US20120215249A1 - Compressive Device for Percutaneous Treatment of Obesity - Google Patents

Abstract

An apparatus and method for treating morbid obesity in mammals using a gastric reduction assembly that reduces the gastric volume of a stomach and induces early satiety. The gastric reduction assembly comprises at least two or more expandable devices, each able to be adjustably inflated with a fluid (e.g., a liquid or a gas) using a filling tube. In a preferred embodiment, the gastric reduction assembly is inserted through the abdominal wall and placed at a location exterior to the stomach body, avoiding an abdominal incision. Once positioned near the stomach body, the gastric reduction assembly allows for the external compression of the stomach body to limit food intake. The gastric reduction assembly also minimizes the potential for shifting of the expandable devices after insertion to the stomach body to revert to its pre-compressed state.

Description

• The benefit of the filing date of provisional application Ser. No. 60/494,698, filed 13 Aug. 2003 is claimed under 35 U.S.C. §119(e).
TECHNICAL FIELD
• This invention pertains to multiple expandable devices that can be implanted to treat obesity in mammals by reducing the volume of the stomach.
BACKGROUND ART
• Obesity is a complex, medical disease affecting more than 30% of the population in the United States. Obesity affects an individual's personal quality of life and contributes significantly to morbidity and mortality. Obese patients, i.e. individuals having a body mass index (“BMI”) greater than 30, often have a high risk of associated health problems (e.g., diabetes, hypertension, and respiratory insufficiency), including early death. In the United States, approximately 280,000 deaths annually are attributed to obesity and obesity-related diseases. In the case of morbid obesity, studies have shown that conservative treatment with diet and exercise may be ineffective for reducing excess body weight. In addition, specific diets, medications, behavioral modifications, and exercise programs have over a 95% failure rate in morbidly obese individuals. Consequently, surgery is often the most effective means of treatment. “Bariatric surgery” is the field of surgery that treats people who are so overweight that they are suffering health consequences due to the excess weight. The surgery usually involves operations on the stomach to restrict one's ability to eat, or on the small intestine to restrict the absorption of ingested food. See M. Deitel, “Overview of Obesity Surgery,”World J. Surg., vol. 22, pp. 913-918 (1998).
• A successful bariatric surgery results in a maintained weight loss of greater than 50% of excess body weight and in an increase in patient wellness. An important factor for success is a long-term relationship between the patient and a medical team, which includes the doctor performing the procedure, a dietitian, a psychologist, and a physical therapist. While current bariatric surgery may assist patients in reducing food intake, it may also increase medical risks due to complications inherently associated with surgery, including complications of anesthesia, surgical procedure, wound infections, dehiscence, stomal stenosis, marginal ulcers, thrombophlebitis, and pulmonary problems.
• There are several bariatric surgical procedures for treating morbid obesity. One procedure for treating morbid obesity is referred to as a “biliopancreatic diversion.” Biliopancreatic diversion surgery is a reduction of the stomach volume and a diversion of food from the stomach to the final segment of the small intestine, bypassing the beginning and middle portions of the small intestine to limit the amount of nutrients and calories absorbed by the body. This procedure removes about one half of the stomach, and then connects the stomach to the last 250 cm of the small intestine. Disadvantages of this surgery include patients suffering from protein malnutrition, anemia, gastric retention, diarrhea, abdominal bloating, and intestinal obstruction. See P. Marceau, et al., “Malabsorptive Obesity Surgery,”Surg. Clinics of North America, vol. 81(5), pp. 1113-28 (2001).
• Another bariatric surgery, “gastric bypass,” is a bypass connecting the lower compartment of the stomach to the initial portion of the small intestine. This procedure limits the amount of food that can be ingested at one sitting and reduces absorption of food across the small intestine. In addition to surgical complications, patients may also suffer from acute gastric dilation, anastomotic leak, anemia, and dumping syndrome. See R. E. Brolin, “Gastric Bypass,”Surg. Clinics of North America, vol. 81(5), pp. 1077-1096 (2001).
