A is a perspective view of a stud-type fastener which may be used to connect an internally positioned restrictive device to an external reinforcement device.FIGS. 29B through 29F are side elevation views showing examples of means for connecting the device ofFIG. 29A through stomach tissue to the externally positioned external reinforcement device. The stomach tissue is shown in cross-section.
• FIGS. 30A and 30B are cross-sectional side elevation views showing self-balancing external reinforcements connected to stomach tissue.FIG. 30A shows the reinforcements in an equilibrium state, whereasFIG. 30B shows the alteration of the reinforcements in response to a force.
• FIGS. 31A through 31I are schematic illustrations of a lower esophagus and proximal stomach, each showing a different embodiment of an external collar.
• FIG. 32A is a cross-sectional side elevation view of a distal esophagus, proximal stomach, and external collar.
• FIG. 32B is a perspective view of the collar shown inFIG. 32A in a straightened configuration.
• FIG. 32C is a perspective view of a collar of the type shown inFIG. 32B, but having an alternative locking mechanism.
• FIG. 33A is a perspective view of an example of an alternative restrictive device, in which the restrictive device takes the form of a rigid ring.
• FIG. 33B is a perspective view of another example of an alternative restrictive device, which has a tapered geometry.
• FIG. 33C is a perspective view of still another example of an alternative restrictive device, which has a bellows configuration.
• FIG. 33D is a perspective view of another example of an alternative restrictive device, which includes a collection of separate segments that collectively form a restriction in the stomach.
• FIG. 34A is a side elevation view of a stomach which has been re-shaped to include a tunnel.FIG. 34B is a cross-section view of the stomach showing a restrictive device anchored in the tunnel.
• FIG. 35A is a cross-section view of a stomach which has been re-shaped for retention of an implant.FIGS. 35B and 35C illustrate implants retained by the re-shaped wall of the stomach.
• FIGS. 36A through 36E are a sequence of cross-section views of a stomach illustrating a method of re-shaping tissue to form a circumferential plication, and using the circumferential plication to retain an implant.
• FIGS. 37A through 37D are a sequence of cross-section views illustrating a modification to the method shown inFIGS. 36A through 36F.FIG. 37E illustrates insertion of a restrictive insert into the support ring.FIGS. 37F and 37G show the support ring before and after insertion of the orifice, respectively.
• FIG. 38 illustrates a plication using a reinforcing patch between the tissue layers.
• FIGS. 39A and 39B illustrate formation of plications similar to those shown inFIG. 36F but using a reinforcing patch between the tissue layers.
• FIG. 40 illustrates the use of a reinforcing patch in a tissue pocket similar to the tissue pocket ofFIG. 12E.
• FIGS. 41A and 41B illustrate alternative uses of reinforcing patches for reinforcement of plications and for use in retaining restrictive device.
• FIGS. 42A and 42B illustrate a method similar to the method described in connection withFIG. 8C, but adding the use of a reinforcing patch.
DETAILED DESCRIPTION OF THE DRAWINGS
• The drawings show a number of methods and components that may be used individually or in combination with one another to facilitate retention of an implant in the stomach or esophagus, including in the gastro-esophageal junction region. These methods and components may facilitate retention by (1) re-shaping tissue or otherwise modifying the structure of the tissue at the implant location in a manner which allows a tissue structure to aid in retaining the implant either with or without a physical connection between the tissue and the implant; (2) anchoring the devices in place; and/or (3) facilitating even distribution of forces (e.g. forces resulting from food pressure or stomach motility) around the implant to minimize the chance of tissue erosion at points where the implant contacts or is anchored to tissue. This application also describes alternative embodiments to therestrictive device2 ofFIG. 2A.
• For the purposes of this application, the terms “restrictive devices”, “satiation devices,” “obstructive devices” or “satiation pouches” will be used to mean devices or pouches intended to induce weight loss in one or more of a variety of ways. These include, but are not limited to, slowing the rate at which food passes from the esophagus into the stomach, physically restricting the amount of food that can be consumed, and/or imparting pressure against portions of the body (e.g. stomach, esophagus, esophageal sphincter, etc) causing the patient to experience sensations of fullness, and/or affecting levels of hormones or other substances in the body that control or affect feelings of hunger, and/or affecting the amount of ingested food absorbed by the body. The anchoring devices and methods described herein are useful for various types of satiation implants, including those not specifically described herein and including those positionable in the esophagus, the gastro-esophageal junction region and other portions of the stomach including the proximal stomach, findus, antrum, etc.
• It should be noted that although the embodiments are described in the context of satiation devices, the components and methods described for facilitating retention and/or promoting even distribution of forces may be equally suitable with other types of implants. These implants include, but are not limited to prosthetic valves for the treatment of gastro-esophageal reflux disease, gastric stimulators, pH monitors and drug eluting devices that release drugs, biologics or cells into the stomach or elsewhere in the GI tract. Such drug eluting devices might include those which release leptin (a hormone which creates feelings of satiety), Ghrelin (a hormone which creates feelings of hunger), octreotide (which reduces Ghrelin levels and thus reduces hunger), Insulin, chemotherapeutic agents, natural biologics (e.g. growth factor, cytokines) which aid in post surgery trauma, ulcers, lacerations etc. As yet another example, the implant may provide a platform to which specific cell types can adhere, grow and provide biologically-active gene products to the GI tract. As other alternatives, an implant may provide a platform for radiation sources that can provide a local source of radiation for therapeutic purposes, or provide a platform whereby diagnostic ligands are immobilized and used to sample the GI tract for evidence of specific normal or pathological conditions, or provide an anchor point for imaging the GI tract via cameras and other image collecting devices.
• It should also be noted that the embodiments described herein have broad applicability for retaining implants in parts of the body outside the GI system. The term “implant” will thus be used to refer to satiation devices as well as other types of medical devices that may be implanted in the esophagus, gastro-esophageal junction, stomach, elsewhere within the GI tract, or in other hollow organs, vessels, and cavities of the body.
• Retention Methods Utilizing Re-Shaping Techniques
• FIGS. 3-24 illustrate implants and implantation techniques which minimize or largely avoid connecting the implant and body tissue using connectors (i.e. sutures, staples, clips etc.) that both penetrate the surface of the body tissue and physically connect to the implant. In these embodiments, a portion of the implant is captured by a tissue structure formed within the body by re-shaping body tissue. As will be appreciated from the description that follows, such tissue structures may be strictures created in the stomach to retain the device, or they may be pockets, tunnels, ledges or other barriers against implant migration formed by attaching regions of tissue and/or creating plications in the stomach tissue. The tissue structures may be formed using endoscopic procedures passed through the esophagus into the stomach, and/or using laparoscopic or surgical procedures.
• FIG. 3 shows arestrictive implant10 being retained byplications12 formed in stomach tissue. The plications may be formed by grasping sections of tissue and suturing the tissue together to form pocket-like tissue structures14. Such structures are pocket-like in the sense that they have an interior space bounded by tissue, and at least one opening extending into the interior space. The interior walls of the pocket may lie in contact with one another, collapsing the interior space in the same way the space within a shirt pocket is collapsed. The pockets may also be tunnel-like in the sense that there may be openings on opposite sides of the interior space so that an instrument or portion of a medical device may be passed through the pocket. If necessary, more than two such openings may be provided in the pocket. In other embodiments, the pockets may be more tubular or tunnel-like.
• Theimplant10 includesleg members16 that are retained within thepockets14 of theplications12. During implantation, the leg members may be inserted into thepockets14, or the implant may be positioned before the plications are formed, in which case theplacations12 may be formed around theleg members16.
• Restrictive implant10 includes arestrictive component18 which may be any configuration that slows the passage of food into the stomach, such as by reducing the effective cross-sectional area of the flow path between the esophagus and stomach or between one region of the stomach and another region of the stomach. For example, the restrictive component may be a pouch similar to seepouch2 ofFIG. 2A, or arestrictive ring18a(seeFIGS. 3, 4A,4B) or a notcheddisk18b(FIGS. 4C and 4D), or a mesh screen. The restrictive component might also be a partiallyobstructive balloon18bthat may be implanted in a deflated condition under visualization using an endoscope19 (FIG. 4E and 4F), and then inflated using aninflation tube21 coupled to a source of inflation medium such as air or gas. Theballoon18bmay be torroidal etc so as to include an opening for passage of food, or it may be shaped to permit flow of food around its exterior. As yet another alternative, a ring such asring18aFIGS. 4A and 4B may be provided, and an additional restrictive component (e.g. an obstructive member such as a pouch, disk, balloon, etc.) may be separately attachable to the ring before or after implantation. An examples of this type of configuration is shown inFIG. 37E. This allows the physician to select and alter the amount of restriction needed for a particular patient.
