Patent Grant
8152821
The present invention relates to improvements for endoscopic tissue apposition devices. Specifically, the invention provides an endoscopic apposition device configured to collect a plurality of tissue portions with a single operation of the device so that the tissue can be joined together by a tissue securing means.
Endoscopic apposition devices are devices that can be used in the body of a patient without the need to make an external incision in the patient, the device being controlled externally of the patient by endoscopic means. Apposition devices may comprise a sewing or stapling device for use in flexible endoscopy, though it is also applicable to devices for use in rigid endoscopy.
Endoscopic tissue apposition devices are useful to help perform a gastroplasty procedure to correct gastro-esophageal reflux disease (GERD). This condition results from the inability of the valve at the junction between the stomach and the esophagus to function properly. Such malfunction enables reflux of stomach acid into the esophagus. The object of the gastroplasty procedure is to stitch together certain portions of stomach tissue in a manner that forms a valve-like structure adapted to prevent such reflux.
To perform the procedure, an apposition device, such as a sewing capsule is attached to the end of a viewing endoscope and is inserted through a patient's esophagus to form a plurality of stitches in stomach tissue slightly below the lower end of the esophagus. A first stitch is made through stomach tissue to one side of the esophagus, and a second stitch is made, with the same suture thread, in stomach tissue adjacent to the first stitch. The two stitches then are drawn together to pull together the diametrically opposed, stitched stomach portions. In a preferred procedure, a tubular configuration having a somewhat figure-eight cross-sectional configuration is formed.
After the sutures are applied, the endoscope is removed from the patient and a knot is tied with the free ends of the suture thread that extend outside of the patient to maintain the figure-eight configuration. The knot is pushed down to the site of the sutures by the thread guide device that has been positioned at the distal end of the endoscope. To help navigate the knot to a location where it will effectively hold the tissue, it is helpful to view the knot through the viewing channel of the endoscope as it is guided to the stomach. To be visible through the endoscope, the knot must be maintained in front of the viewing channel port at the distal face of the endoscope, yet the structure of the thread guide device must not block the viewing channel.
The suturing and knotting procedure is repeated several times at longitudinally spaced intervals to create a plurality of figure-eight configurations extending longitudinally of the esophagus into the stomach. Suturing the stomach tissue in this manner essentially lengthens the esophageal passage and defines a structure having a valving action that is effective to prevent gastro-esophageal reflux. After a sufficient number of knots and sutures have been placed, a thread cutter, also operable through the endoscope, may be employed to cut the suture thread at points that are close to the tissue.
Endoscopic sewing devices are described in, for example, U.S. Pat. Nos. 5,080,663 and 5,792,153. Those patents disclose a sewing device for passing a thread through a tissue portion, which comprises a hollow needle movable between a first position in which it is out of the said tissue portion and a second position in which it passes through the said tissue portion, and a thread carrier adapted to be attached to the thread and being receivable within the hollow needle. The sewing device comprises a body, which defines a cavity within which the tissue portion can be held by means of suction, and the hollow needle is mounted for movement in the body between the first and second positions.
U.S. Pat. No. 5,792,153 discloses two suturing device embodiments: a single stitch sewing device and a multiple stitch sewing device. In the single stitch device, a thread carrier is transported by the needle through the tissue as the latter passes from its first position to its second position. When the needle returns to its first position, the thread carrier is left behind in the distal end of the sewing capsule. In the multiple stitch device, the same procedure occurs, but it is followed by a further step in which the hollow needle travels from its first position to its second position, picks up the thread carrier, and returns it. A second stitch may be formed during the next step. The whole sequence of steps is repeated as many times as may be required to form the desired number of stitches.
Minimizing the number of intubations and reducing the procedure time during which the patient must be kept under conscious sedation are important considerations in any endoscopic procedure. The prior art suturing device must be withdrawn from the patient for each successive stitch made with the single-stitch embodiment and must otherwise be repositioned for each stitch made with the multi-stitch embodiment. The use of the devices is, thus, long and cumbersome. It would be desirable to provide an endoscopic tissue apposition device that minimizes procedure time and the number of intubations while still joining the same number of tissue plications together during the procedure. The present invention endeavors to provide such an improvement with a multiple suction port tissue apposition device.
A variable in the success of keeping tissue joined together with the above-described suturing procedure is the quality of the surgical knot tied to secure the tissue. Surgical knots are difficult to tie successfully, especially for non-surgical physicians that may be performing the endoscopic suturing procedure. It would be desirable to improve the reliability of the suture knot to increase the level of confidence in the procedures performed using the above-mentioned endoscopic devices. To improve the reliability of know methods of securing tissue together, the methods should be improved, or safeguarded with a secondary securement operation or eliminated entirely in favor of another procedure. The present invention is intended to provide an improved mechanism for joining internal tissue.
The present invention pertains to improvements to an endoscopic apposition device. The improvements may be embodied in a tissue apposition device similar to those disclosed in U.S. Pat. Nos. 5,792,153 or 5,080,663, or a stapling device such as is disclosed in U.S. Pat. No. 5,037,021. The disclosures of the above listed patents are incorporated by reference herein, in their entirety. The prior art endoscopic tissue apposition devices provided a mechanism for capturing only a single fold, double thickness of tissue through which a needle and suture were passed. The present invention provides a multiple suction port tissue apposition device is capable of capturing two or more separate folds of tissue simultaneously so that a tissue securement device, such as a suture, permanent suture tag and or tag lock system, implant clip or staple, may be passed through the multiple folds with one endoscopic intubation.
The device is comprised of a capsule attachable to the distal end of an endoscope, preferably a flexible viewing endoscope. The capsule comprises a body having multiple suction ports into which can be captured multiple portions of tissue. Each suction port defines an opening to an independent vacuum chamber or a vacuum chamber shared commonly with another suction port. Independent vacuum chambers may be operated simultaneously, through one vacuum source line, or sequentially, with each chamber in communication with an independent vacuum source.
Alternatively, the capsule may be configured such that multiple suction ports are in communication with a single, common vacuum chamber. Because only one vacuum chamber is provided, tissue is sucked into all suction ports simultaneously, when vacuum is applied to the common chamber. However, although a common vacuum chamber is used, tissue is collected into distinct multiple portions drawn through the separately defined suction ports. The multiple portions of collected tissue may then be secured by a tissue securement device such as a suture, permanent tag, implant, clip, staple or other means.
The several suction ports maybe arranged in a variety of configurations on the capsule. Ideally, the ports are arranged to coincide with desired final arrangement of secured tissue portions. Therefore, with appreciation for how the capsule will approach the subject tissue area being navigated at the distal end of an endoscope, the capsule should be configured such that the suction ports are positioned in relation to each other where the captured tissue portions are desired to be secured in relation to each other. In addition to the desired arrangement of tissue portions, consideration must be given to how securement means will be applied to the tissue portion given the arrangement of suction ports in relation to the working channel or channels of the endoscope.