• A third bariatric surgical procedure is “gastric banding,” which constricts the stomach to form an hourglass shape. This procedure restricts the amount of food that passes from one section to the next, which induces a feeling of satiety. A band is placed around the stomach near the junction of the stomach and esophagus. The small upper stomach pouch is filled quickly, and slowly empties through the narrow outlet to produce a feeling of satiety. In addition to surgical complications, patients undergoing this procedure may also suffer from esophageal injury, splenic injury, band slippage, staple line disruption, reservoir deflation/leak, and persistent vomiting. See E. J. DeMaria, “Laparoscopic Adjustable Silicone Gastric Banding,”Surg. Clinics of North America,” vol. 81(5), pp. 1129-44 (2001).
• A fourth bariatric surgical procedure is “vertical-banded gastroplasty,” which restricts the volume of the stomach by using staples. In this procedure, staples are placed in the upper stomach region to create a small pouch with a narrow outlet to the remaining portion of the stomach. A lap-band is placed around the narrow outlet to provide support and inhibit stretching of the stomach. In addition to surgical complications, patients undergoing this procedure may suffer from vomiting, ulcers, band erosion, and leaks. See C. Doherty, “Vertical Banded Gastroplasty,”Surg. Clinics of North America, vol. 81(5), pp. 1097-1112 (2001).
• U.S. Pat. No. 6,102,922 describes a device and surgical method for reducing the food intake of a patient by forming a restriction in the stomach using a band. In one embodiment, the band is looped around the esophagus and a portion of the stomach is pulled up through the band loop. This forms a small stomach pouch and a narrow outlet to the remaining portion of the stomach. This allows for a quick filling of the small stomach pouch, and a slow emptying of the stomach through the narrow outlet to produce a feeling of satiety.
• U.S. Pat. No. 6,475,136 describes a device for treating heartburn and reflux disease by restricting the amount of food flowing into a stomach or an esophagus, comprising a restriction device (a sphincter or a cuff) that can be adjusted. In one embodiment, the restriction device performs like an artificial sphincter that opens and closes the food passageway in the stomach. In an alternative embodiment, the restriction device comprises an adjustable cuff, a clamp, or a roller to bend or rotate the esophagus or stomach to close or almost close the junction between the stomach and esophagus.
• U.S. Pat. No. 4,246,893 describes a device and method for treating obesity by compressing the stomach and reducing its capacity using a single adjustable distensible device (e.g., a balloon) whose volume can be adjusted from an external port.
• U.S. Pat. No. 5,993,473 and WO 99/25418 describe a device and surgical method for treating obesity by decreasing the volume of the stomach by using a single expandable device placed inside the stomach cavity.
• U.S. Pat. No. 4,694,827 describes a device and method for controlling obesity by deterring ingestion of food using a single balloon that is placed inside the stomach.
• U.S. Publication No. 2002/0188354 describes a device for treating obesity by inserting an hourglass-shaped device into the junction between the stomach and the small bowel, which delays gastric emptying of food.
• U.S. Pat. No. 6,511,490 describes a device for the treatment of morbid obesity by restricting food passage in the stomach by placing an inflatable band around the stomach to create a pouch with a small opening adjacent to the esophagus. The inflatable band is secured and then inflated until the appropriate sized opening is achieved.
DISCLOSURE OF INVENTION
• We have discovered an apparatus and method for effectively treating morbid obesity in mammals, while minimizing the health risks associated with traditional surgery. The device reduces the gastric volume of the stomach and induces early satiety. The “gastric reduction assembly” comprises at least two or more expandable devices (e.g., balloons), each able to be independently inflated and adjusted from an external port. Each expandable device can be filled with a fluid (e.g., CO2, isotonic dextrose solution, isotonic saline solution, etc.) using a filling tube (e.g., a catheter), which can be easily accessed externally. In a preferred embodiment, the gastric reduction assembly is inserted percutaneously through the antero-lateral abdominal wall, and placed at a location exterior to the stomach body, avoiding an abdominal incision. Laparoscopic guidance, optionally, may be used to assist in placing the gastric reduction assembly near the stomach body. Once positioned near the stomach body, the gastric reduction assembly can be inflated to compress the volume of the stomach and effectively limit food intake. The gastric reduction assembly, with multiple expandable devices, minimizes the potential for post-implantation movement. The expandable devices have a size and shape to complement each other, such that they form a barrier when inflated that minimizes post implantation movement.
• To further minimize inferior migration, a subcutaneous anchor (e.g., a balloon or ring placed within the fatty layer between the skin and the abdominal wall), may be attached to the filling tubes to anchor the expandable devices to the abdominal wall. In addition, each expandable device may use an intragastric anchor (e.g., a collapsible fixation disc) to anchor the expandable device against the stomach body.
