Patent Grant
11166704
The invention relates to a device and a system for the treatment of perianal fistulas.
A perianal fistula is an artificial tunnel that, in the majority of cases, develops from an infection that begins within a blocked anal gland. If the infection cannot be cleared from the anal gland an abscess forms and the infection burrows though the sphincteric muscles and exits at the buttocks integument. Patients experience pain associated with the tract and associated abscesses and suffer faecal and blood discharge from the fistula tract. Perianal fistulas may also result from gastro-intestinal diseases such as Crohn's disease, ulcerative colitis, colorectal cancers and their associated treatment and complications due to rectal fissures and trauma.
The global incidence of perianal fistula is 2 per 10,000 population. Over 100,000 fistula procedures are performed between the United States and Western Europe each year. Thirty percent of the procedures performed are reoperations due to treatment failure contributing to a significant preventable cost to the healthcare systems.
Given the inadequate treatment options and poor surgical outcomes there is a defined clinical need for a more effective perianal treatment device.
There is currently no single “gold standard” technique that a surgeon can perform to effectively cure a perianal fistula and not render the patient incontinent. A common fistula treatment is a fistulotomy procedure. A fistulotomy involves the dissection of the sphincteric muscles and the laying open of the fistula tract. Fistulotomies have a relatively high cure rate, however, this procedure results in a high risk of faecal incontinence.
From a patient's point of view, many are happy to assume the risk of incontinence in order to resolve the painful fistula tract. However, this is obviously not an ideal treatment pathway and for many patient population groups the secondary outcome is far from acceptable.
Another commonly used fistula treatment methodology is the use of a seton. Setons are used as a sphincter sparing technique and is simply a suture or vascular strap that is passed through the tract of the fistula and the rectum and tied in a loop. The seton maintains tract patency allowing the infection in the fistula tract to drain, help the tract constrict in length and may cure the tract. If the tract is not cured by the seton the physician can perform a fistulotomy. This approach of trying to preserve the sphincter with setons has been used for over 2500 years and is still the preferred method used by surgeons today.
In an effort to provide a non-destructive perianal fistula treatment various glues and plugs have been developed and introduced to colorectal surgeons in the past 20 years. However, these techniques are not very successful and their use is not widespread. Such glues which are injected into the fistula tract generally become brittle and are not able to occlude the tract for a long enough period to fully heal, faeces re-enter the tract resulting in abscess formation and refistulisation. Physicians often attempt to treat perianal fistulas with glues and plugs even though there may only be a 10 percent chance of effectiveness because it is a sphincter sparing technique and they can always resort to a seton and eventual fistulotomy if all fails.
Attempts have also been made to use plugs to occlude perianal fistula tracts. For example, US2005/004926A describes a plug-like fistula closure device with an attached flexible application string which also serves to evacuate liquids out of a fistula. However, generally the plugs fail because they become extruded from the tract, allowing faeces to enter the tract resulting in reinfection, abscess formation and refistulisation.
There is therefore a need for an improved method and device for the treatment of perianal fistulas.
According to the invention there is provided a fistula treatment system comprising a guide which is adapted to extend at least partially around a tissue tract. Also provided is an implant element which is adapted to track the pathway of a guide.
In one embodiment the implant element has a tracking configuration in which the implant element follows the pathway of the guide and an activated configuration, the implant in the activated configuration being adapted to draw tissue surrounding a tract inwardly.
The implant element in some cases comprises an anchor.
The anchor may comprise at least one barb.
The anchor may have a collapsed delivery configuration and a radially extending configuration.
The anchor may comprise a plurality of filaments.
In some cases the anchor is located at a distal end of the implant element.
In one embodiment the implant element forms a coil in the collapsed deployed configuration.
The coil in one case has a substantially uniform lateral extent along a length thereof.
The coil may be tapered along a length thereof.
In one embodiment the implant element is an activatable element. The activatable element may have a collapsed delivery configuration, a deployed configuration and an activated configuration. The activatable element may comprise an expansile element such as a balloon, or a foam.
In some embodiments the implant element comprises a shape memory material such as Nitinol.