In the example of a cylindrically shaped capsule, the ports are configured as arc shaped openings formed into the outside surface of the capsule. In one embodiment, the openings may be arranged in-line, parallel to the longitudinal axis of the capsule. Alternatively, the ports may be arranged to be side by side such that they are angularly displaced about the circumference of the capsule, but not displaced longitudinally along the length of the capsule. In one embodiment, four ports are arranged around the circumference of the capsule at equally spaced angular intervals. Ports can be arranged to be spaced apart at virtually any angular or longitudinal distance apart on the suturing capsule. For example ports arranged 90 degrees apart angularly and slightly apart longitudinally are positioned diagonally across the circumference of the capsule. The description of several various arrangements below is believed to be sufficient to enable one to extrapolate the requisite parameters to construct capsules having any desired arrangement of suction ports.
In the side-by-side tissue apposition embodiments, novel needle arrangements may be employed to penetrate tissue portions that are captured in the suction ports that are arranged away from the longitudinal axis of the capsule. A forked needle capable of simultaneously penetrating tissue portions held side-by-side is provided. For independent penetration of the tissue portions held captured in a side-by-side arrangement, a capsule design having a diverter in the needle track serves to guide independent needles to the selected suction port as they are advanced distally to penetrate tissue.
The multiple port apposition device of the present invention offers another advantage over previous designs in that the entire capsule body may be injection molded from a polymer material. A single piece injection molded unit is easier to produce than previous capsule designs, which were machined from metal and comprise several assembled components.
Another feature of the present invention is increased flexibility of the body. One or more points of longitudinal flexibility may be provided along the length of the capsule body by means of hinge. Due to the added length of the sewing capsule required to house two or more suction ports, the capsule may be too long to pass comfortably through natural body passageways such as the esophagus during an endoscopic procedure. To address the issue of passing a long rigid instrument through a curved natural body lumen, the present invention incorporates one or more hinged points along the length of the sewing capsule. The hinged portion permits the sewing capsule body to bend longitudinally, in at least one direction, so that the capsule body can be passed around a curve in the body lumen. If the hinge operates in only one direction, the endoscope and, thus, the sewing capsule body can be rotated upon reaching a curved portion of the body lumen so that the direction of bending flexibility coincides with the direction of the curve. After being navigated to the intended treatment location, a reinforcing rod may be advanced distally through all segments of the tissue apposition capsule body, locking the hinged body in place so that no bending at the hinges occurs during the procedure.
In another aspect of the invention, the tissue apposition capsule body is modified to utilize special tissue securement mechanisms. One tissue securement mechanism embodiment comprises sutures having anchoring elements at one end that permit them to be passed through tissue and then become anchored behind the tissue layer to permit suturing and retention of the fold of tissue. The anchoring element of the special suture material, such as polypropylene, may comprise a T-structure. The anchoring element is arranged in a T-structure in that the anchoring element is perpendicular to the longitudinal axis of the main portion of the suture element. In this arrangement the T-portion may be easily deformed so that it lies parallel to the main portion of the suture so that it may be passed through tissue when carried by a hollow needle that is part of the sewing capsule. After passing through the tissue, the T-portion of the suture may be ejected from the needle and the needle withdrawn from the tissue so that the T-portion resiliently returns to an orientation that is perpendicular to the axis of the main body portion of the suture, thus becoming anchored on the through side of the tissue.
The sewing capsule body can be modified to facilitate the operation of such a T-style suture anchor by formation of a ramp positioned distal to the most distal vacuum chamber that guides the T-portion of a suture being ejected from an advanced needle upward and outward, away from the sewing capsule so that it becomes oriented perpendicular to the longitudinal axis of the suture behind tissue through which the suture has been passed.
Another aspect of the invention provides for a multiple suture or staple magazine incorporated in the capsule body. The magazine helps to reduce a number of intubations required to place multiple tissue securement devices such as staples or sutures by holding several such devices and incorporating a mechanism to automatically and sequentially advance new securement devices into position for insertion into the tissue. Specifically, in the case of the suturing device having a reciprocating needle, multiple suture tags, or T's may be stored within the magazine during an endoscopic procedure. After the needle advances the first suture tag through tissue portions, the needle may be retracted to a proximal position whereby a spring loaded advancement mechanism may cue forward the next suture tag stored in the magazine into position to be carried by the needle through the next tissue location.
Another tissue securement device for use with the multiple suction port devices employs a suture tag lock system. The tag lock system uses a series of sutures and associated suture tags and tag lock blocks to hold the tissue portions in the desired plication orientation after the completing the procedure. The tag lock system hold sutures in a pre-arranged orientation on the suture capsule during navigation to the treatment site. Delivery of suture carrying tags through captured tissue by the needles serves to lock the tags into the lock blocks on the through side of the tissue, thereby completing the preconceived arrangement of sutures necessary to accomplish the plication form desired. A tag lock band may alternatively be employed to capture the suture tags on the through side of the tissue in place of the lock blocks.
Another tissue securement device for the multiple suction port embodiments comprises a helical coil implant that is threaded into the captured portions of tissue to hold them together. The coil implant embodiment may be used in a variety of procedure where endoscopic delivery of a tissue implant may be desirable. An example of other uses for the tissue implant may be to achieve tissue bulking in a region of gastro-intestinal tissue to treat GERD. The implant may also facilitate the delivery of bulking agents to a treatment site if the implant is configured to carry the agent by such means as coating.
In another aspect of the invention, tissue abrasion means are provided with the capsule to improve the adherence of tissue surfaces that are joined together. The abrasion means serves to create a slight injury to the tissue surfaces that will be joined by the apposition capsule. The injury initiates a healing process on those tissue surfaces that will lead to common tissue ingrowth between the surfaces over time to permanently join the tissues. The improved tissue apposition device and methods provided by the present invention can be used to join internal tissues via an endoscope for a wide variety of purposes such as: attaching a feeding tube to the small intestine; enclosing intestinal openings in the case of the fistula, repairing esophageal tears and suturing tissue sites of localized bleeding. However, the present invention is believed to be especially useful in endoscopic treatment of gastroesophageal reflux disease (GERD).
The abrasion means provided by the present invention may operate by a variety of mechanisms. Mechanical abrasion means may be provided by providing a roughened surface area to frictionally engage and abrade the tissue near the suction ports of the device. Alternatively, mechanical abrasion means may be employed by ejecting from the device an abrasive substance such as salt or sugar crystals. Chemical abrasion may be provided by releasing a chemically abrasive substance such as a suitably high concentration of hydrochloric acid. Electrical abrasion may be actuated by providing electrical elements near the suction port through which electrical current is passed to heat and abrade areas of tissue. Laser energy may also be applied to tissue to abrade and initiate the healing process. Alternatively, ultrasonic energy may be applied near the suction port opening. However, a preferred method of abrading a tissue is through the use of radio frequency (RF) energy adjacent the opening of the suction port.