BRIEF DESCRIPTION OF THE DRAWINGS
• FIG. 1 illustrates a perspective view of one embodiment of the gastric reduction assembly, implanted in the peritoneal cavity around the stomach.
• FIG. 2 illustrates a front view of one embodiment of the gastric reduction assembly which has three expandable devices: two spherical-shaped and one crescent-shaped.
• The invention provides a reliable, inexpensive method for treating obesity in mammals by reducing the volume of the stomach without abdominal surgery, thus reducing postoperative surgical complications. The gastric reduction assembly can provide either an intraperitoneal or an extraperitoneal method to compress the stomach. The placement depends on the surgeon's preference, and the physical condition and body habitus of the patient. In the intraperitoneal cavity, expandable devices can be placed either at a pregastric location (i.e., either anterior or anterolateral to the stomach) or a retrogastric location (i.e., either posterior or posterolateral to the stomach), or both. In the extraperitoneal cavity, the expandable devices can be placed in any of the anatomical compartments, spaces, or layers of the abdominal wall. Candidates for this minimally invasive procedure include patients with a BMI greater than 40, or patients with a BMI less than 40 and a debilitating disease related to the obesity such as diabetes, hypertension, and respiratory insufficiency.
MODES FOR CARRYING OUT THE INVENTION
• The basic design comprises a gastric reduction assembly having at least two or more expandable devices (e.g., balloons), each able to be adjusted and independently inflated. Each device can be inflated with a fluid (e.g., CO₂, isotonic dextrose solution, isotonic saline solution, etc.) using a filling tube. The filling tube is accessed externally by way of an access device. To inflate each expandable device, the inlet of each filling tube is attached to a corresponding port, and fluid is injected into the inlet via a carrier (e.g., a hypodermic syringe). Fluid flows through the filling tube into each expandable device. Alternatively, fluid can be removed by reversing the process. The filling tubes may be locked together inside a single catheter or other large tubing such that only one tube crosses the abdominal wall to the access port.
• In a preferred embodiment, compression of the stomach is achieved using two or more spherical-shaped expandable devices to form a compressive barrier that reduces the volume of the stomach and minimizes post-implantation movement. Optionally, at least one crescent-shaped expandable device may be used to support the spherical-shaped expandable devices. The shape of the barrier formed by the multiple expandable devices may be adjusted to complement that of surrounding tissues and organs of the patient by changing the volume of the devices.
• To further minimize post-implantation movement, a subcutaneous anchor may be used to help anchor the expandable devices to the abdominal wall. In one embodiment, the subcutaneous anchor is a balloon-like device adapted to circumscribe the filling tubes subcutaneously or below the abdominal wall, at the muscular layer level. The volume of the subcutaneous anchor is adjusted by adding fluid. Alternatively, a ring lock may be placed around each filling tube at the muscular layer. In another embodiment, the expandable devices may be anchored to the stomach using an anchor e.g., a collapsible, fixation disc placed inside the stomach. One method of placement is to pass the intragastric anchor through a separate tube that crosses the expandable device and ends inside the stomach cavity. The tube can be accessed externally.
• The expandable devices can be implanted by passing through the skin and across the anterior abdominal wall via a larger tube to a predetermined implantation site. The expandable devices remain at the site, attached to filling tubes that can be accessed externally through a small single access port.
• The gastric reduction assembly has several advantages. First, the potential for incisional hernia and wound infections is substantially reduced, since no surgical incision of the abdominal wall is needed. The expandable devices are inserted through the skin and across the anterior abdominal wall via a small puncture. The access device for refilling or deflating the expandable devices is placed in the fatty layers of the abdomen, between the skin and the anterior abdominal muscles. Second, post-implantation movement is substantially reduced, almost eliminating a need to re-orient the expandable devices following implantation. Third, modifications (e.g., inflation, deflation, reorientation, or removal) may easily be done without surgery.