• Theleg members16 may be long enough to be retained in tissue pockets formed well into the stomach, such as in the antrum, the fundus or other regions of the stomach while still positioning the restrictive orifice of the device in the proximal stomach. Alternatively, theleg members16 may be shorter for retention by plications in the gastro-esophageal junction region or other proximal portions of the stomach. This concept of retaining the implant using tissue plications may be applied to implants positionable in other regions of the stomach (and throughout the body) as well, and is not limited to use with implants that provide restriction in the proximal stomach.
• Implant10aofFIG. 4A includes retention elements such assoft stops24 at the ends ofmembers16a. These elements deform for passage into a pocket and expand upon exiting the pocket. Inflatable retention elements may likewise be used. As another alternative shown inFIG. 4B, the soft stops may be replaced with barbs or hooks24athat are deployed through thepockets14 in a straight orientation and that are deformable or adjustable to a curved orientation following deployment to facilitate retention.
• Formation of Pockets
• The orientation of the pockets may be selected depending on the purpose to be achieved by the plications and/or the orientation of the implant to be retained. Referring again toFIG. 3, pockets14 may be formed to have a more vertical orientation (i.e. more or less radiating away from the gastro-esophageal junction) as opposed to the more horizontal pockets shown in later drawings which may line up somewhat circumferentially around a portion of the stomach. Referring toFIG. 5A, thepockets14 may compriseplications12 created by drawingfolds20 of tissue around amandrel22 within the stomach, and then attaching the folds together usingsutures24. The mandrel may then be removed, leaving apocket14 in its place. Afterwards,legs16 of theimplant10 are inserted into thepocket14 as shown inFIG. 5B. Over time, the regions of tissue held in apposition will adhere together due to the body's physiological or biological response, such as formation of fibrous tissue or scar tissue, growth of new tissue, or a growing, healing, or knitting together of the opposed tissue layers. The term “adhesion” will be used in this application to refer to the adhering of opposed tissue layers as a result of any physiological or biological response, including but not limited to those listed above.
• FIG. 6A illustrates formation ofplications12 using asurgical stapler28 approaching the exterior surface of the stomach in a laparoscopic or open surgical procedure. As shown, thestapler28 is provided withstaples30 in the distal most portion of its jaws, but there are no staples in the moreproximal portion32 of the jaws. To form a plication, the jaws are clamped onto a section of stomach tissue andstaples30 are passed through the tissue. As shown inFIG. 9B, the section of tissue34 that was within proximal portion32 (FIG. 6A) of the jaws is not stapled, and thus forms atissue pocket14. Referring to the top cross-section view ofFIG. 6D, several such tissue pockets14 may be formed around the stomach so that portions of a restrictive device (such as leg members16) may be positioned within thepockets14 as shown inFIG. 3. As will be discussed in greater detail below, the manner of joining the tissue to form the tissue plications should be chosen to allow the plications to withstand the expansion forces F (FIG. 6D) that occur along the stomach walls.
• FIG. 7 is a top cross-section view of a portion of a stomach wall, illustrating that thevertical plications12 may be formed from within the stomach (e.g. endoscopically using access through the esophagus) to createtissue pocket14. This may be performed using an endoscopic staple, suturing device, or clip applier introduced transorally into the stomach.
• FIGS. 8A and 8B illustrate methods of forming a tissue pocket such as that shown inFIG. 7 using endoscopic devices passed into the stomach via the esophagus. These methods may also be performed using a surgical or laparoscopic approach through the stomach wall.
• According to these methods, an endoscopic grasper36 (FIG. 8A), corkscrew mechanism38 (FIG. 8B), vacuum device40 (FIG. 8B) or alternative device is passed through the stomach via the esophagus and used to pinch folds42 of tissue, on the interior stomach wall. Sutures (or clips, staples etc.) are passed through the folds42 to draw the folds into contact with one another into the configuration shown inFIG. 7. It may be desirable to addrows46 of sutures or staples through each fold42 before the folds are joined together, as shown inFIG. 8C The sutures/staples etc. may optionally be passed through patches or strips44 (FIG. 7) of buttressing material such as bovine pericardium strips, Teflon strips or polycarbonate strips so as to facilitate retention of the staples/suture within the body tissue until such time as the contacting tissue layers adhere together. Alternatively, pledgets, t-bars, etc. of the type described in connection withFIGS. 26A-30B may be used to buttress the sutures/staples until such time as tissue adhesion occurs.
• Over time, adhesions form between the tissue surfaces held in contact by the sutures, thereby creating a much stronger bond between the tissue surfaces than would be achieved using sutures alone. If desired, dissolvable or bioabsorbable sutures may be used to create the plications.
• The procedure illustrated inFIGS. 8A through 8C is particularly advantageous in that it relies in part on adhesion of the serosal tissue lining the outer surface of the stomach. It has been found that serosal tissue layers can adhere to form relatively strong bonds when held in apposition to one another. Because the procedure ofFIGS. 8A-8C also strives for adhesion of some interior stomach tissue after tissue folds ortabs20 are attached together, modification of the interior tissue surface may further be needed in order to optimize adhesion of opposed regions of internal stomach tissue. In particular, it is believed that better adhesion of the interior wall surfaces may be achieved when a portion of the mucosal layer of tissue lining the stomach interior is removed, such that the tissue surfaces sutured in apposition to one another are serosal, sub-mucosal or muscularis layers. It is believed that opposed layers of mucosal tissue do not adhere together as well as opposed layers of serosal, sub-mucosal, or muscularis tissue.
• Referring toFIG. 8C, one surface modification method for promoting tissue adhesion includes cutting, ablating (using RF, laser, or chemical ablation) or abrading the mucosal surface of each tissue fold20 within the stomach as indicated by dashed lines. This modification is ideally performed before the folds are placed in apposition and sutured together. Depending on the depth to which cutting, ablation or abrasion is performed, the sub-mucosal, musclaris, or serosal layer beneath the mucosal layer is exposed, and the corresponding abraded/cut sections of each fold are placed in apposition and sutured/stapled together as indicated inFIG. 8D. This allows the exposed regions of tissue to be sutured together and causes the opposed surfaces to tightly adhere over time. During the procedure, it may be helpful for the physician to mark the exposed tissue regions using dyes or other markers to allow the tissue to be easily identified when it is time to position the exposed regions in apposition to one another.
• FIG. 8E is a perspective view of aplication12aandtissue pocket14aformed using the method described in connection withFIGS. 8A through 8D. As can be seen, the plication includes long serosal contact lines220. The mucosal or submucosal contact line222 (assuming tissue modification as shown inFIG. 8D) is relatively small. Because an adhesion which forms along theserosal contact line220 is believed to be stronger than adhesions which form along the mucosal orsubmucosal contact line222, it is desirable to proportion the plication such that the dimension identified by arrow “X” is greater than the dimension identified by arrow “Y”. This configuration allows the greatest of the forces imparted against the stomach (see forces F ofFIG. 6D) to be borne by the serosal adhesion. As illustrated inFIG. 8F, an elongated versions of the plications ofFIG. 8E may be formed to further extend the length of the contacting regions so as to optimize the strength of the adhered tissue. Another configuration resulting from even longer adhesions is illustrated inFIG. 8G.
• FIG. 9A illustrates another configuration of atissue pocket14bwhich relies in large part on regions ofserosal contact220 and relatively smaller regions of mucosal orsubmucosal contact222. In addition, as illustrated inFIG. 9B, the contact lines which result in adhesions are oriented “in shear” relative to the primary forces F experienced by the stomach, and thus may be less likely to pull apart in response to such forces. This is in contrast to thepockets14FIG. 6D in which the contact lines are oriented “in peel” relative to the forces F.
• FIG. 9C illustrates another configuration oftissue pocket14cin which the contactlines forming plications12care oriented in shear. This configuration utilizes three plication folds and forms a very long region ofserosal contact220.
• FIGS. 10A, 11D, and36A illustrate alternative forms of tissue structures that may be formed, in which the serosal contact lines form an adhesion that is in peel, but that differ from theFIG. 6D plications in that they utilizes a serosal adhesion line rather than a mucosal adhesion line.
• Referring toFIG. 10A, to formplication12d, tissue within the stomach interior is pinched together to draw serosal layers on the stomach exterior into contact with one another, thereby forming foldedtissue tab20d. Ahole15 is formed in thetab20d, andstaples17 or sutures, etc., are placed around thehole15 to keep the tissue pinched together until a serosal adhesion forms.Multiple tabs20dmay be formed as shown inFIG. 10B, and a portion of the restrictive device (such legs16 shown inFIG. 3) may be passed into theholes15 in the tabs to secure the implant within the stomach. Alternatively, an implant may be hung from thetabs20dusing sutures or clips.
• As yet another alternative, theFIG. 10A plications may be used without tissue pockets by eliminating theholes20dand by using sutures or clips to penetrate the tissue and to connect the tissue to the implant. A variation of this alternative is described in connection withFIGS. 3A-36F described below.
• To form a structure of the type shown inFIG. 11D, tissue within the stomach interior again is pinched to draw the serosal layers into contact as shown inFIG. 11A, thereby forming a foldedtab20e. Next,staples17 or sutures etc. are used to define a C-shaped (or similarly shaped) line through thetab20e.Cuts21 are formed through the full thickness of the stomach tissue as shown inFIG. 11B. It should be noted that because thecuts21 are full thickness cuts, thestaples17 are used to seal the stomach interior from the stomach exterior.