The abrasion means may be incorporated in devices having a single suction port as those disclosed in the patents referenced above, but preferably the abrasion means is incorporated in an apposition device having multiple suction ports such as described herein. The arrangement and operation of the suction ports facilitates use of the abrasion means in that tissue can be held in place, in contact with the abrasion means, by applying light vacuum pressure through the vacuum chambers to collect tissue into the suction ports. By positioning the abrasion means adjacent the suction ports, tissue is reliably brought into contact with the abrasion means. Also facilitated is the correct positioning of the abrasion in the tissue area that will be brought into contact during the apposition procedure.
It is believed that joining area of tissue that have been injured slightly or abraded will undergo a healing process that promotes tissue ingrowth between the joined tissue surfaces resulting in a new, unified tissue mass rather than two separate tissues attached together by a tissue securement mechanism that could be subject to failure over time. Another advantage of the tissue ingrowth process is that biodegradable tissue securement means can be used which will degrade over time. In this situation, the tissue securement need only hold the tissues together temporarily, for sufficient time for the healing tissues to join together to form a unified tissue segment. In abrading the tissue to a sufficient degree to initiate the healing process, it is believed that only slight abrasion affecting the mucosal layer of the tissue is required. Accordingly, the tissue abrasion means discussed herein are intended to inflict only a slight amount of abrasion.
It is an object of the invention to provide an endoscopic tissue apposition device that reduces the number of intubations required to attach or repair internal tissue by a tissue securement mechanism comprising suture or staples.
It is another object of the invention to provide an endoscopic apposition device that is simple and economical to fabricate by injection molding techniques.
It is another object of the invention to provide a tissue apposition device having longitudinal flexibility to be easily navigable through a natural body lumen while mounted at the distal end of an endoscope.
It is another object of the invention to provide a tissue apposition device having multiple suction ports into which subject tissue may be collected and joined by a tissue securement device.
It is another object of the invention to provide a simplified tissue suture means having an anchor at one end which can remain on the through side of tissue during the process of tissue securement.
It is another object of the invention to provide an endoscopic tissue apposition device having a multiple suction ports in communication with a common vacuum chamber that operates to collect tissue into the multiple ports by applying vacuum to the common vacuum chamber.
It is another object of the invention to provide an endoscopic tissue apposition device having multiple suction ports in communication with multiple vacuum chambers that are independently operable to collect tissue sequentially into the multiple ports.
It is still another object of the invention to provide a tissue apposition device having a tissue securing device magazine configured to automatically and sequentially advance tissue securement devices into position for advancement through the tissue.
It is another object of the invention to provide a tissue apposition device with improved tissue suction capability.
Another object of the invention is to provide a method of joining internal tissue that comprises capturing at least two areas of tissue simultaneously to delivery tissue securement device through the areas of tissue to join them together.
It is an object of the present invention to provide an improvement to endoscopic tissue apposition devices that will provide a more reliable securement of internal tissues by promoting common ingrowth between those tissues in addition to attachment of tissue securement means.
It is another object of the invention to provide an endoscopic tissue apposition device that incorporates an abrasion means that utilizes a mechanical, electrical, chemical, laser, ultrasonic or radio frequency energy to abrade the subject tissue.
It is another object of the invention to provide an endoscopic tissue apposition device that safely abrades tissue sufficiently to initiate an injury response in that tissue without adversely and permanently damaging the tissue.
It is another object of the invention to provide an abrasion means that may be employed with an endoscopic tissue apposition device having a single or multiple suction ports.
It is another object of the invention to provide a tissue abrasion means that is equally applicable to tissue apposition devices utilizing a staple, suture, or suture tag securement means.
It is another object of the invention to provide a method for joining internal tissues of the human body comprising the abrading an area of tissue and joining multiple tissue portions such that the abraded area of tissue is brought into contact with itself or other tissue and undergoes a healing process that unites results in the bonding of the multiple tissue portions.
The foregoing and other objects and advantages of the invention will be appreciated more fully from the following further description thereof, with reference to the accompanying diagrammatic drawings wherein:
A description of the embodiments of the present invention is best presented in conjunction with an explanation of the operation of a prior art tissue apposition device, which this invention serves to improve.
A hollow needle 8 is mounted in the biopsy channel 3, with its beveled tip extending into the sewing device. The needle has a channel 9 extending therethrough. A flexible, wire-wound cable 10 has its forward end attached to the rear of the needle 8, and a center wire 11 runs within the cable 10, along the entire length thereof, and is longitudinally movable with respect thereto. The diameter of the wire 11 is such that it is longitudinally movable within the channel 9 and, in the position shown in
At the distal end of the sewing device is defined a hollow head portion 16 defining a chamber 20 therein. Between the chamber 20 and the cavity 7 is a wall 17, in which an aperture 18 is formed. The aperture 18 has a diameter that is marginally greater than the external diameter of the needle 8, and is aligned therewith. The clearance between the needle 8 and the aperture 18 must be sufficiently small to prevent tissue being forced through the aperture and causing the needle to jam. Finally,
In operation, suction is applied to the suction pipe 4, and thence, via the perforations 6 in the tube 5 to the cavity 7. This sucks into the cavity a U-shaped portion 19a of the tissue 19, as shown in
The wire 11 is then withdrawn proximally, followed by proximal withdrawal of the cable 10, to withdraw the needle 8 from the tissue portion 19a. The suction is then discontinued allowing the U-shaped tissue portion 19a to be released from the cavity 7. As shown in
With both ends of the thread 14 outside of the patient, the thread can be knotted and the knot endoscopically pushed down to the suture site and severed by an endoscopic knot pusher such as that disclosed in U.S. Pat. No. 6,010,515 (Swain et al). As an alternative to tying a knot, a suture lock or clip may be guided over the suture thread, down the esophagus and secured via an endoscope or suitable delivery catheter to hold the suture thread tight against the tissue. Examples of suitable suture locks and delivery systems are disclosed in U.S. patent application entitled Suture Lock, Delivery Systems and Methods filed Feb. 2, 2001.
In using the endoscopic suturing device to treat G.E.R.D. it is believed that capture of multiple tissue portions and suturing and gathering them together provide an effective treatment. To accomplish this using the prior art device, multiple intubations of the endoscope down the patient's esophagus are required. Once, multiple (tissue portions, have been captured and sutured with thread, they are gathered together and secured by tying of surgical knots in the thread or application of suture lock devices. It should be noted that a multiple stitch embodiment also is disclosed in U.S. Pat. No. 5,792,153. However, that embodiment requires the user to release the currently sutured tissue portion and relocate the device to collect a new tissue portion before making the second stitch. It is an object of the present invention to reduce the number of intubations required to capture multiple tissue portions and to enhance the security of the attachment of the tissue portions.