In one case the implant element is at least partially bioabsorbable.
In some embodiments there are a plurality of implant elements.
In some embodiments the guide comprises a guide coil.
The guide coil may have a substantially uniform lateral extent along a length thereof.
The guide coil may be tapered along a length thereof.
In some cases the coil comprises a rail for the implant element.
The coil may be solid or hollow.
In one case the guide coil comprises a sharp distal tip.
In some embodiments the system comprises a drain or seton having an anchoring feature for anchoring the drain/seton in situ.
The anchoring feature may be provided at a compression zone or region of the seton.
In some cases the anchoring feature comprises a step or projection on the seton, such as one or more of a knot, a barb or a quill.
The seton may be hollow or solid.
In some cases the seton has a plurality of peripheral holes.
In some embodiments the shape of seton in cross section is selected from one or more of round, oval, star and cross.
The seton may comprise multiple elements. The elements of the seton may be braided.
In some cases at least a portion of the seton is bioabsorbable. In one case the seton is of differential bioabsorption. A proximal portion of the seton may be bioabsorbable.
The seton may extend from the implant.
In some cases at least a portion of the implant is bioabsorbable and at least a portion of the seton is configured to bioabsorb in advance of bioabsorption of the implant.
In another case the seton is bioabsorbable and the implant is not bioabsorbable.
The invention also provides a method for treating a perianal fistula comprising the steps of:
The method may further comprise:
The method may comprise anchoring the implant in the tissue.
In some cases the implant is anchored prior to activation of the implant.
The invention further provides a method for closing a fistula comprising:
The method may further comprise activating the implant element to draw tissue surrounding the tract inwardly. The method may further comprise anchoring the implant element in tissue, prior to activating the implant element.
According to the invention there is also provided a perianal fistula treatment device comprising an implant coil having an anti-rewind feature. The anti-rewind feature may be selected from one or more of:
In one embodiment the device comprises a tapered portion which is configured for insertion into bulk tissue surrounding a fistula and a driver interface portion which is configured for engagement with a driver for rotation of the coil to draw tissue surrounding a fistula inwardly.
The invention also provides a drainage seton having an anchoring feature for anchoring the seton in situ. In some cases the anchoring feature is provided at a compression zone or region of the seton.
In some embodiments the anchoring feature comprises a step or projection on the seton, such as one or more of a knot, a barb or a quill.
The invention further provides a fistula treatment system comprising a fistula treatment device of the invention and a driver implement for rotation of the coil to draw tissue surrounding a fistula inwardly. In one embodiment the driver implement comprises a driver coil which is configured for engagement with the driver interface of the implant coil.
In some cases at least a portion of the outer surface of the driver coil is lubricious.
There may be engagement features on the driver coil and/or the implant coil for temporarily locking the driver coil to the implant coil for delivery of the implant coil.
The invention also provides a fistula treatment system comprising a fistula treatment device of the invention and a tissue stabilising device for stabilising the mucosal tissue for delivery of the implant.
In some embodiments the stabilising device comprises a hollow element attached to the delivery mechanism and surrounding the implant prior to delivery. The hollow element may be spring loaded or otherwise to apply pressure to the mucosal surface.
In one embodiment a leading surface of the hollow element that interfaces to the mucosal surface interacts with the mucosal surface to prevent rotation and/or twisting of the mucosal lining. The hollow element may comprise features such as needles for penetration into the mucosal surface.
The invention also provides a method for treating a perianal fistula comprising the steps of:
In some embodiments the method comprises:
Also provided is a method for treating a perianal fistula comprising the steps of:
In some cases, after insertion of the implant coil, the delivery device is released from the coil.
The method may further comprise:
The method may comprise:
According to the invention there is provided a perianal fistula treatment device comprising an implant coil having a tapered portion which is configured for insertion into bulk tissue surrounding a fistula and a driver interface portion which is configured for engagement with a driver for rotation of the coil to draw tissue surrounding a fistula inwardly.
In one embodiment the driver interface portion of the coil has a substantially uniform lateral extent along a length thereof.