• After thecuts21 are formed, the areas of tissue surrounding thecuts21 are folded downwardly as indicated by arrows inFIG. 11B. The remainder of thetab20eis opened as shown inFIG. 11D to create aserosal pocket14ewhich is accessible from the mucosal (interior) side of the stomach. The serosal tissue forming the interior of the pocket may be lined with a small stent-like device or another liner to protect it from stomach acids. Over time, a mucosal tissue layer may grow over this serosal interior of the pocket (and/or over the stent or liner) and thereby further protecting it from the acidic stomach environment.
• FIGS. 12A through 12G illustrate another method of forming tissue pockets that take advantage of the strong adhesions formed when serosal tissue surfaces are held in apposition. Referring toFIG. 12A, arod226 is positioned on the exterior surface of the stomach, andsutures228 are attached to therod226 and passed through the stomach walls. Thesutures228 are drawn inwardly using an endoscopic grasper (not shown) to “tent” asection230 of tissue of the type shown inFIG. 12C. If desired, therod226 may be eliminated, in which case a pair ofsutures228amay be passed from the stomach interior, through the stomach wall, and then back into the stomach interior, and then drawn inwardly using anendoscopic grasper232 to tent the tissue as shown in dashed lines.
• Next, aline234 of staples or sutures are applied across the tented tissue from the mucosal side of the stomach—thereby forming anenclosed pocket236 on the exterior surface of the stomach as shown inFIG. 12D. The rod226 (if used) is enclosed within thepocket236. Stapling/suturing may be performed using an endoscopic stapler238apassed through the esophagus into the stomach, or using alaparoscopic stapler238bintroduced into the stomach through a surgical gastronomy site—both of which are shown inFIG. 12C. The stapler/suture device preferably has characteristics that will form a suture/staple line234 that is sufficiently patent to seal the serosal tissue together to prevent stomach leakage prior to complete serosal adhesion, but that ensures good blood flow so as to promote healing of the stapled tissue. For example, a conventional stapler modified to have a staple cartridge in which alternate staples have been removed may achieve this purpose.
• Acollar220 may be placed around thetented tissue230 as shown inFIG. 12C prior to suturing/stapling so as to apply tension to the wall tissue to facilitate suturing or stapling.
• Thesuture line234 holds the serosal layers of tissue together as shown inFIG. 12E, thereby holding thepocket236 together. The ends242 of the pocket are cut, turning the pocket216 into atissue pocket244 having ends that open into the stomach interior. Therod226, if used, is removed from thepocket244. As with the other embodiments, the tissue preferably heals together to form an adhesion that maintains the pocket.
• Because thetissue pocket244 is formed of serosal tissue, it may be desirable to line thepocket244 with a stent-like device246 or another liner to both reinforce the pocket and protect the serosal surface from the acidic stomach environment.
• As with the other embodiments, the procedure continues with formation of as many pockets as are needed to retain the desired implant in the stomach. Then, implants (or portions of implants) are fed into the pockets for retention within the stomach. As one example,legs16 of a device such as device10 (FIG. 3) may be extended through the pockets. Alternatively, other forms of implants (e.g. capsules containing diagnostic or therapeutic agents or devices, c-bars248 ofFIG. 12G to which implants or space occupying devices may be attached) may be positioned within thepockets244. A drug-eluting capsule or similar implant may be proportioned to fit in its entirety within the pocket form using this or other methods. The openings in the pocket may be closed following insertion of the capsule such that drugs eluted by the capsule pass through the walls of the pocket and into the stomach.
• As a third alternative, a member may be positioned in a pocket and tethered to a gastric balloon or other space-occupying device used in for inducing weight loss, or to another type of medical device such as a therapeutic or diagnostic device.
• Tissue Surface Modification
• As discussed in connection withFIGS. 8C and 8D, when interior stomach surfaces are to be placed in apposition so as to induce adhesion, it may be advantageous to modify the tissue surface so that submucosal, serosal, or muscularis tissue (rather than mucosal tissue) is used to form the adhesion.FIGS. 13A through 14B illustrate various methods for altering the interior stomach surface for this purpose.
• As one example, a single device may be used to modify regions of surface tissue and to join modified tissue surfaces.FIGS. 13A and 13B, illustrate a cutting andsuturing device48 that may be used for slicing a layer of tissue from the interior of the stomach and passing a suture through a portion of the remaining tissue. In particular, the device can modify neighboring surface regions of tissue, and then drawing the modified surface regions into contact with one another to promote adhesion and to form a tissue pocket.
• Referring toFIG. 13A,device48 includes anelongate shaft50 extending from ahandle52. Means is provided in thehandle52 for articulating theshaft50 in one or more planes using methods known to those skilled in the art.
• Referring toFIG. 13B, arecess54 is formed in the distal end of thedevice48. Asuture lumen56, aneedle lumen58, and acutting blade lumen60 extend through theshaft50 and separately open into the recess. The device may optionally be provided with a vacuum source (not shown) that allows a vacuum to be applied to draw tissue into therecess54. For this purpose, a fourth lumen having a plurality of inlets exposed to the interior of the recess may be provided and be connectable to a vacuum source.
• Asuture62 is disposed within thesuture lumen56. Thesuture62 has asuture catch64 on its distal end, positioned adjacent to the opening of thelumen56 into therecess54. Asuture needle66 is slidable within theneedle lumen58. Theneedle lumen58 andsuture lumen56 are oriented such that duringoperation needle66 may be extended from theneedle lumen58, through tissue disposed within the recess and into engagement with thesuture catch64. As will be described in further detail below, subsequent retraction of thesuture needle66 carries thesuture catch64 and the end ofsuture62 through the tissue and intoneedle lumen58.
• Acutting blade68 is slidable within thecutting blade lumen60 to shave a layer from tissue disposed within therecess54. The handle52 (FIG. 13A) includes actuators (not shown) for extending and retracting both thecutting blade68 and theneedle66.
• Use of thedevice48 will next be described with reference toFIGS. 13C through 13H.
• First, thedevice48 is introduced into the stomach under endoscopic visualization. Thedevice48 is placed into contact with the target stomach tissue, and tissue is drawn into therecess54. This may be accomplished by pressing therecess54 against the tissue surface, or by activating a vacuum source configured to draw tissue into therecess54. As discussed previously and as indicated inFIG. 13C, the tissue is comprised of several tissue layers: the mucosa MUC which lines the stomach interior, the submucosa SM beneath the mucosa MUC, the muscularis M, and the serosa S which lines the stomach exterior. The dimensions of therecess54 and the position of theblade68 are chosen such that tissue will be drawn intorecess54 by an amount that will appropriately align the tissue layer(s) to be removed with theblade68. In preferred examples, the mucosa MUC will be removed to expose the submucosa SM or both the mucosa and submucosa SM will be removed to expose the muscularis M. For purposes of illustration, removal of the mucosa MUC will be described in connection withFIGS. 13C through 13F.
• Once tissue has been drawn intorecess54, thecutting blade68 is advanced (FIG. 13D) into therecess54 to shave off the mucosa MUC, thereby leaving an exposed region El of submucosa (FIG. 13E). A source of RF energy (not shown) may be electrically connected to thecutting blade68 to coagulate tissue during or after resection, so as to reduce bleeding and promote tissue healing. If ablation energy is used, a grounding electrode is positioned in contact with the patient during use of the device.
• Next (or simultaneously with advancement of the cutting blade68), thesuture needle66 is driven through the tissue, engages with the suture catch64 (FIG. 13D), and carries thecatch64 and the suture end back through the tissue into thedevice48. The tissue is released from therecess54, and the suture end is retrieved from the proximal end of the device, leaving a loop of suture in tissue as shown.
• Next, the process is repeated at an adjacent location (preferably using the same unit ofdevice48 but alternatively using a second unit), thus creating a second exposed patch E2 of submucosa and placing asecond suture70 through the tissue as shown inFIG. 13F. The exposed patches El and E2 of submucosal tissue are brought into contact with one another, such as by pulling thesutures62,70, thereby forming tissue pocket72 (FIG. 13G). The sutures are anchored together to retain contact between the exposed patches. Eventually, the exposed submucosa (or muscularis) surfaces adhere together, forming a strong tissue adhesion that retains the tissue pocket within the stomach. As shown inFIG. 13G, both the interior of the stomach and the interior of thepocket72 remain lined with healthy mucosa MUC.
• Referring toFIG. 13H, theleg members16 of theimplant10 are secured within thetissue pocket72. This may be done at a later date so as to allow tissue adhesion to occur before the tissue is subjected to loading by the implant. The tissue pockets72 may be marked using dyes or other markers to allow them to be easily identified when it is time to secure theimplant10.
• Depending on the length of theleg members16, only one or twosuch pockets72 may be needed for retaining aleg member16, or each leg member may be retained by an elongate array ofpockets72 as shown.
• Other techniques may also be used for modifying the tissue surface to achieve optimal tissue adhesion between opposed tissue surfaces. Referring toFIG. 14A, thecutting blade68 of theFIG. 13B embodiment may be replaced with anRF loop snare74. During use, theloop snare74 is oriented such that tissue passes into the loop when tissue is drawn into therecess54. Once tissue is within the recess, the snare (which is energized with RF energy) in retracted in a proximal direction to shave off the target tissue layer.