The dual suction port tissue apposition device shown in
In one embodiment of the invention, multiple suction ports are defined in line on the sewing device, along a common longitudinal axis that is parallel to the longitudinal axis of the device. An isometric view of an in-line dual suction port endoscopic tissue apposition device 50 is shown in
In
Tissue portions are drawn into the suction ports and into the vacuum chambers by suction introduced to the chambers through air passages 88. The air passages are open to independent internal channels in the body that are joined to vacuum lines 90. The vacuum lines extend from the proximal end of the capsule body, external to the endoscope, to the proximal end of the scope. Outside the patient, the vacuum lines can be joined to a portable or institutional vacuum source (not shown). A control valve may be inserted in-line near the proximal end of the tubes for selective control of the vacuum by the user. The air passages of all cambers may be joined and controlled by a single vacuum line. Alternatively, as shown in
Independent vacuum supply to the air passages of each chamber not only helps to ensure adequate vacuum pressure to each chamber, but also permits sequential suctioning of tissue into the chambers. When tissue is collected into both chambers simultaneously, the distal chamber is blocked from the viewing lens 48 on the distal face 46 of the endoscope 1, as shown in
The needle 80 is longitudinally slidable through the capsule body 50, as in the prior art devices. In the in-line dual chamber embodiment shown in
Another feature that may be integrated into the multiple chamber tissue apposition device to reduce intubations and procedure time is a magazine 102, shown in
When the needle advances distally from its starting position shown in
Another aspect of the invention, shown in
Because the capsule body must aligned and straight to accept passage of the reciprocating needle during the procedure, a remotely operable locking mechanism is provided to lock the hinged halves 126 and 128. A locking rod 124 is longitudinally slidable through a locking channel 130, which extends longitudinally through both articulating halves 126 and 128 of the hinged body 120. The rod 124 extends to the proximal end of the endoscope to be operable by the physician. In its retraced position, shown in
In the embodiment shown in
The operation of the present embodiment is essentially the same as has been outlined above for the previous embodiment. Specifically, the device 140 is secured to the distal end of an endoscope and is navigated to a site of internal tissue intended to be sutured. Using the viewing capability of the endoscope, the suction ports 144 are positioned adjacent tissue to be treated. Vacuum is introduced through vacuum line 50, in communication with air passages 88 to provide suction to the vacuum chamber 142, commonly shared by suction ports 144. Tissue is collected into the chamber 142 through individual suction ports 144, forming distinct portions of tissue within each chamber. Because the suction ports 144 share a common vacuum chamber, sequential suctioning of tissue into individual suction ports is not possible with this embodiment, unless several vacuum chambers are provided, each serving multiple suction ports.
A tissue securement advancement mechanism such as a hollow and slotted needle 80 carrying a pusher wire 98 may then be advanced distally through needle track 92 and through the vacuum chamber 142 where the tissue has been collected. As the needle 80 is advanced distally, it receives in its lumen 81 a suture tag 68, which is joined to a suture 64. As the needle penetrates the individual portions of tissue that have been collected in the vacuum chamber 142, it passes the suture tag and suture through the tissue as well. After passing through all portions of tissue, the suture tag is ejected from the distal end of the needle into exit channel 96 extending distally of the most distal suction port 144. Ramp 100 of the exit channel guides the suture tag 68 upward and outward from the device when the vacuum is discontinued and tissue is released from the suction ports 144. The suture 64 passes through the suture chamber 94 extending along the top surface of the capsule 148. The suture and tag then remain permanently with the tissue as is described in detail above in connection with the preferred embodiments.
As tissue is drawn into the suction ports 202 under vacuum, the partition 204 causes the tissue to be separated into two distinct mounds or portions into which tissue securement means such as sutures may be driven as is described below. The suction ports 202 may be in communication with a single, common vacuum chamber 206 (as shown in
As shown in
With the side-by-side capsule embodiment 200, there are several possible mechanisms for tissue securement may be employed. Tissue securement may comprise suture material passed through the tissue portions. Alternatively, the tissue securement mechanism may comprise a clip that is driven into the tissue to secure the portions and remains in the patient, such as a helical wire coil described below. Several tissue securement advancement mechanisms are also possible. Specifically, several needle configurations and suture tag securement embodiments are possible with the multiple suction port capsule 200.
In one embodiment of the side-by-side device, shown in
The forked needle 212 is slidable within the capsule and track 224, best shown in the sectional views of the capsule in
In use, the side-by-side suture capsule 200 is advanced into the patient at the distal end of an endoscope. The forked needle 212 is withdrawn proximally so that the needle prongs 216 reside within the fork guides 230, to keep the suction ports 202 open and ready to receive tissue. The forked needle 212 is placed sufficiently proximal so that the pointed suture tags 222 are also withdrawn into the fork guides 230. Sutures 236 joined to tags 222 are also partially withdrawn into the fork guides 230 slightly and are permitted to extend outward from the fork guides and out from the suction ports 202 then extend along the endoscope and outside of the patient's body. The sutures 236 are securely fastened to the center of the suture tags 221 either by heat bonding in the case of polymer tag, or by a knot formed internal of the tag if formed of a hollow rigid material such as stainless steel. The tags are located in the tag receptacles 220 or within the inside diameter of the needle by a friction fit.
The capsule is maneuvered to the treatment site and the suction ports 202 are placed against tissue to be joined. After positioning the capsule, suction is applied through the vacuum channel 234 causing tissue to be drawn into the suction ports 202 and into the vacuum chamber 206. The partition 204 and sidewalls 208 cause the tissue to conform into two equally shaped mounds or portions, useful in forming a plication once sutures have been applied and secured. Next, the forked needle 212 is advanced distally through the tissue that has been captured and retained in the vacuum chamber 206. The prongs 216 of the distally advancing needle continue across the suction ports 202 as the pointed suture tags 222 pierce and penetrate the tissue.
After exiting the tissue portions the prongs of the needle continue distally slightly into the area of tag catches 238 located at the distal side of each suction port 202. The sutures 236 will have been drawn through the tissue along the pathway that has been created by the forks 216 of the needle 212. The tag catches are formed as notches in the top surface of the capsule that are aligned with the path of the advancing forked needle. The tags may be expelled from the needle forks on the through side of the tissue by several mechanisms. The suture catches may be sized so that the suture tags become temporarily frictionally engaged in the suture catches such that when the forked needle 212 withdraws proximally, the tags remain in the catches 238, being withdrawn from the tag receptacles 220 of the withdrawing needle. Alternatively, the suture tags may be ejected from the hollow needle forks by a distal movement of a pusher wire 11 slidable within the control cable and needle (as shown in the prior art device of
After the needle has been withdrawn so that both forks 216 are again concealed within fork guides 230, proximal to the suction ports 202, suction may be discontinued to release the tissue portions, now with sutures 236 passing through the tissue portions. As the tissue withdraws from the capsule and the capsule is withdrawn from the patient, suture tags 222 are pulled from the suture catches 238, overcoming the force of the frictional engagement with the sidewalls of the catches. The freed catches 222 will tend to rotate perpendicular to the longitudinal axis of the suture that is passing through the suture. Accordingly, the suture and suture tag form a T-shape that effectively anchors the suture in the tissue. The tag 222 becomes oriented to transverse to the path of the suture through the tissue so that penetration into the tissue is resisted when a pulling force is applied to the suture material in the proximal direction. Alternatively the tags 222 may be driven into securement device that remains in the patient, such as a tag lock device described in greater detail below. The free ends of the sutures passed through the two portions of tissue may then be tied in a knot that that is advanced to the suture location or may be secured by a suture lock device in order to secure and hold the tissue portions together to form a plication.