• FIG. 1 illustrates a perspective view of one embodiment of thegastric reduction assembly2, in accordance with the present invention. In this embodiment, the device comprises anaccess device6, asubcutaneous anchor8, and at least two or moreexpandable devices4, each having anintragastric anchor10 and a fillingtube12. Multipleexpandable devices4 are sized and shaped to complement each other such that when inflated, they cluster to form a compressive barrier capable of reducing the stomach volume and minimizing post-implantation movement. To adjustably inflate theexpandable devices4 in the peritoneal cavity, fluid is injected into each fillingtube12 of eachexpandable device4 via theaccess device6.
• As shown inFIG. 1,gastric reduction assembly2 comprises three spherical-shaped expandable devices4 (e.g., balloons) placed at a pregastric location. Alternatively,gastric reduction assembly2 may comprise another number of expandable devices4 (e.g., two, four, five, six, etc.). Optionally, at least one crescent-shapedexpandable device13 may be used, as shown inFIG. 2. This enhances the compressive barrier by forming a carrier ridge to support spherical-shapedexpandable devices4.Expandable devices4 can be made of any durable, distensible biocompatible material, such as rubber, latex, or polyurethane elastomer.
• As shown inFIG. 1, each fillingtube12 has an inlet at theaccess device6 and an outlet to the interior of eachexpandable device4 to allow for inflation with fluid. In an alternative embodiment, asingle filling tube12 that has an inlet and outlet (not shown) for eachexpandable device4 may be used. Fillingtubes12 should be made of a durable, flexible, biocompatible material, such as TYGON® tubing, polyurethane, or other plastics.
• As shown inFIG. 1,subcutaneous anchor8 is a distensible balloon-like device that circumscribes fillingtubes12 within the fatty layer between the skin and abdominal wall or at a subperitoneal (i.e., below the abdominal wall) region to anchor theexpandable devices4 to the abdominal wall. The balloon-like device is inflated via itsown filling tube14. Alternatively,subcutaneous anchor8 can be a ring lock (not shown) that joins all fillingtubes12. When the ring lock is placed around fillingtubes12 and advanced towards the abdominal wall, it forms an anchor against the muscular layer of the abdominal wall.Subcutaneous anchor8 should be made of a durable, distensible biocompatible material, such as rubber, latex, or polyurethane elastomer.
• As shown inFIG. 1,intragastric anchor10 is a collapsible, fixation disc which can be inserted through the stomach wall viatube12 with asecond channel16 that extends through eachexpandable device4. The disc, once opened in the stomach, anchorsexpandable device4 against the stomach. Onceintragastric anchor10 is positioned within the stomach and unfolds, an attached suture may be pulled to form a snug fit between the exterior surface of the stomach body andexpandable devices4. The size and shape ofintragastric anchor10 is chosen to complement the inner surface of the stomach, and to provide a sufficient surface area (when unfolded) to preventintragastric anchor10 from dislodging from the stomach when tension is applied.Intragastric anchor10 should be made of a biocompatible material capable of shape memory, e.g., nitinol coated with polytetrafluoroethylene.
• Anaccess device6 comprises ports (not shown) to fillingtubes12. The size and shape ofaccess device6 is adapted to allow for a tight seal with fillingtubes12 and a fluid carrier (e.g., a hypodermic syringe). The number of ports is determined by the number of tubes (12 and14) that need to be accessed from the outside.
• A preferred method of implanting the gastric reduction assembly is to go though the skin with a minimally invasive puncture. For example, a nasogastric tube (Bard, Covington, Ga.) is inserted into the stomach. The stomach is then inflated to better visualize it under fluoroscopy so that the proper location for an access site through the skin can be determined. The access site should be below the rib cage, near the gastric chamber. Once the access site is determined, a micropuncture needle (e.g., 22 g; Cook, Inc., Bloomington, Ind.) is inserted into the peritoneal cavity immediately in front of the anterior gastric wall. A microwire (e.g., 0.018 in; Cook, Inc., Bloomington, Ind.) is passed through the needle under fluoroscopic guidance and into the peritoneal cavity. Once the microwire reaches the peritoneal cavity, the micropuncture needle is removed over the wire.
• An access sheath (e.g., 6 French introducer; Cook, Inc., Bloomington, Ind.), a hollow tube that fits through the skin to form a temporary pathway to the peritoneal cavity, is then inserted over the microwire. The microwire is then removed, leaving the access sheath in place. A guidewire (e.g., 0.035 in stiff regular or hydrophilic; Boston Scientific, Natick, Massachusetts.) is then inserted through the access sheath to provide additional support. The opening in the abdominal wall is progressively dilated with dilators (Cook, Inc. Bloomington, Ind.) from 6-14 French. When the opening is sufficiently large, a larger access sheath (e.g., 14 Fr peel-away sheath; Cook, Inc. Bloomington, Indiana) is placed over the 0.035 in stiff guidewire, and the dilator and guidewire are removed. Air is then evacuated from the stomach through the nasogastric tube to provide space for thegastric compression assembly2.