• In another alternative shown inFIG. 14B, the cutting blade is replaced by anRF electrode plate76 disposed within the recess. Tissue drawn into therecess54 is thus drawn into contact with theplate76 and is ablated.
• Positioning Implants within Tissue PocketsFIGS. 15A and 15B illustrate one method for securingimplant10 using pockets of the type formed withdevice48. Referring toFIG. 15A, ahollow guide sheath78 is passed into the patient's esophagus via the mouth.Implant10 is passed in a streamlined position through the guide sheath and into the stomach using a plurality ofmandrels80 individually attached to each of thelegs16 and to theimplant body18, if necessary. Themandrels80 are preferably steerable to allow for manipulation of the legs to the desired positions within the stomach. After theimplant10 enters the stomach, it is allowed or caused to open to its expanded position. Anendoscope82 is passed through theguide sheath78 and into the stomach.
• Laparoscopic incisions are next formed into the abdominal cavity, atrocar84 is positioned in the incision, and the abdominal cavity is insufflated using procedures well known to those of skill in the art. Suture device48 (or another type of device such as a laparoscopic stapler or clip applier) is passed through thetrocar84 and used under endoscopic visualization to plicate tissue pockets around thedevice leg members16. The laparoscopic procedure is repeated for each of theleg members16. Naturally, an open surgical procedure may be carried out in place of the laparoscopic procedure. In a less invasive procedure, thesuture device48 may be introduced through the esophagus into the stomach rather than through surgical or laparoscopic incisions.
• As discussed previously, it may be desirable to form the tissue pockets72 before introducing the implant. The pre-formed tissue pockets72 may be plicated as described in connection withFIGS. 13D through 13G or using alternative methods.
• One method of delivering thelegs16 into the tissue pockets72 is shown inFIGS. 16A and 16B. In preparation for introducingimplant10, the distal ends of a plurality ofguidewires86 are passed down the esophagus into the stomach. The number of guidewires is selected to match the number oflegs16 on theimplant10.
• An articulatingendoscopic grasper88 is passed through the esophagus and into the stomach, and its distal end is fed into the distal end of atissue pocket72 until it exits the pocket's proximal end. Thegrasper88 engages one of theguidewires86 and pulls the guidewire through the tissue pocket such that the distal end of the guidewire extends out the pocket's distal end. The procedure is repeated for each guidewire. Outside the body, eachleg16 of theimplant10 is attached to the proximal end of one of the guidewires. Thegrasper88 then engages the distal ends of theguidewires86 and draws the distal ends102 of theguidewires86 out of the body, thereby towing the implant through the esophagus towards the stomach. As theimplant10 approaches the stomach, the distal ends of theguidewires86 are individually manipulated to separately draw eachleg16 into a corresponding one of the tissue pockets72.
• Although anchoring of an implant using tissue pockets has been described with respect toimplant10, it should be kept in mind that other types of implants may also be retained using one or more tissue pockets. For example, a drug-eluting capsule may be positioned within a tissue pocket, or a drug-eluting device may include a capsule attached to one or more anchoring members that are retained within tissue pockets. Similar arrangements may be configured for other forms of diagnostic or therapeutic implants of the types mentioned above.
• Alternative Methods
• FIGS. 17 through 24 and34A through36F show alternative ways in which a stomach wall may be re-shaped to facilitate implant retention.
• The configuration shown inFIG. 17 is advantageous in that it can be used without sutures or other physical attachments between the implant or body tissue, although it can also be used with partial thickness sutures or anchors (which only go through a portion of the wall thickness) or “full thickness” sutures or anchors that penetrate through the full thickness of the wall of the gastro-esophageal junction, esophagus, or stomach.
• Referring toFIG. 17, components positionable within the stomach include a hourglass shapedliner90 having awaist section92, and an implant such aspouch2 positioned within theliner90. Preferably, the contour of theliner90 silhouettes that of the proximal portion of thepouch2 as shown. Theliner90 is sufficiently rigid to restrict movement of thepouch2 up or down within the stomach.
• Aring94 is positioned on the exterior surface of the body wall surrounding thewaist portion92 of thehourglass liner90, such that it causes the body wall tissue to conform to the hourglass shape of theliner90, altering the shape of the stomach by creating a stricture as shown. If necessary, thering94 may be secured in place using partial or full thickness sutures, barbs, clips etc. Thering94 may have features similar to thecollar56 described in connection withFIG. 31G below.
• The relative positions of thering94,liner90 andpouch2 are such that the ring holds theliner90 in position, and the liner in turn holdspouch2 in position. Optional mountingstuds96 may be connected to thepouch2 and sutured through theliner90 to the body wall using partial or full thickness sutures. Further details of studs of this type are described in connection withFIGS. 29A-29F. Theliner90 protects the mucosal lining of the stomach against erosion, and both theliner90 and thering94 are themselves sufficiently flexible to prevent/minimize tissue erosion caused by their own surfaces.
• An optional feature in theFIG. 17 configuration includes afundal component98 extending in a distal direction from theliner90. Thefundal component98 functions to reduce the area of the findus exposed to ingested food. Over time, the presence of the fundal component may cause cells within the stomach to decrease their production of Ghrelin, the hormone that causes feelings of hunger. Thus, the overall level of hunger experienced by a patient will decrease and may result in weight loss by the patient. Contact between the fundal component and surrounding tissue may additionally aid in weight loss by causing the patient to experience sensations of fullness.
• Another optional feature in theFIG. 17 configuration includes aproximal chute100, which extends thepouch2 into the esophagus. This restricts dilatation of the stomach in the region above thering94 and thus provides additional restriction against overeating by the patient.
• Another configuration shown inFIG. 18 is similar to theFIG. 17 configuration, but it addssutures102 extending between tissue above and below thering94 to formplacations104 in the tissue to retain the ring in place. Theplications104 are formed by grasping tissue above and below the ring, and then suturing the grasped bunches of tissue together (seeFIGS. 12A and 12B and associated discussion). Obviously, in this and each of the described embodiments staples or clips may be used in place of the sutures. Pledgets or anchors106, which may be of a type described below, may be attached to the free ends of the sutures to prevent them from sliding through the tissue. Over time, the serosal and/or mucosal tissue layers contacting one another as a result of the plications will adhere together at regions labeled108 and thereby increase the strength of the plications. Tissue shaving, abrasion, ablation etc. of the type described above may additional be used to ensure optimal tissue adhesion. This embodiment may be varied by eliminating thering94, and by simply using the plications to create the narrowing in the stomach that retains thehourglass liner90 and thepouch2.
• FIG. 19 shows a variation of theFIG. 18 configuration in which all components may be implanted endoscopically, thereby eliminating the need for a laparoscopic or surgical step. In theFIG. 19 embodiment, thering94 is positioned within the stomach, surrounding thehourglass liner90 andpouch2 as shown.Plications104 are formed using sutures102 (or clips, staples, etc.) applied from within the stomach to retain thering94 as shown. In theFIG. 18 and19 embodiments, bioabsorbable sutures may be used such that once adhesion occurs across the plications, the sutures may be absorbed by the body, leaving thering94 captured by the body tissue alone. Although in each of theFIG. 17-FIG. 19 configurations thering94 may be proportioned to affect stomach function or eating behavior, it may be desirable to proportion thering94 to have no such effect, so that when thepouch2 is removed by the physician, thering94 may be left in place without interfering with normal eating by the patient.
• FIG. 20A is a top perspective view looking down into a stomach. The figure showsplications104 used to retain thering94. Theplications104 may be spaced apart around the circumference of thering94 as shown.FIG. 20B illustrates that the sutures may be passed through only the interior mucosal layer of tissue as indicated bysuture line102a, or through the interior mucosal and exterior serosal layers of tissue as indicated bysuture line102b.
• As discussed in connection withFIGS. 18 and 19, thering94 may be used to “shape” the stomach in order to restrain a restrictive device and/or associated component (e.g. liner90) against migration within the stomach. As another example shown inFIG. 20C, thering94amay be more disk-like and includewindows110 for receiving the plication tissue as well as an integral or detachablerestrictive orifice114. Preferably, the exterior perimeter of the ring seals against the surrounding tissue sufficiently to prevent passage of large amounts of food between the perimeter and adjacent tissue.
• Thering94 may also function as an anchor to which the implant may be attached using sutures, clips etc. In yet another alternative shown inFIG. 20D, bars116 (or hooks, individual rings, hooks, buttons, barbs etc.) may be supported usingtissue plications104 and a restrictive device may be mounted to them during the same or a subsequent procedure. Because each of these embodiments relies primarily on tissue plications to support the implant, reliance on sutures or clips to connect the implant to the tissue may be minimized or even eliminated. This may in turn increase the amount of time that the implant will remain in place within the stomach.
• FIGS. 21A and 21B illustrate that aplication104 may be formed without a ring, bar or other component simply by forming a fold in the tissue and passing asuture102 through the fold.Pledgets118 may be connected to the ends of thesuture102 to prevent it from slipping out of the tissue. Theplications104 may be used to “shape” the stomach to support theliner90 as shown, such as in an arrangement similar to those shown inFIGS. 18 and 19.