An alternative side-by-side capsule embodiment utilizes separate vacuum chambers 206 for each suction port 202 that may be opened to vacuum independently. In this embodiment (not shown in the figures), separate vacuum chambers may be formed by extending the partition 204 downward through the chamber 206 dividing it into two separate chambers that may be independently opened to negative pressure. An advantage provided by separate vacuum chambers 206 is the ability to draw tissue portions into the chambers separately and sequentially. Sequential capturing of the tissue portions permits the physician to verify that the first tissue section has been fully captured in the vacuum chamber before attempting to capture a second tissue portion. The physician may verify complete tissue capture visually by using the viewing capability of the endoscope. Additionally, the physician may capture a first tissue section then reposition the capsule slightly against the tissue to alter where the second captured tissue section will be to better orient the placement of the sutures and the configuration of the resulting tissue plication.
In another embodiment of the side-by-side tissue apposition device shown in
During distal advancement, the needles are diverted from their path along the longitudinal axis of the capsule by a diverter 310 placed within the needle track 306, as best shown in the sectional views of the capsule in
The needles of the diverter capsule embodiment 300 may be moved independently. The proximal ends of the needles may be joined to two independently movable elongate pushing cables extending through the working channel 3 of an endoscope in place of the single elongate cable 10 that serve to move the single needle of the previously described embodiments. Two cables of a reduced diameter may be placed within a single working channel endoscope to provide independent movement of the needles. Alternatively, an endoscope having dual working channels may be used with a pusher cable for each needle 302 placed in each working channel and joined to the proximal ends of the needles to provide independent control over their movement through the capsule 300. Alternatively, the needles 302 of the diverter capsule embodiment 300 may be joined to a single elongate cable to provide tandem, unified movement of the needles through the capsule with movement of the single cable.
In use, the diverter capsule 300 is navigated to an internal tissue location within a patient at the distal end of an endoscope. The needles 302 are maintained proximally withdrawn inside the left and right needle pathways 320 and 318 during delivery. Sutures 326 extend from tags 328 frictionally located at the distal tips of the needles 312. As with the embodiments described above, the tags 328 may form the piercing distal tip of the needle that is later separated from the needle to become a cylindrical anchor that later rotates to be perpendicular to the pathway of the suture extending through the tissue. Alternatively, if the needles are hollow, the tags 328 may be frictionally held within the tip of the needle and later ejected from the needle by a pusher wire slidably contained therein as with the embodiment 200 described above. Receptacles 330 formed distal to the suction ports 304 provides space for the tags to be ejected from the needle to rotate free of the capsule after being driven through the tissue portions. Alternatively, rather than receptacles, a passageway may be formed at the distal end of the suction ports 304 that permits the tags to be ejected into a chamber at the distal tip of the capsule where the tags will become captured, in similar fashion to the embodiments and prior art devices described above in
Continuing with the operation of the diverter capsule embodiment, after the capsule is navigated to a tissue location, suction is applied to the vacuum chamber 324 through vacuum channel 332 to draw tissue portions into the suction ports 304 so that the tissue becomes seated in vacuum chamber 328. In the case of a diverter capsule embodiment having separate vacuum chambers 324 for each suction port 304, tissue portions may be drawn into the suction port sequentially as vacuum may be selectively open to each of the side-by-side chambers. If vacuum is open to one of the chambers to draw in tissue to that chamber, the needle 302 corresponding to that chamber may then be advanced distally to immediately capture the tissue section without necessitating that the needle for the other chamber be activated. After one tissue section has been sucked into the suction port 304 and pierced by the needle 302 driven distally through it, the physician can be assured that the tissue section will remain captured if repositioning of the capsule is required to capture the second section of tissue in the remaining suction port. Next, vacuum is introduced into the remaining free vacuum chamber 324 to capture a second section of tissue through the suction port 304. The second needle 302 may then be advanced distally to penetrate and capture the second tissue portion. The suture tags 328 may then be ejected from the needles 312 either by a pusher wire slidably received in one or both of the needles or by frictional engagement with the receptacles 330 or tag locks as will be described below. After the suture tags 328 have been ejected on the through side of the tissue, the needles may be withdrawn proximally from the tissue and vacuum is discontinued to release the tissue portions from the device. The free ends of the sutures, which extend outside the patient's mouth may then be secured by surgical knots or suture locks to secure the tissue.
As with the previous embodiments, suction ports 402 open to vacuum chambers 404 into which tissue is drawn when vacuum is applied. It is preferred that in the offset embodiment 400 that the vacuum chambers 404 be configured to operate separately, each serving only one suction port 402 so that tissue can be selectively captured in the suction ports. Additionally, it is preferred that the needles 408 be separate and independently operable.
As best shown in
An alternative tissue securement device for the captured tissue portions is shown in
The suture material 616 is conventional surgical suture of about 0.010 inches in diameter. The suture material may be joined to the tags by heat bonding if a polymer material such as PEEK is used to form the tags. Sutures may be attached to stainless steel tags by forming the tags to be hollow and forming a hole through the surface of the tag. The suture material may be passed through the hole and knotted to create a diameter that will not pass back through the hole. This securement mechanism is also used for the prior art suture tag described in connection with
As an alternative to capturing the suture tags by frictional engagement, the tag receptacles 614 may be sized to permit the tag to pass completely through the lock block 608 and become captured on the through side of the lock block. To accomplish successful capture of the tag by this method, the suture should be joined to the center of the tag as shown in
In the diagrammatic representation of the resulting tissue configuration shown in
Suture tag 630 is delivered by the right needle fork 628, through the lock block 634 and into the right lock block 620 where it becomes secured in receptacle 612. Tag 630 carries with it a length of suture 616 (not shown) only sufficiently long to traverse the right tissue section 656 as the suture is also securely fastened at the other end to the second right lock block 634.
After the tags are ejected from the needles and the needles are withdrawn proximally, the tag lock band and captured tags may be pulled from the capsule. The tag lock band 660 is easily removed from its receptacle 664 and tag receptacles 234 are sized to easily release the tags as the capsule is withdrawn from the patient. The tag lock band offers a broader tissue contact surface area that offers better support and confinement of tissue that is being secured, which may help to form more usefully shaped tissue plications.