• Introducer tubes (e.g., catheters) containing expandable devices4 (e.g., balloons) attached to fillingtubes12 are inserted through the access sheath to a predetermined position near the stomach.Expandable devices4 are released from the introducer tubes. Theexpandable devices4 are then partially inflated sequentially near the stomach using a syringe to introduce fluid (e.g., CO2, isotonic saline solution, or isotonic dextrose solution) to theexpandable devices4 through the fillingtubes12. Introducer tubes are slowly withdrawn, and each fillingtube12 is pulled until each partially inflatedexpandable device4 contacts the abdominal wall. The access sheath is then removed, and a subcutaneous anchor8 (e.g., a balloon or ring lock) is placed within the fatty layer between the skin and abdominal wall or the subperitoneal region (i.e., below the abdominal wall) to anchorexpandable devices4.Expandable devices4 are then inflated to a volume sufficient to compress the stomach, and fillingtubes12 cut to an appropriate length. The inlets to fillingtubes12 are then attached to the ports ofaccess device6, andaccess device6 is placed within the fatty layer between the skin and abdominal wall. The skin is then closed with sutures.
• In an alternative embodiment, eachexpandable device4 is individually introduced to a preselected stomach compression site near the stomach and then anchored to the stomach, as described below. In this embodiment, fillingtube12 to eachexpandable device4 has at least two channels. Filingtube12 is positioned to pass throughexpandable device4 and abut the side ofexpandable device4 that is near the stomach. One channel of fillingtube12 has an opening that allows fluid to flow intoexpandable device4 to inflate the device. The second channel of fillingtube12 passes intact throughexpandable device4 to the wall near the stomach. This channel allows anintragastric anchor10 to be placed inside the stomach to help anchorexpandable device4 as described below. Initially, a needle (e.g., an 18-gauge needle; Cook, Inc. Bloomington, Ind.) is passed through the access sheath to puncture the stomach wall. A contrast medium (e.g. gastrograffin) is then injected into the stomach to determine the needle's location. Once the location is determined, asuture22 is attached tointragastric anchor10, and the collapsed anchor is advanced through the needle into the stomach in a collapsed form using a stiff guidewire (e.g., 0.035 cm guidewire; Boston Scientific Corp, Natick, Mass.). Upon exiting the needle outlet within the stomach,intragastric anchor10 resumes its disc-shaped configuration.Intragastric anchor10 can be covered with a biocompatible material (e.g., GORTEX®, DACRON®, polyethylene or silicone) to help seal the gastric puncture site. The 18-gauge needle is then removed, while the stiff guidewire and suture remain attached to theintragastric anchor10. Preferably,suture22 is attached to the guidewire to allow for withdrawal. This process is repeated for each of the remainingexpandable devices4. The stiff guidewire is then passed through the second channel of fillingtube12 for eachexpandable device4.Expandable devices4 are then positioned at preselected stomach compression sites as described above. After verifying the compressive effects of eachexpandable device4 on the gastric volume of the stomach, the stiff guidewires are disconnected fromsutures22 and removed. Eachsuture22 is then pulled back through the second channel of fillingtube12 to anchor the device to the stomach wall. The access sheath is then removed, and fillingtubes12 are cut to an appropriate length. The ends of each suture are pulled through the second channel and attached to accessdevice6 to anchorexpandable devices4.Expandable devices4 can then be inflated or deflated throughaccess device6, as necessary.Access device6 is then placed within the fatty layer between the skin and the abdominal wall, and the skin is closed with sutures.
• Clinical trials will initially involve testing two groups (a test and a control) of pigs weighing more than 50 kg. The gastric reduction assembly will be implanted into the test group. Once the gastric reduction assembly has been implanted, an upper gastrointestinal study (“UGI”) will be conducted with barium to check the gastric volume and passage of material through the stomach into the small intestine. The volume of the expandable devices will be adjusted in the test group based on the findings of the UGI. UGIs will be conducted at various intervals to check on the location and volume of the expandable devices. The two groups will be weighed weekly. After six months, the animals will be euthanized and the position of the gastric reduction assembly evaluated during necropsy. The data will be analyzed for differences in weight loss between the two groups.
• The complete disclosures of all references cited in this specification are hereby incorporated by reference. In the event of an otherwise irreconcilable conflict, however, the present specification shall control.