• FIGS. 22A through 24 show additional arrangements in which a ring or band may be used to facilitate retention of an implant. In the arrangement ofFIG. 22A, rings94 or restrictive bands are positioned above and below animplant2ato provide “stops” that prevent proximal and distal movement of the device within the stomach. A similar configuration using only aring94 below theimplant2bis shown inFIG. 22B. As a third alternative, therings94 may be eliminated and plications may instead be formed in tissue above and below (or only below) the implant to prevent its migration.
• InFIG. 23, aring94 or band is again positioned below the implant to create a stop against distal migration of the implant. In this configuration, theimplant2cmay take the form of an inflatable or self-expandingballoon120 that is free floating in the region above thering94. Theballoon120 occupies a large percentage of the gastro-esophageal junction region and thus restricts food intake by only allowing food to pass through the spaces between the balloon and the surrounding body wall as indicated by arrows.
• FIG. 24 shows another variation of theFIG. 22B embodiment in which thering94 includes magnetic elements that are of the same polarity as magnet elements in the proximal portion of theimplant2d. Thus, repulsive forces between theimplant2dand thering94 prevent distal movement of theimplant2d.
• FIG. 25 shows an arrangement of components intended to form a framework within the stomach that an implant device may later be attached to. The components include amesh band122 positionable around the interior wall of the stomach.Interior pledgets124 are spaced apart along the interior wall of themesh band122.Exterior pledgets126 are spaced apart along the exterior wall of the stomach. Thepledgets124,126 are connected to the mesh band bysutures128. Over time, the mesh band will migrate into the wall tissue.Exterior pledgets126 prevent the mesh band from migrating completely through the wall tissue, while theinterior pledgets124 prevent the mesh band from moving inwardly and separating from the wall tissue in the stomach interior. Eventually, the mesh band will become encapsulated within the wall tissue and form a sturdy structure to which implants such aspouch2 may be attached using sutures, clips or other devices.
• FIGS. 34A and 35A illustrate embodiments in which the stomach wall tissue may be re-shaped to allow an implant to seat against the re-shaped tissue. As shown inFIG. 34A, the stomach wall may be re-shaped to create atunnel220 extending from the esophagus E into the stomach S. Thetunnel220 may be formed endoscopically or surgically by suturing/stapling tissue alongline222. As illustrated inFIG. 34A, arestrictive device224 may include an expandable stent-like structure positionable within thetissue tunnel220 formed from re-shaped wall tissue.
• Referring toFIG. 35A, an alternative re-shaping method may including forming one or more suture/staple lines226 extending into the stomach to form a location within which an implant may seat. For example, arestrictive pouch228 or an obstructivegastric balloon230 may be seated within the created location such that the re-shaped wall tissue prevents the implant from descending into the intestinal tract. In theFIG. 34A and 35A embodiments, the tissue surfaces along the suture/staple lines will eventually adhere together. If desired, the orientation of the suture/staple lines may be selected such that while the re-shaped tissue provides a platform for supporting an implant that causes a patient to eat less, removing the implant will allow the person to eat without experiencing restriction caused by the re-shaped tissue.
• FIGS. 36A through 36F illustrate another method in which the stomach wall may be re-shaped for retention of an implant. According to this method, a circumferential ridge of tissue may be formed around the interior stomach wall, such as at the gastro-esophageal junction region, and the circumferential ridge may be used to retain the implant. Referring toFIG. 36B, a serosal plication may be formed by engaging a region of the interior stomach wall using anendoscopic grasper240, hook, pronged instrument, or similar device. By pulling the engaged wall region inwardly, sections of external serosal tissue are drawn into contact with one another to form serosa-to-serosal plication242 (FIG. 36D). With the plication engaged by the endoscopic instrument, asuture243, staple or other fastener is passed through theplication242 as shown inFIG. 36B to retain the plication. A plurality of theplications242 are formed around the interior circumference of the stomach, thus creating a circumferential ridge244 (FIG. 36E) of plicated tissue encircling the wall of the stomach. Over time, the opposed serosal layers form an adhesion. Arestrictive implant246 is then positioned in the stomach, proximally of theridge244 as shown inFIG. 36F.
• In one embodiment, the circumferential ridge may function as a physical barrier that prevents migration of the implant away from the proximal stomach, similar to the manner in which the wall re-shaped byring94 inFIG. 22B prevents migration. Alternatively, the implant may be physically connected to theridge244 usingsutures248, staples or clips as shown inFIG. 36F. This may be performed by grasping theridge244 using an endoscopic instrument and drawing theridge244 in the direction of the esophagus, advancing theimplant246 into contact with theridge244 while retaining the ridge with the endoscopic instrument, and passing sutures/staples etc. through the implant and theridge244.Pledgets250 may be used as shown in order to distribute forces over a larger surface area as described elsewhere in this application.
• Attachment of theimplant246 may be performed during the same procedure in which the circumferential ridge is formed, or at a later date to permit the adhesions to form before the ridge is subjected to the stresses that will be imparted against it by the implant.
• FIGS. 37A through 37D illustrate a slightly modified method for using serosal-to-serosal plication of wall tissue to form a circumferential ridge, and for securing an implant to the ridge. Referring toFIGS. 37A and 37B, tissue is plicated using anendoscopic instrument240awhich includesprong members241. To form a plication,prong members241 are used to pull stomach wall tissue in a proximal direction while asuture needle243 or other fastening instrument advanced distally to drive sutures, t-bars, rivets or other fasteners downwardly into the plicated tissue as shown inFIG. 37B. Force dissipating elements such as pledgets may be used to dissipate forces against the tissue surface.
• Referring toFIG. 37C, a few (for example two to four) such plications are formed around the wall to formcircumferential ridge244a(FIG. 37C).
• Introduction of an implant may be performed immediately following formation of the plications, or at a later date after the opposed serosal tissue has adhered as described above. In one method of introducing the implant, a plurality ofwires252 having hooked distal ends are passed through asheath254 and used to hook thecircumferential ridge244a.Implant246a, which has a plurality of small holes (not shown), is slipped over the wires by telescoping each of the small holes over a corresponding one of thewires252. Theimplant246ais compressed and passed into thesheath254, and is then advanced through the sheath into contact with theridge244awhile tension is maintained on thewires252. Theimplant246amay be physically connected to theridge244ausing sutures, t-bars, or other fasteners as described in connection withFIG. 36F. This step may be performed with continued application of tension on thewires252. As shown inFIG. 37D, a portion of theimplant246ais thus left seated against the ridge as shown inFIG. 37D.
• Although various types of implants may be retained using this method as well as the other methods described in this application, theimplant246ais shown inFIG. 37D as aring247 that may be similar to ring18afound onimplant10aofFIG. 4A. As with the other embodiments that utilize rings, the ring may itself function as a restrictive device, or a restrictive device may be used in combination with the ring. For example, a restrictive device may be attached to, hung from, seated against, or inserted into thering247.
• Ring247 may be formed of any of the materials described above in connection withpouch2, including silicone, polyurethane, or one of a variety of types of polymers. A reinforcing element formed of an annular band of stainless steel, polymer, shape memory materials such as nitinol, shape memory alloys, or shape memory polymers may extend through thering247. The ring may be constructed so as to be self-expanding, so that it will spring radially open into an expanded condition upon ejection from a deployment sheath. Alternatively, the ring may be inflatable using an inflation medium such as a gas or liquid (e.g. saline), or using a photochemically or thermally curable polymer. As another alternative, the ring may be formed of a material that will degrade or erode within the body over a period of time.
• Thering247 may include anapron256 having anannular groove258 as shown inFIG. 37E. Various materials may be used for the ring, including PET, nylon or any of the other materials described herein. Arestrictive insert260, which may have properties similar topouch2 described above, is insertable into thering247 as shown. Therestrictive insert260 has a restrictive opening proportioned to slow the rate at which food passes through the insert and into the stomach. A selection of restrictive inserts may be provided, thus giving the physician a choice as to how much restriction should be used for a particular patient.
• Insert260 includes arim262 that may be snapped intogroove258 to engage the ring and insert.FIG. 37F is a view looking down the esophagus into the stomach, showing theimplant246apositioned against theplication244.FIG. 37G is a similar view showing theimplant246aafter theinsert260 has been attached to it.
• In one method of using this type of implant, the physician may implant thering247 and delay placement of theinsert260 until the patient has had several days to adjust to the presence of the implant. Later, theinsert260 may be endoscopically passed down the esophagus and into the stomach, and be snapped into place. On a later date, the physician may choose to remove theinsert260 and replace it with a more restrictive (i.e. one having a smaller exit orifice) or a less restrictive insert (i.e. one having a large exit orifice), depending on the needs of the patient. If desired, the insert may be formed of a material that degrades or erodes after a period of time, thereby eliminating the need for removal of the insert.