In use, the capsule 700 is delivered to a tissue location at the distal end of an endoscope as with the previous embodiments described above. Suction is applied to the vacuum chamber 712 to draw tissue through the suction ports 702 and into the chamber. The tissue is divided into two sections by partition 704. Despite the presence of slots 710, broad surfaces 720 at the top of each prong 706 help to hold tissue back along the partition wall 704 so that it does not herniate into the openings of the slots 710. After the tissue has been captured within the vacuum chamber 712 through each suction port 702, the helical coil 708 is rotated and advanced distally through the vacuum chamber and along the center partition 704, threading into left and right tissue portions captured in the vacuum chambers to hold them together. The leading tip of the helical wire 722 is sharpened to facilitate penetration through the tissue. A stop may be provided at the distal end of the partition to prevent further rotation and distal advancement of the coil once it has been threaded through all slots that are open to the suction ports 702. After the helical wire has been completely threaded through the tissue portions, spaces 710 permit the helical wire to move upward and out from the vacuum chamber without interference with the partition 704 when vacuum is discontinued to release the tissue. It is believed that the helical wire securement device may provide a more reliable securement of the tissue portions because of its multiple penetration points through both portions of tissue in comparison to the single penetration a suture thread may provide.
In addition to securing tissue, the present embodiment may be used to endoscopically deliver implants to internal tissue locations for other purposes. Implants such as coil implant 708 may be delivered into tissue to promote bulking of the tissue area. Tissue bulking in certain regions of tissue may achieve a similar effect in the treatment of GERD that tissue plication formation achieves. Use of implants to achieve bulking may be useful in the Z-line region between the esophagus and stomach, which is easily reachable by an endoscope carrying capsules of the present invention. Additionally the implant may configured to carry bulking agents to the tissue site, by coating or other means.
In another aspect of the present invention the tissue apposition device may incorporate tissue abrasion means in the capsule body. It is believed that abrading the portions of tissue sufficiently to initiate a healing process, before securing the tissue portions into contact, will lead to combined tissue ingrowth throughout the tissue surface interface. The tissue will heal together, eventually becoming one tissue portion. Such connective strength would be an improvement over the reliability and strength of means currently available to secure tissue plications together in procedures such as endoscopic suturing for GERD treatment.
It is noted that with the mechanical abrasion means, as well as with all abrasion means discussed herein, light vacuum is applied at the vacuum chamber to hold tissue in or against the suction ports and in contact with the surface 852 of the device 850 during the abrasion activity. Holding the tissue against the device not only insures that abrasion takes place, but also insures that the abrasion is applied to the tissue surfaces that will placed into contact with each other when the tissue portions are joined. After the abrasion action is complete, a full vacuum is applied to fully draw tissue into the vacuum chamber for tissue securement means attachment such as by needle and suture or staple placed through the tissue or other form of tissue adhesion.
Alternatively, or in addition to, the mechanical abrasion caused by structural elements applied to the capsule body 852, abrasive substances may be ejected from the capsule through an ejection port 862 arranged near the suction ports. Abrasive substances include salt or sugar or any biocompatible crystalline substance capable of flowing adequately to be injected through a tube running the length of the endoscope and being ejected through the small port 862. The substance may be carried in an aqueous media to facilitate delivery. It is expected that the presence of the abrasive substance will abrade the tissue adequately through its motion rubbing against itself and against the device to initiate a healing response.
Alternative means can be used for abrading the tissue with elements, such as element 866 that transmit other types of energy such as laser, ultrasonic or electrical energy. In the case of laser energy, an optical fiber can be extended through the endoscope to transmit the laser energy to a lens on the capsule surface. Ultrasonic energy may be transmitted through a small vibratory horn element, also positioned on the surface of the capsule, adjacent the suction port. Electrical energy, which injures the tissue by heat generated from electrical resistance at the element 866 may be transmitted from a source outside the patient through small wires led through a channel of the endoscope, as can be arranged for the transmission of RF energy or ultrasonic energy.
Chemical abrasion is also possible with the above-described devices. To utilize chemical abrasion, a chemically abrasive substance such as hydrochloric acid of a greater concentration than which naturally occurs in the stomach may be ejected from a port adjacent the suction port similar to port 862 discussed above with reference to
Utilizing abrasion techniques in conjunction with a single suction port tissue apposition requires that the procedure be carried out in a specific manner in order to achieve the desired result of tissue segments healing together and bonding as one. Specifically, a tissue portion is first captured by the capsule body by applying light pressure through the suction port 860. The vacuum is achieved through suction ports 870 at the bottom of chamber 860, which are in communication with vacuum lines connected to a vacuum source external to the patient. A light vacuum applied should be sufficient only to hold the tissue against the opening 872 of the suction port, without sucking tissue inside the chamber. With the tissue held against the surface 852 of the capsule, the abrasion mechanism can be activated with assurance that it will be in contact with the tissue and that the tissue will not move relative to the abrasion mechanism. After the abrasion is complete, the tissue may be sucked into the vacuum chamber under full vacuum and a tissue securement device applied such as a suture, permanent tag or staple as is described in the prior art.
The tissue abrasion mechanism should be spaced from the suction port an appropriate distance so that when the tissue is later sucked completely into the chamber, and the suture is passed through the tissue portion, the abraded tissue will be near the suture entry point or otherwise in an area on the tissue surface that will be placed in contact with other abraded tissue when the plications are secured together. After a tissue securement device has been placed through the collected tissue, the vacuum may be terminated to release the tissue from the device, and the device moved to an adjacent area of tissue where the same process will be undertaken. After the second tissue securement device is placed through the second tissue portion, the tissue securement devices may be joined together by a surgical knot or suture lock component to hold the tissue plications together as a group. It is between these plications that tissue ingrowth and bonding is desired to supplement the connective force of the tissue securement device (suture, permanent tag or staple). Accordingly, the second and subsequent tissue treatment sites should be selected carefully so that the abrasion and tissue securement device are positioned in such a manner that the several tissue portions will align and have an opportunity to heal together. Ensuring proper alignment of the multiple tissue portions is made easier when the abrasion means is employed with a multiple suction port tissue apposition device as is described below.
As shown in
As shown in
Accordingly, the process for utilizing the multiple suction port tissue apposition devices with abrading means as shown in
After the tissue abrasion is complete, full vacuum may be applied through the suction ports 872 to draw the tissue portions 890 fully into each vacuum chamber 860. The needle 880 may then be advanced through the double folds of tissue simultaneously, carrying the suture 878 and suture tag 874 through the two double fold portions of tissue. After the tag is ejected on the through side of the tissue and the needle 880 is withdrawn, the vacuum may be discontinued to release the double folds of tissue or plications 890 newly formed by the suction into the vacuum chamber. The securement mechanism for the anchored suture will later be tightened to draw the plications into close contact.
After the tissue is released from the device, the suture material 878 passes through channel 894 formed between the suction ports to permit release of the system in the in-line embodiment of
Because the tissue healing that will occur at tissue areas 892 is believed to ultimately bond the tissue portions 890 together, the suture material 878, tag 874 and lock 650 may be fabricated from biodegradable materials such as polymers of the poly-l-lactide family, configured to degrade after sufficient time for healing has occurred.