In one case the coil has a leading end, a transition region, and a trailing end, the tapered portion of the coil extending from the leading end to the transition region and the driver interface portion extending from the transition region.
Preferably the tapered portion of the coil decreases in lateral extent between the leading end and the transition region.
In one case the leading end of the tapered portion has a pointed tissue insertion tip.
In one embodiment at least the driver interface portion of the coil is solid.
Alternatively at least the driver interface portion of the coil is hollow.
In one case the coil is solid.
Alternatively the coil is hollow.
In some cases the shape of the coil in cross section is selected from one or more of round, oval, triangular, multifaced and ribbon.
In one embodiment at least a portion of the coil is bioabsorbable.
In one case the fistula treatment device further comprises a drainage seton.
The seton may extend from the coil.
In one case the seton is hollow.
In one case the seton is solid.
In one embodiment the seton has a plurality of peripheral holes.
The shape of seton in cross section in some cases is selected from one or more of round, oval, star and cross.
In one embodiment the seton comprises multiple elements. The elements of the seton may be braided.
In one case at least a portion of the seton is bioabsorbable.
In one case the seton is of differential bioabsorption. In one embodiment a proximal portion of the seton is bioabsorbable, for example, to facilitate removal of a remainder of the seton. In another embodiment a distal portion of the seton is bioabsorbable to facilitate closure of the enternal opening of the fistula prior to full absorption of the seton.
In one embodiment at least a portion of the coil is bioabsorbable and at least a portion of the seton is configured to bioabsorb in advance of bioabsorption of the coil.
The invention also provides a fistula treatment system comprising a fistula treatment device and a driver implement for rotation of the coil to draw tissue surrounding a fistula inwardly.
In one case the driver implement comprises a driver coil which is configured for engagement with the driver interface of the implant coil.
In one embodiment the driver coil has a substantially uniform lateral extent along a length thereof for engagement with the corresponding driver interface portion of the implant coil.
In one case the driver coil is hollow and the corresponding driver interface portion of the implant coil is solid.
In another case the driver coil is solid and the corresponding driver interface portion of the implant coil is hollow.
The invention also provides a perianal fistula treatment device comprising an implant coil which is configured for insertion into bulk tissue surrounding a fistula and being rotatable to draw tissue surrounding the fistula inwardly and a drainage seton extending from the tapered coil.
In one case the coil is tapered.
The invention also provides a perianal fistula treatment device comprising a tapered coil and a drainage seton mounted to and extending from the tapered coil.
The invention also provides a perianal fistula treatment device comprising an implant coil which is configured for insertion into tissue surrounding a fistula and a drainage seton wherein at least a portion of the seton is bioabsorbable.
In one embodiment the seton is of differential bioabsorption.
In one case a proximal portion of the seton is bioabsorbable to facilitate removal of a remainder of the seton.
The tapered coil is preferably configured for insertion at the site of the internal opening of a fistula and being rotatable to draw bulk tissue, including sphincteric muscle, surrounding the fistula inwardly.
In one case the coil has a leading end and a trailing end, the coil decreasing in lateral extent between the leading and trailing ends. The leading end may include a pointed tissue insertion tip.
In one embodiment the device comprises a seton attachment feature.
The attachment feature may be selected from one or more of:—a protrusion such as a ball-shape; a hook; a cleat; a butt joint; or a bond such as a thermal and/or adhesive bond.
In one embodiment the centering element has a recess or hole for reception of a seton. The seton may be bonded or fixed to the recess or hole in the centering feature, for example by adhesive and/or thermal bonding, and/or crimping.
In another embodiment the device comprises a delivery mechanism attachment feature.
In one case the device comprises a centre element which extends at least partially along a longitudinal axis of the coil.
The centre element may extend from the trailing end of the coil towards the leading end of the coil.
The centre element may extend to a distance beyond the leading end of the coil.
The centre element may comprise a seton attachment feature and/or a delivery mechanism attachment feature.
In one case the seton is hollow.
The seton may have a plurality of peripheral holes.
The shape of the seton in cross section may be selected from one or more of round, oval, star and cross.
In one case the seton comprises multiple elements which may be braided.