• External Reinforcements
• Several components described in this disclosure function as external reinforcement devices. As discussed inFIG. 2B, the implant such aspouch2 may be sutured or clipped into place by passing afull thickness suture8afrom thepouch2 through the adjacent stomach tissue and back to the pouch. However, in some patients it may be desirable to “buttress” thesutures8aby passing them through an external reinforcement device positioned on the exterior surface of the wall. Some of these types of reinforcing devices have been mentioned in the preceding section.
• Examples of external reinforcement devices include pledgets130 (FIG. 26A) or t-bars132 (FIG. 26B), each of which distributes forces imparted against the suture over a larger surface area. Pledgets or t-bars may be quite large (e.g. 10-30 mm in diameter) or fairly small (e.g. 1-2 mm in diameter) as dictated by the particular application. Examples of material suitable for the pledgets or t-bars include silicone, felt, and/or the materials listed above for use in constructing the pouch. T-bars may also be formed of metallic bars crimped onto suture ends.
• During implantation of thepledgets130, the implant such as pouch2 (FIG. 2A) may be introduced into the stomach endoscopically, while the pledgets are placed in contact with the exterior of the stomach a laparoscopic or surgical approach. Sutures are passed from within the stomach, through the stomach wall, through the pledgets, and back to the interior of the stomach. If desired, this may be carried out in two procedures: for example a first laparoscopic procedure in which pledgets are laparoscopically sewn onto the exterior wall of the stomach, and a second endoscopic procedure in which the implant is passed through the esophagus and into the stomach and in which sutures are passed between the implant, stomach wall, and pledgets.
• During implantation of the t-bars, the end of the suture having the t-bar attached to it is endoscopically positioned adjacent the exterior wall of the stomach, and the free end is sewn through the stomach wall and the internally positioned implant wall.
• FIG. 27A shows an alternative external reinforcement device which takes the form of a “moly bolt”type fasteners134 that may be introduced endoscopically through the esophagus into the stomach. Referring toFIG. 27B, during implantation, the implant (e.g. pouch2) is positioned against the stomach andfasteners134 are passed from the interior of the implant through the implant wall and through the stomach wall. Eachfastener134 includes an internal wire or string (not shown) that is attached to itsdistal portion136. Thedistal portions136 of thefasteners134 are expanded into the position shown inFIG. 27C by pulling on these wires or strings, thereby anchoring thefasteners134 in place.
• Other types of external reinforcement devices are shown inFIGS. 28A through 28C. In theFIG. 28A embodiment,inflatable balloons138 may be passed through the implant and stomach wall from the stomach interior (in similar fashion to that shown inFIG. 27B for the moly bolt type fasteners), and then subsequently inflated such that the expanded balloons remain on the exterior surface of the stomach.
• FIGS. 28B and 28C illustrate alternatives to thepledgets130 described with respect toFIG. 26A. As with theFIG. 26A pledget, the pledgets ofFIGS. 28B and 28C are positioned on the exterior wall of the stomach and sutures are passed through the pledgets to attach the implant to the stomach wall. As shown inFIG. 28B, thepledgets130amay have roughened surfaces to prevent them from slipping through the suture openings in the stomach wall.FIG. 28C illustrates thatpledgets130bmay be formed of mesh or other material known to promote cell ingrowth, such that over time the stomach wall tissue will grow into the pledget to enhance anchoring.
• As another alternative to thepledget130, a pledget may be formed in situ by injecting a drop of gel onto the exterior surface of the stomach, where the gel is a type that will solidify on the tissue surface. The gel may be delivered laparoscopically by approaching the stomach wall from outside the stomach, or it may be delivered endoscopically by injecting the gel using a needle passed through the wall of stomach from the stomach interior. Once the gel hardens into a pledget, the implant may be anchored to the hardened gel pledget using sutures, clips, etc. passed through the stomach wall. As yet another alternative, the gel may be injected in between the serosal and mucosal layers of stomach wall tissue to form the gel pledget within the stomach wall.
• Naturally, each of the external reinforcement devices described above must in some way be connected to the implant located in the interior of the stomach.FIG. 29A shows a “stud”type fastener96 of a type that may be attached to a implant within the stomach, and that is also connected to an external reinforcement device (not shown inFIG. 29A).Fastener96 includes afirst button142 having apin144, andsecond button146 having a bore for receiving thepin144. As shown inFIG. 29B,pin144 is passed through the wall of the implant (e.g. pouch2) such that one of thebuttons142 is on the exterior of the implant and theother button146 is on the exterior of the pouch.Fastener96 is then connected to an external reinforcement device such as apledget130 positioned on the exterior wall of the stomach as shown.
• As shown inFIGS. 29B through 31F, various devices may be used to connect thefastener96 to thepledget130. It should be noted that although the implant is only shown inFIG. 29B, it should be assumed that inFIGS. 29C through 29F implant is attached to the fastener such as in the manner shown inFIG. 29B.
• Referring toFIG. 29B, asuture148 may be sewn through the stomach wall and attached to both thefastener96 and thepledget130 using suitable means. For example, to secure thesuture148 to thefastener96, the suture may be tied to thepin144, or it may be threaded through an opening in thebutton142 and into a bore in thepin144, and thepin144 may be crimped down to secure the suture within it. A variety of types of sutures may be used for this purpose, for example monofilament, braided suture, cotton, silk, or bioabsorbable suture. The length of suture between thefastener96 andpledget130 may be highly tensioned or loosely tensioned. Referring toFIG. 29C, if it is desirable to keep the suture in tension, thepledget130 andfastener96 may be magnetized to the same polarities such that they will resist movement towards one another as indicated by arrows and to thus maintain the tension of the suture. Alternatively, as shown inFIG. 29D thepledget130 andfastener96 may be magnetized to opposite polarities such that the attraction between them holds both the pledget, implant, and fastener against the stomach tissue. This embodiment may utilize a rigid post150 (e.g. stainless steel, nitinol, plastic) extending between thepledget130 andfastener96 to protect the tissue from being compressed between thepledget130 andfastener96. As another alternative, therigid post150 may provide the connection between thepledget130 andfastener96, without the use of magnetism. As shown inFIGS. 29E and 29F, a physical connector between thepledget130 andfastener96 may be formed of a material that promotes tissue ingrowth, such as achain152aormesh152bformed of nitinol, stainless steel, polymer, or bio-absorbable material.
• Referring toFIG. 30A, external reinforcement may alternatively be provided by a combination of self-balancing anchors. This may take the form of a pair ofballoon pledgets154a,154bconnected by asuture148 extending through the stomach wall such that oneballoon154ais within the stomach and theother balloon154bis outside the stomach. The suture preferably extends through the interior of each balloon and is attached to the balloon at a point that is furthest from the adjacent stomach wall. The implant (not shown) is connected to the suture adjacent to theballoon154apositioned within the stomach. As illustrated inFIG. 30B, the balloons are proportioned such that when force draws one of theballoons154aaway from the stomach wall (such as when the implant pulls inwardly in response to food pressure) the other balloon compresses and flattens against the wall, thereby increasing the effective pledget size and thus distributing the force over a larger area. It should be noted that the balloon pledgets could be replaced with other resilient structures such as three-dimensional mesh, stent-like frame structures, deformable elastomers, or other structures that will deform when subjected to force but that will resume their original shape upon release of the force.
• Collars
• Another form of external reinforcement device is an external collar encircling the exterior of the stomach.FIGS. 31A through 31I show a variety of collar configurations. Some of these configurations are intended to be physically connected to the implant using sutures or other connection methods, including those shown inFIGS. 29B-29F for connecting the implant to the pledget-type devices. These connections may be made with or without the stud fasteners ofFIG. 29A. When connected to the implant, the collars may function like thepledgets130 to facilitate even distribution of forces around the implant. The collars and pledgets may also be combined such that a collar encircles the exterior stomach wall and pledgets on the exterior surface of the collar are connected to the device using sutures passed through the collar and the stomach wall. In this configuration, the collar aids in force distribution and also prevents the pledgets from eroding the stomach wall.
• For other configurations, the collar is not physically connected to the implant, but may be positioned to restrict movement of the device.
• The collar embodiments ofFIG. 31A through 31F are designed to have the implant device anchored to them at anchor points156. The collars are intended to be flexible so as to more evenly distribute forces rather than to have significant forces build at any one anchor point. In theFIG. 31A embodiment, the flexibility of thecollar158 comes from its pleated structure. Theimplant2 within the stomach is attached to the collar at158 anchoring points156. TheFIG.31B collar160 is formed of a coil spring. In both of these embodiments, the flexibility of the collar allows the anchoring points156 to move with the stomach rather than allowing forces at the anchor points to build when such stomach movement occurs.