From the forgoing it should be understood that novel and useful tissue apposition devices employing multiple suction ports and methods for their use have been provided. Various mechanisms and methods for tissue capture and tissue securement that are compatible with the apposition devices have also been presented. It should also be understood that while the inventive embodiments have illustrated in the context of forming tissue plications for GERD treatment, the invention may be used in a variety of other endoscopic procedures where tissue manipulation is required. Examples include: segregating portions of the stomach to reduce it's size in obese patients; delivery of radiopaque elements for use as fluoroscopic markers used to identify sections of cancerous colon that need to be resected by a surgeon; attachment of sensor devices, such as pH, to the gastro-intestinal wall; closure of perforations or ulcers; and creation of anastomoses.
It should be understood however, that the foregoing description of the invention is intended merely to be illustrative thereof and that other modifications, embodiments and equivalents may be apparent to those who are skilled in the art without departing from its spit. Having thus described the invention what we desire to claim and secure by Letters Patent is:
This application is a continuation of U.S. application Ser. No. 10/220,379, filed Mar. 24, 2003, now U.S. Pat. No. 7,399,304 which is the U.S. National Stage of International Application No. PCT/US01/06835, filed Mar. 2, 2001, which claims the benefit to U.S. Provisional Applications Nos. 60/186,771, filed Mar. 3, 2000, 60/186,650, filed Mar. 3, 2000, and 60/187,275, filed Mar. 6, 2000, the entire contents of which are incorporated herein by reference.
| Number | Name | Date | Kind |
|---|---|---|---|
| 3868448 | Hahn et al. | Feb 1975 | A |
| 4133315 | Berman et al. | Jan 1979 | A |
| 4246893 | Berson | Jan 1981 | A |
| 4403604 | Wilkinson et al. | Sep 1983 | A |
| 4416267 | Garren et al. | Nov 1983 | A |
| 4739758 | Lai et al. | Apr 1988 | A |
| 4899747 | Garren et al. | Feb 1990 | A |
| 5037021 | Mills et al. | Aug 1991 | A |
| 5080663 | Mills et al. | Jan 1992 | A |
| 5084061 | Gau et al. | Jan 1992 | A |
| 5250053 | Snyder | Oct 1993 | A |
| 5259399 | Brown | Nov 1993 | A |
| 5327914 | Shlain | Jul 1994 | A |
| 5474565 | Trott | Dec 1995 | A |
| 5562689 | Green et al. | Oct 1996 | A |
| 5571116 | Bolanos et al. | Nov 1996 | A |
| 5665376 | Russo | Sep 1997 | A |
| 5792153 | Swain et al. | Aug 1998 | A |
| 5868141 | Ellias | Feb 1999 | A |
| 5868760 | McGuckin | Feb 1999 | A |
| 5887594 | LoCicero, III | Mar 1999 | A |
| 5938668 | Scirica et al. | Aug 1999 | A |
| 5977175 | Lin | Nov 1999 | A |
| 6009877 | Edwards | Jan 2000 | A |
| 6044846 | Edwards | Apr 2000 | A |
| 6092528 | Edwards | Jul 2000 | A |
| 6102922 | Jakobsson et al. | Aug 2000 | A |
| 6139555 | Hart et al. | Oct 2000 | A |
| 6234955 | Silverman et al. | May 2001 | B1 |
| 6238335 | Silverman et al. | May 2001 | B1 |
| 6248058 | Silverman et al. | Jun 2001 | B1 |
| 6251063 | Silverman et al. | Jun 2001 | B1 |
| 6251064 | Silverman et al. | Jun 2001 | B1 |
| 6398795 | McAlister et al. | Jun 2002 | B1 |
| 6427089 | Knowlton | Jul 2002 | B1 |
| 6447533 | Adams | Sep 2002 | B1 |
| 6494888 | Laufer et al. | Dec 2002 | B1 |
| 6530878 | Silverman et al. | Mar 2003 | B2 |
| 6533717 | Silverman et al. | Mar 2003 | B2 |
| 6540789 | Silverman | Apr 2003 | B1 |
| 6543456 | Freeman | Apr 2003 | B1 |
| 6558400 | Deem et al. | May 2003 | B2 |
| 6572629 | Kalloo et al. | Jun 2003 | B2 |
| 6575896 | Silverman et al. | Jun 2003 | B2 |
| 6592596 | Geitz | Jul 2003 | B1 |
| 6595909 | Silverman et al. | Jul 2003 | B2 |
| 6595910 | Silverman et al. | Jul 2003 | B2 |
| 6608029 | Kolterman et al. | Aug 2003 | B1 |
| 6627206 | Lloyd | Sep 2003 | B2 |
| 6663639 | Laufer et al. | Dec 2003 | B1 |
| 6675809 | Stack et al. | Jan 2004 | B2 |
| 6712814 | Edwards et al. | Mar 2004 | B2 |
| 6716222 | McAlister et al. | Apr 2004 | B2 |
| 6749607 | Edwards et al. | Jun 2004 | B2 |
| 6758219 | Sapala et al. | Jul 2004 | B2 |
| 6773440 | Gannoe | Aug 2004 | B2 |
| 6773441 | Laufer et al. | Aug 2004 | B1 |
| 6845776 | Stack et al. | Jan 2005 | B2 |
| 6846312 | Edwards et al. | Jan 2005 | B2 |
| 6858576 | Young et al. | Feb 2005 | B1 |
| 6955643 | Gellman | Oct 2005 | B2 |
| 6997931 | Sauer | Feb 2006 | B2 |
| 7037315 | Sancoff et al. | May 2006 | B2 |
| 7037344 | Kagan et al. | May 2006 | B2 |
| 7083630 | DeVries et al. | Aug 2006 | B2 |
| 7090684 | McGuckin et al. | Aug 2006 | B2 |
| 7125413 | Grigoryants | Oct 2006 | B2 |
| 7175638 | Gannoe et al. | Feb 2007 | B2 |
| 7204842 | Geitz | Apr 2007 | B2 |
| 7229428 | Gannoe | Jun 2007 | B2 |
| 20010011543 | Forsell et al. | Aug 2001 | A1 |
| 20020022851 | Kalloo et al. | Feb 2002 | A1 |
| 20020055750 | Durgin et al. | May 2002 | A1 |
| 20020065523 | McAlister et al. | May 2002 | A1 |