Claims (17)

1-105. (canceled)

106. A method of fastening a device to one wall of a gastrointestinal organ comprising:

passing said device through a patient's abdominal skin, wherein the device is in an undeployed configuration; passing an anchor through a patient's abdominal skin wherein said anchor is in an undeployed configuration;

deploying said device;

connecting said device and said anchor by a connector such that said anchor and device are fastened to a wall of said gastrointestinal organ by said connector, wherein said connector prevents said device and said anchor from moving apart; and

deploying said anchor to its deployed configuration;

wherein said device induces satiety in said patient.

107. The method ofclaim 106, wherein said connector is a suture.

108. The method ofclaim 106, wherein the gastrointestinal organ is the stomach, and said device is located outside the stomach.

109. The method ofclaim 108, wherein said anchor is located at least partially inside the stomach, said device comprises an inflatable balloon and said connector is a suture.

110. The method ofclaim 106, wherein said device comprises an inflatable balloon.

111. The method ofclaim 106, wherein said anchor is covered with a mesh and said connector is a suture.

112. The method ofclaim 106, wherein the gastrointestinal organ is the stomach, said device comprises an inflatable balloon, and said anchor is located outside of the stomach.

113. The method ofclaim 112, wherein said device is located outside of the stomach.

114. The method ofclaim 106, wherein the gastrointestinal organ is the stomach, said device is located outside of the stomach, said connector is a suture and said anchor is covered with a mesh.

115. A method of treating an obese patient comprising:

penetrating through the abdominal wall of a patient with a balloon adapted to track over a connector, wherein the balloon is expandable from a first undeployed configuration to a second deployed configuration, and wherein the balloon is fixed to a least two points inside the abdomen and wherein the balloon is further contoured to maintain contact with the gastrointestinal organ.

116. A method of placing a device to restrict flow of food in to the stomach of a patient comprising:

penetrating the abdominal wall of a patient;

contacting the stomach of the patient with a connector;

pushing an extragastric balloon through the abdominal wall while the extragastric balloon is in contact with the connector and while the extragastric balloon is undeployed and thence contacting the stomach of the patient with the balloon; and

fixing the extragastric balloon to an outer portion of the stomach.

117. The method ofclaim 116, further comprising cutting the connector so that the residual of the connector remains in the abdominal cavity.

118. The method ofclaim 116, further comprising cutting the connector so that the residual of the connector traverses at least a part of the abdominal wall.

119. The method ofclaim 118, further comprising attaching an access port to the connector operable to inflate or deflate the extragastric balloon.

120. The method ofclaim 116, further comprising visualizing the connector under fluoroscopy.

121. The method ofclaim 116 wherein said method is performed laparoscopically.

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