• Similar properties are found in theFIG. 31C-31E embodiments. In theFIG. 31C embodiment, thecollar162 is formed of material such as stainless steel, polymeric, or nitinol mesh that has flexibility in multiple directions. TheFIG.31E collar164 is also capable of stretching in multiple direction due to its use of a thin flexible polymeric sheet. In theFIG. 31F embodiment, thecollar166 includes a plurality ofindividual pledgets168 mounted to anelastic member170.FIG. 31D shows anexpandable collar172 formed oftelescoping components174a,174b.Spring members176 connect thecomponents174a, allowing the collar to expand and contract with the stomach.
• Referring toFIGS. 31G, 31H and31I, the collar may be a simple round or oval-shaped ring. It may have a torroidal shape like thecollar178 ofFIG. 31G, or a tapered shape like thecollar180 ofFIG. 31H which conforms to the tapered shape of the exterior stomach wall. The collar may be rigid or flexible. Alternatively, referring toFIG. 31I,collar182 may be flexible but include a tensioning cable that may be activated to increase the rigidity of the collar. With these embodiments, sutures attached to the implant may be sewn through the stomach wall and be attached to the collar, or the collar may remain physically separate from the implant but function to maintain the implant's position as discussed in greater detail in connection withFIG. 17.
• FIG. 32A shows a front cross-section view of thecollar178 surrounding an exterior stomach wall. As shown,collar178 may have a D-shaped cross-section to minimize tissue trauma.
• Because the collar is intended to be wrapped around the stomach, its design must be such that it can be introduced into the stomach cavity in an elongate configuration, and then have its free ends attached to form it into a loop around the stomach. As illustrated inFIG. 32B,collar178 may include aslot184 at one end and atab186 at the opposite end.Tab186 is engageable within the slot to form the collar in to a loop. Raisedbuttons188 on thetab186 may snap intorecesses190 in the slot to lock the collar in the closed loop. The size of the collar may be pre-selected by cutting thetab186 to the desired length before it is inserted into the slot.
• As an alternative shown inFIG. 32C,collar178 may include asleeve192 that is slidable over the collar as indicated by arrows to retain the ends of thecollar178 together once the collar has been positioned around the stomach.
• Alternative Restrictive Devices
• The flexible nature of thepouch2 allows it to move in response to stomach movement, thereby producing little or no stress on the sutures or anchors holding the pouch in place. This is believed desirable towards minimizing the chance that the implant will detach from the stomach wall. Other restrictive devices and methods of retaining them are shown inFIGS. 20C, 22A,22B,23 and24.
• FIGS. 32A through 32D show restrictive devices having alternative features which may likewise minimize risk for detachment. These devices may be used with or without the various attachment devices described in this application.
• FIG. 32A shows arigid ring194 positionable in the gastro-esophageal junction region and attached using sutures or other means similar to those described forpouch2. Thering194 may be flexible for endoscopic insertion, and then convertable (e.g. by inflation to a high pressure using a detachable inflation tube) to a rigid ring following implantation so as to restrict movement of the stomach. Such restriction of stomach movement is intended to minimize stresses on the sutures or anchors and thus reduce the risk of detachment.
• Ring194 includes a flow-restrictive orifice196 through which food passes. If desired, thering194 may include a circumferential region surround theorifice196 that is independently inflatable or deflatable to adjust the diameter of the exit orifice.
• FIG. 32B shows an alternativerestrictive device198 which has a tapered configuration, such that forces imparted against the device by the stomach (as indicated by arrows) as well as forces imparted by food passing through the taperedpassageway200 in thedevice198 will cause the device to seat more tightly within the gastro-esophageal junction region. As with the other embodiments, sutures, anchors, clips, adhesives etc. may be used to attach thedevice198 to the stomach walls.
• FIG. 32C shows arestrictive device202 that is pleated between anchor points204. The pleats allow thedevice202 to expand in response to forces against it, and thus minimize stress at the anchor points. As with the other restrictive devices,device202 includes arestrictive orifice206.
• Restrictive device208 ofFIG. 32D is formed of a plurality ofindividual members210, each of which is separately attachable to the tissue of the gastro-esophageal junction using sutures, clips or the like at anchoring points212. Theindividual members210 collectively form a restriction at the gastro-esophageal junction so as to minimize food intake by the patient. The amount of restriction may be reduced by reducing the size of themembers210. Because theindividual members210 are physically separate from one another, movement of the stomach will produce little or no stress on the anchors.
• Tissue Modification to Increase Tissue Strength
• If desired, the tissue of the stomach, esophagus, or gastro-esophageal junction may be treated using techniques such as mechanical abrasion, RF ablation/coagulation, laser ablation, or chemical abrasion that can strengthen the tissue such as by forming a layer of scar tissue. Cyanoacrylate coatings or growth inhibitors may also be applied to the tissue to strengthen it. These forms of tissue modification may be used in embodiments in which implant devices are physically connected to the tissue using sutures, staples, etc, or in embodiments in which there is no such physical connection but in which increased tissue strength is desired for prevention of erosion.
• Reinforcement of Tissue Adhesions
• Many of the embodiments described above rely upon formation of tissue adhesions between opposed tissue layers. Referring toFIG. 38, a reinforcingpatch300 may be positioned between the tissue layers (e.g. serosal layers as shown, or alternatively mucosal layers). The patch may function as a scaffolding that promotes tissue ingrowth and/or function to reinforce the adhesions that form.
• The patch may be a synthetic or non-synthetic mesh, porous material, slotted material, or any other material through which adhesions will form or onto which tissue will grow. Examples include, but are not limited to, polypropylene, materials sold under the trade names Goretex or Dacron, or tissue graft material such as the Surgisis material sold by Wilson Cook Medical, Inc. The material may be treated with tissue-ingrowth promoting substances such as biologics. Sutures (which may be bioabsorbable), pledgets, t-bars or other fastening means are used to hold the tissue layers together at least until adhesions bond the tissue layers together. Eventually, adhesions form between the tissue layers (and through and/or onto the interstices of the patch) and serve to reinforce the bond between the tissue layers. A patch of this type may be used in connection with any embodiments which create tissue adhesions between tissue layers. A few examples are illustrated inFIGS. 39A through 42B.
• FIGS. 39A and 39B illustrate an embodiment similar to theFIG. 36F embodiment in whichserosal plications242 are formed to create acircumferential ridge244 and in which arestrictive implant246 is attached to theridge244 or seats against the ridge without a physical connection. TheFIG. 39A/B embodiment differs, however, in thatpatch300 is positioned between the serosal layers. Anchoring studs orpledgets250 may be passed through the serosal tissue layers and thepatch300 as shown to secure the plication and (if desired) to serve as an attachment point for an implant such as a restrictive device.
• FIG. 40 illustrates an embodiment similar toFIG. 12E in which apocket236 is formed using a serosal to serosal connection, but which has been modified to includepatch300 between the serosal tissue layers.Patch300 may be formed of a strip of material formed into a loop, such that it lines a portion of thepocket236 as shown, thereby protecting the lined portion of the pocket against friction imparted by a device element (not shown) positioned within thepocket236. As an alternative shown inFIG. 41A, a plication of the type shown inFIG. 38 is formed, and acut302 is then formed to remove the innermost portion of the tissue fold.Patch300 is formed into a loop and anchored in place between the serosal layers forming the plication, with the loop extending into the stomach as shown. Using this configuration, a device element may be positioned within the loop formed by the patch.
• In an alternative to the embodiment ofFIG. 41A,patch300 may include anextension306 in place of theloop300. A restrictive device (not shown) may be attached to theextension306 using sutures or other fasteners, or the restrictive device may simply seat against the extension without being physically attached to it. Although theextension306 is shown as a mesh element, it should be appreciated that the extension need not be formed of the same material as the patch. Instead, it may have any type of material and shape (e.g. a hook) to which the restrictive device may be coupled or against which the restrictive device may be seated. As yet another alternative, one ormore extensions306 may be configured to obstruct passage of food into the stomach and thus themselves function as the obesity-controlling device without the addition of a separate device.
• An embodiment similar to that shown inFIG. 8C is illustrated inFIGS. 42A and 42B. Here a pair of serosal plications are formed, each with apatch300 between the serosal layers. Thefolds20 of the two plications are connected to one another as shown inFIG. 42B to form apocket304 between the plications. The ends of thefolds20 may be cut prior to attachment as described with respect toFIGS. 8C and 8D, or they may be left uncut. Additionally, another patch may be positioned between the folds to reinforce the adhesions that will ultimately grow between them.
• Various components and methods have been described herein. These embodiments are given by way of example and are not intended to limit the scope of the present invention. It should be appreciated, moreover, that the various features of the embodiments that have been described may be combined in various ways to produce numerous additional embodiments. Also, while various materials, dimensions, shapes, implantation locations, etc. have been described for use with disclosed embodiments, others besides those disclosed may be utilized without exceeding the scope of the invention. For example, the retention methods and devices are not limited to use within the gastro-intestinal system and may be used for implants placed elsewhere in the body.