| 20020082616 | McAlister et al. | Jun 2002 | A1 |
| 20020107530 | Sauer et al. | Aug 2002 | A1 |
| 20020115991 | Edwards | Aug 2002 | A1 |
| 20020139379 | Edwards et al. | Oct 2002 | A1 |
| 20020143346 | McGuckin et al. | Oct 2002 | A1 |
| 20020169357 | Chen | Nov 2002 | A1 |
| 20020183765 | Adams | Dec 2002 | A1 |
| 20020183768 | Deem et al. | Dec 2002 | A1 |
| 20020193816 | Laufer et al. | Dec 2002 | A1 |
| 20030009165 | Edwards et al. | Jan 2003 | A1 |
| 20030021822 | Lloyd | Jan 2003 | A1 |
| 20030109892 | Deem et al. | Jun 2003 | A1 |
| 20030113310 | Van Laere et al. | Jun 2003 | A1 |
| 20030158601 | Silverman et al. | Aug 2003 | A1 |
| 20030188755 | Milbocker | Oct 2003 | A1 |
| 20030208209 | Gambale et al. | Nov 2003 | A1 |
| 20030233108 | Gellman et al. | Dec 2003 | A1 |
| 20030236536 | Grigoryants et al. | Dec 2003 | A1 |
| 20040006351 | Gannoe et al. | Jan 2004 | A1 |
| 20040039452 | Bessler | Feb 2004 | A1 |
| 20040044353 | Gannoe | Mar 2004 | A1 |
| 20040044354 | Gannoe et al. | Mar 2004 | A1 |
| 20040059289 | Alvarez | Mar 2004 | A1 |
| 20040082963 | Gannoe et al. | Apr 2004 | A1 |
| 20040087977 | Nolan et al. | May 2004 | A1 |
| 20040092892 | Kagan et al. | May 2004 | A1 |
| 20040097415 | Kolterman et al. | May 2004 | A1 |
| 20040097986 | Adams | May 2004 | A1 |
| 20040097989 | Trigueros | May 2004 | A1 |
| 20040116949 | Ewers et al. | Jun 2004 | A1 |
| 20040117031 | Stack et al. | Jun 2004 | A1 |
| 20040122456 | Saadat et al. | Jun 2004 | A1 |
| 20040122473 | Ewers et al. | Jun 2004 | A1 |
| 20040133147 | Woo et al. | Jul 2004 | A1 |
| 20040158263 | McAlister et al. | Aug 2004 | A1 |
| 20040162567 | Adams | Aug 2004 | A9 |
| 20040162568 | Saadat et al. | Aug 2004 | A1 |
| 20040167546 | Saadat | Aug 2004 | A1 |
| 20040193190 | Liddicoat et al. | Sep 2004 | A1 |
| 20040194157 | Meguid | Sep 2004 | A1 |
| 20040194790 | Laufer et al. | Oct 2004 | A1 |
| 20040199180 | Knodel et al. | Oct 2004 | A1 |
| 20040210243 | Gannoe et al. | Oct 2004 | A1 |
| 20040220682 | Levine et al. | Nov 2004 | A1 |
| 20040225183 | Michlitsch et al. | Nov 2004 | A1 |
| 20040225305 | Ewers | Nov 2004 | A1 |
| 20040236356 | Rioux et al. | Nov 2004 | A1 |
| 20040258621 | Stern | Dec 2004 | A1 |
| 20040267378 | Gazi | Dec 2004 | A1 |
| 20050022827 | Woo et al. | Feb 2005 | A1 |
| 20050033319 | Gambale et al. | Feb 2005 | A1 |
| 20050033320 | McGuckin et al. | Feb 2005 | A1 |
| 20050043817 | McKenna | Feb 2005 | A1 |
| 20050049614 | Cendan | Mar 2005 | A1 |
| 20050055038 | Kelleher et al. | Mar 2005 | A1 |
| 20050065536 | Ewers et al. | Mar 2005 | A1 |
| 20050075653 | Saadat et al. | Apr 2005 | A1 |
| 20050080444 | Kramer et al. | Apr 2005 | A1 |
| 20050090837 | Sixto et al. | Apr 2005 | A1 |
| 20050119671 | Reydel et al. | Jun 2005 | A1 |
| 20050119674 | Gingras | Jun 2005 | A1 |
| 20050143760 | Imran | Jun 2005 | A1 |
| 20050149067 | Takemoto et al. | Jul 2005 | A1 |
| 20050149072 | DeVries et al. | Jul 2005 | A1 |
| 20050149200 | Silverman et al. | Jul 2005 | A1 |
| 20050171556 | Murphy | Aug 2005 | A1 |
| 20050177176 | Gerbi et al. | Aug 2005 | A1 |
| 20050216036 | Nakao | Sep 2005 | A1 |
| 20050251162 | Rothe et al. | Nov 2005 | A1 |
| 20050256587 | Egan | Nov 2005 | A1 |
| 20060020277 | Gostout et al. | Jan 2006 | A1 |
| 20060047289 | Fogel | Mar 2006 | A1 |
| 20060149316 | DeVries et al. | Jul 2006 | A1 |
| 20060212053 | Gertner | Sep 2006 | A1 |
| 20060282087 | Binmoeller | Dec 2006 | A1 |
| 20070055292 | Ortiz et al. | Mar 2007 | A1 |
| 20070129735 | Filipi et al. | Jun 2007 | A1 |
| 20070167963 | Deem et al. | Jul 2007 | A1 |
| 20070173931 | Tremulis et al. | Jul 2007 | A1 |
| 20070175488 | Cox et al. | Aug 2007 | A1 |
| Number | Date | Country |
|---|---|---|
| 0 571 938 | Dec 1993 | EP |
| 1 397 998 | Mar 2004 | EP |
| 1 749 480 | Feb 2007 | EP |
| 1 749 482 | Feb 2007 | EP |
| 1 759 639 | Mar 2007 | EP |
| WO 9320819 | Oct 1993 | WO |
| WO 9525468 | Sep 1995 | WO |
| WO 9935987 | Jul 1999 | WO |
| WO 9960931 | Dec 1999 | WO |
| WO 0048672 | Aug 2000 | WO |
| WO 0166020 | Sep 2001 | WO |
| WO 02060328 | Aug 2002 | WO |
| WO 02096327 | Dec 2002 | WO |
| WO 2004019765 | Mar 2004 | WO |
| WO 2004021894 | Mar 2004 | WO |
| WO 2004034973 | Apr 2004 | WO |
| WO 2004069056 | Aug 2004 | WO |
| WO 2004084808 | Oct 2004 | WO |
| WO 2004112563 | Dec 2004 | WO |
| WO 2005011463 | Feb 2005 | WO |
| WO 2005011519 | Feb 2005 | WO |
| WO 2005020802 | Mar 2005 | WO |
| WO 2005037072 | Apr 2005 | WO |
| WO 2005037152 | Apr 2005 | WO |
| WO 2005039458 | May 2005 | WO |
| WO 2005058239 | Jun 2005 | WO |
| WO 2007019268 | Feb 2007 | WO |
| WO 2007095096 | Aug 2007 | WO |
| Number | Date | Country | |
|---|---|---|---|
| 20080215069 A1 | Sep 2008 | US |
| Number | Date | Country | |
|---|---|---|---|
| 60186771 | Mar 2000 | US | |
| 60186650 | Mar 2000 | US | |
| 60187275 | Mar 2000 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 10220379 | US | |
| Child | 12070809 | US |