In one case the coil is solid. In another case the coil is hollow.
The shape of the coil in cross section may be selected from one or more of round, oval, triangular, multifaced and ribbon.
The invention also provides a fistula treatment device comprising a tapered coil which is configured for insertion into bulk tissue surrounding a fistula and being rotatable to draw tissue surrounding the fistula inwardly, the coil having a centering element that extends at least partially along a longitudinal axis of the coil.
The device may further comprise a drainage seton mounted to and extending from the tapered coil.
In one case the coil has a leading end and a trailing end, the coil decreasing in lateral extent between the leading and trailing ends. The leading end may include a pointed tissue insertion tip.
In one embodiment the device comprises a seton attachment feature.
In one embodiment the device comprises a delivery mechanism attachment feature.
In one case the centering element extends from the trailing end of the coil towards the leading end of the coil.
In one embodiment the centering element comprises a seton attachment feature. The attachment feature may be selected from one or more of:—a protrusion such as a ball-shape; a hook; a cleat; a butt joint; or a bond such as a thermal and/or adhesive bond.
The centering element may have a recess or hole for reception of a seton. The seton may be bonded or fixed to the recess or hole in the centering feature, for example by adhesive and/or thermal bonding, and/or crimping.
In one embodiment the centering element comprises a delivery mechanism attachment feature. The seton may be hollow or solid. The seton may have a plurality of peripheral holes. The seton in cross section may be selected from one or more of round, oval, star and cross. The seton comprises multiple elements. The elements may be braided. The coil may be solid or hollow. The shape of the coil in cross section may be selected from one or more of round, oval, triangular, multifaced and ribbon.
The invention also provides a system comprising a fistula device of the invention and a delivery device for the perianal fistula treatment device.
In one embodiment the delivery device comprises a hollow element through which the tapered coil is delivered.
In one embodiment the delivery device comprises a solid element over which a hollow tapered coil is delivered.
In one embodiment the delivery device comprises a hollow element through which a straight cylindrical coil is delivered.
In one embodiment the delivery device comprises a solid element over which a hollow straight cylindrical coil is delivered.
The hollow delivery element may comprise a coil.
In one embodiment the delivery device comprises a rail for the delivery of the tapered coil. The rail and the coil may comprise interengagable track features.
The invention also provides a method for treating a perianal fistula comprising the steps of:
In one embodiment the method further comprises:
In one case the method comprises embedding the seton in the sphincter muscle complex and leading the seton so that the distal end of the seton protrudes through the external opening of a fistula tract.
The invention also provides a method for treating a perianal fistula comprising the steps of:
In one embodiment, after insertion of the implant coil, the delivery device is released from the coil.
The method may further comprise:
The method may comprise:
The perianal fistula treatment device has the advantages of:
The device preserves the patient's continence by protecting the sphincteric muscles from division. The device is securely anchored into the fistula tract, effectively sealing the tract and preventing faecal matter from entering the internal opening during the healing process.
The device allows any remaining abscess materials to drain from the tract during the healing process. The device may be integrated into the tissue over the healing process, and may be ultimately absorbed as the tract is healed.
The invention removes variability due to surgeon skill by providing a standardised technique for treating perianal fistulas.
The device facilitates gathering and apposing sphincter muscle tissue allowing repair of a defect in the muscle bulk.
A single ended drainage seton is attached to allow drainage of a fistula tract post closure of the internal opening of a tract.
A delivery mechanism is provided with attachment feature(s) to interface with the tapered coil and seton.
The tapered coil may have an anchor for a single ended seton.
The tapered coil may be of metal, bioabsorbable polymer, bioabsorbable metal.
The drainage seton may be made from any suitable materials including bioabsorbable, synthetic.
The system may be capable of delivering multiple coils.
The system may be capable of delivering a tapered coil located at the distal portion of an endoscope.
The method for treating an anal fistula may include any or all of the following steps:
Aspects of the present disclosure may be directed to a method of treating a perianal fistula with an implant. The implant may have a proximal end and a distal end, and the perianal fistula may have an internal opening from the rectum, an external opening in an external surface of a buttocks, a fistula tract extending between the internal opening and the external opening, and fistula tissue surrounding the fistula tract. The method may include:
The sealing may include sealing against pressure of up to 150 mmHg.