Claims (12)

1. A medical implant system, comprising:

an instrument insertable into a body for attaching regions of body tissue on the wall of a body cavity to form a plication; and

patch positionable between the regions of body tissue; and

retaining means for retaining the plication at least until an adhesion forms between the regions of body tissue.

2. The medical implant system ofclaim 1, further including

a medical implant positionable within the body cavity and configured to be retained within the body cavity by the plication.

3. The implant system according toclaim 2, wherein the medical implant is a drug delivery device.

4. The implant system according toclaim 2, wherein the medical implant is a diagnostic device.

5. The implant system according toclaim 2, wherein the medical implant is an anti-reflux device.

6. The implant system according toclaim 2, wherein the medical implant is positionable within a stomach for inducing weight loss.

7. The implant system according toclaim 2, wherein the medical implant is an expandable space-occupier positionable within a stomach to decrease the effective volume of the stomach.

8. The implant system according toclaim 2, wherein the medical implant is a flow-restrictive device positionable within a stomach to restrict the rate of flow of food into the stomach.

9. The implant system according toclaim 1, wherein the instrument is a suturing instrument.

10. The implant system according toclaim 1, wherein the instrument is a stapling instrument.

11. The implant system according toclaim 1, wherein the instrument is a clip-applier.

12. The implant system according toclaim 1, wherein the retaining means is selected from the group consisting of sutures, staples, clips, fasteners, t-bars, pledgets, adhesives and studs.

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