The sealing may include sealing against pressure of up to 200 mmHg.
The compressing may include compressing fistula tissue in an apposed configuration.
The method may further include facilitating a passageway through the external opening to allow for draining.
The method may further include positioning a drainage member within the fistula tract.
At least a portion of the drainage member may extend from a location within the fistula tract and through the external opening.
The compressing may include progressively compressing fistula tissue such that a compression force imparted to fistula tissue via the distal end of the implant may be less than a compression force imparted to fistula tissue via the proximal end of the implant.
Following the compressing, a majority of the fistula tract may remain open.
Aspects of the present disclosure may be directed to a method of treating a perianal fistula with an implant. The implant may have a proximal end and a distal end, and the perianal fistula may have an internal opening from the rectum, an external opening in an external surface of a buttocks, a fistula tract extending between the internal opening and the external opening, and fistula tissue surrounding the fistula tract. The method may include:
The forming the perianal sinus may include rotating the implant to advance the implant through fistula tissue toward the external opening.
The rotating of the implant may cause compression of the fistula tissue.
The method may further include drawing fistula tissue radially inwardly, a first region of fistula tissue may be drawn radially inwardly to a greater extent than at least a second region of fistula tissue, and the first region may be closer to the internal opening than the second region.
The implant may comprise a tapered portion, the forming the sinus may include drawing tissue radially inwardly via the tapered portion, a proximal end of the tapered portion having a diameter less than a distal end of the tapered portion, the implant being deployed such that the proximal end may be closer to the internal opening than the distal end.
The method may further include positioning a drainage member within the fistula tract, at least a portion of the drainage member may extend from a location within the fistula tract and through the external opening.
The method may include embedding the proximal end of the implant in the fistula tissue.
The forming of the perianal sinus may further include forming a seal against pressure of up to 150 mmHg.
Aspects of the present disclosure may be directed to a method of treating a perianal fistula with an implant. The implant may have a proximal end and a distal end, and the perianal fistula may have an internal opening from the rectum, an external opening in an external surface of a buttocks, a fistula tract extending between the internal opening and the external opening, and fistula tissue surrounding the fistula tract. The method may include:
The method may further include compressing fistula tissue via the implant, the compressing may include progressively compressing fistula tissue such that a compression force imparted to fistula tissue via the distal end of the implant may be less than a compression force imparted to fistula tissue via the proximal end of the implant.
The method may further include compressing fistula tissue so as to close the internal opening while maintaining the external opening open.
The facilitating drainage through the external opening may include positioning a drainage member in the fistula tract, at least a portion of the drainage member may extend from a location within the fistula tract and through the external opening.
The at least one of the implant or the drainage member may be bioabsorbable.
Both of the implant and the drainage member may be bioabsorable, and a rate of absorption of the implant may be faster than a rate of absorption of the drainage member.
Both of the implant and the drainage member may be bioabsorable, and a rate of absorption of the drainage member may be faster than a rate of absorption of the implant.
A method of closing an opening in tissue may include:
The method may further include drawing tissue around the opening radially inwardly toward a center of the implant, a first region of tissue may be drawn radially inwardly to a greater extent than at least a second region of tissue.
The implant may include a tapered coil portion tapering toward a proximal end of the coil.
The method may further include sealing closed only one end of the opening.
The method may further include engaging a tapered distal section of a delivery device with an inner surface of the implant.
The method may further include engaging a non-tapered distal section of a delivery device with an external surface of the implant.
An implant for treating a fistula may comprise:
The shaft may further include a non-tapered portion.
Each of the plurality of barbs may be located distally of the non-tapered portion.
The non-tapered helical coil portion may extend along a minority of a length of the shaft between the proximal end and the distal end.
Each of the plurality of barbs may be a pre-formed, positive, anti-rotation feature.
An implant for treating a fistula may comprise:
The tapered portion may include more coil loops than the non-tapered portion.
A longitudinal length of the non-tapered portion may be smaller than a longitudinal length of the tapered portion.
The implant may include a channel extending along a surface of at least some of plurality of coil loops.
The implant may further include a drainage member having a deployed configuration in which the drainage member may be fixed relative to the implant.
The implant may further include a driving abutment positioned between the proximal end and the distal end.
A system for treating a fistula may comprise:
The implant may include a channel extending along a surface of at least some of plurality of coil loops.
The driver coil may be a non-tapered coil.
The implant may further include a non-tapered portion.
The implant may further include a driving abutment located along the non-tapered portion.
The non-tapered portion may extend along a minority of a length of the implant between the proximal end and the distal end of the implant.
In the first configuration, one of the section of the driver coil and the portion of the implant may be received within the other of the section of the driver coil and the portion of the implant.
The portion of the implant may be the non-tapered portion.
The system may further include a drainage member having a deployed configuration in which the drainage member may be fixed relative to at least one of the implant or the driver coil.
A kit for closure of an opening in human tissue may comprise:
The helical coil may further include a non-tapered coil portion.
The tapered coil portion may include a first plurality of coil loops and the non-tapered coil portion may include a second plurality of coil loops, the first plurality of coil loops may include a greater number of coil loops than the second plurality of coil loops.
A longitudinal length of the non-tapered helical coil portion may be smaller than a longitudinal length of the tapered helical coil portion.
A driving abutment may be positioned between the proximal end and the distal end.
At least one of the implant or the drain member may be bioabsorbable.
Both of the implant and the drain member may be bioabsorable, and a rate of absorption of the implant may be faster than a rate of absorption of the drain member.
Both of the implant and the drain member may be bioabsorable, and a rate of absorption of the drain member may be faster than a rate of absorption of the implant.
The invention will be more clearly understood from the following description of an embodiment thereof, given by way of example only, with reference to the accompanying drawings, in which:
The device is capable of one or more of the following:
The perianal fistula treatment device ensures sparing of the sphincter, occluding of the fistula tract internal opening, and promotion of drainage and tissue healing.
The device consists of a head with anchoring and sealing mechanisms which is secured in the tissue tract and prevents re-infection of the wound. A tail section provides seton-like drainage and prevents re-abscessing due to premature closure of the skin site.
The anchoring and sealing mechanism of the device consists of a tapered coil. The coil geometry is designed to pull tissue together as is it deployed into the sphincter muscle complex, resulting in a strong anchor but also, importantly, an effective compressive seal preventing reinfection of the fistula tract and close tissue approximation to enhance tissue healing.
The perianal fistula treatment device preserves sphincteric and anatomical conditions and functions, prevents re-fistulisation, and improves healing time over the current treatment methods. The device consists of a tapered coil and a drainage seton. There may be a centering alignment feature. A delivery mechanism is also described. The coil may be led into the fistula tract by the drainage seton and centered into the tract by means of the centering feature. The larger diameter of the tapered coil is abutted against the tissue surface, surrounding the internal opening of the fistula tract with adequate margin. The delivery mechanism rotates the coil until it is just submucosal positioned. The coil closes the fistula internal opening by compressing the tract's surrounding tissue inwardly such that the tissue is brought within close approximation creating a seal impermeable to foreign materials and promoting tissue growth across the closely approximated fistula tract. The drainage seton provides a conduit to drain any abscess and remaining or newly formed exudate and fluids from the fistula tract throughout the time of the healing process. The centering feature insures the coil device is placed easily into the fistula tract and the outer coil is placed within the adequate margins surrounding the fistula tract and acts as a securing mechanism for the drainage seton.
The following numerals are used in the drawings:
The tapered coil 11 is brought into apposition to the mucosal tissue wall of the rectum 20 as shown in
The driver mechanism 17 delivers the coil 11 through the mucosal lining 20 of the rectum 1 via rotatory or other means (
The mechanism of action of the delivery of the tapered coil results in sphincter muscle complex tissue being drawn into the centre of the coil 11 construct. The mechanism of action is illustrated in
Referring to
The implant is a coiled body structure. The leading end of the implant is the largest coil and initially surrounds the tissue defect with appropriate margin. As the implant is advanced the leading end provides a large surface area to effectively anchor the implant. Each subsequent coil provides (adds to) the anchoring and compression function. The smallest coil towards the trailing end provides the highest amount of tissue compression. As the implant is turned into the tissue each coil further compresses the captured tissue toward the center of the tissue defect, thus effectively completely compressing the surrounding tissue inwardly. The close approximation of tissue allows for the tissue to heal together. This compression provides an effective seal against the pressures generated in the rectum and prevents entering of passing faeces into the fistula tract thus preventing re-infection. The smaller diameters of the implant coils retain the captured tissue from separating and prevents the breakdown of the healing process or foreign material from entering the tissue defect. This is a major advantage over sutures and suture based surgical techniques such as the advancement flap (dermal flap) and the LIFT procedures.
The compression ensures close approximation of tissue throughout the center of the implant. At the most proximal surface the close approximation of tissue provides support to the healing mucosal lining of the rectum over the implant and tissue defect. Thus the healing tissue is fully supported by the implant during the healing process and is capable of surviving pressures of 150 mmHg and upwards of 200 mmHg which can be generated in the rectum.
The coil is delivered submucosal (at a predetermined depth) below the surface of the mucosa. This is to ensure that there is a full mucosal seal at the rectal mucosa surface to provide for a bacterial seal barrier. With the implant just below the surface the tissue is drawn inwards for complete compression and supports the mucosa healing process.
As the implant is turned into the tissue the compression becomes greater along the depth of the coil (progressive compression) and the length of the tract captured internal of the implant is compressed completely. This close approximation of tissue aids in the healing process.
Referring to
It will be appreciated that a coil device with a centering feature such as the centering feature 36 illustrated in
It will be appreciated that the tapered coil may be of any suitable shape in transverse cross section. Some examples are illustrated in
The coil may be intended for subsequent removal or may be bioabsorbable.
Typical materials for the coil include
A bioabsorbable tapered coil would be beneficial to treatment of perianal fistulas due to the body's natural tendency to reject foreign materials.
The system of the invention also comprises a delivery device for the perianal fistula treatment device.
The delivery device may comprise a hollow element such as illustrated in
The system consists
It will be appreciated that the system may be reversed with a hollow coil delivered over a solid delivery element.
In some cases the delivery device comprises a rail for the tapered coil. The rail and the coil may have interengagable features. Some examples are illustrated in
The rail system
It will be appreciated that the system may be reversed with an inner implantable coil delivered over an outer support rail.
Ball Attachment
The centre feature may have a ball feature along the shaft to aid in anchoring a seton that may be tied or looped around the centre feature. The ball provides a back stop where the knotted or looped seton will not detach from the centre feature.
Hook Attachment
The centre feature may have a hook feature along the shaft to aid in anchoring a seton that may be tied or looped around the centre feature. The hook provides a back stop where the knotted or looped seton will not detach from the centre feature.
Cleat Attachment
The centre feature may have a cleat feature along the shaft to aid in anchoring a seton that may be tied or looped around the waist of the cleat feature. The cleat provides a back stop where the knotted or looped seton will not detach from the centre feature.
Internal to Centre Feature
The centre feature may be hollowed as in
Butt Joint
The seton may be attached by a butt joint as shown in
Thermal Bond
The seton and centre feature may be thermally bonded/joined together as in
It will be appreciated that the embodiments of this system may also incorporate features such as previously described, including, but not limited to, a centre feature, a seton attachment feature, an integrated drainage seton and an integrated sharp tip located on the drive rail.
The seton 12 is used as a guidance and positioning mechanism and once the device is implanted serves as a means of fistula tract drainage. The seton 12 may be constructed of bioabsorbable materials, tissue healing enchantment properties, infection control agents and be constructed of part or composite of these materials.
After the fistula tract preparation, the seton 12 is attached using standard surgical technique to the existing surgical probe, suture, or seton already in place in the fistula tract. Once the seton 12 is attached, the system is pulled through the fistula tract proximally (towards the physician) until the coil device is adjacent to the tissue wall (rectal wall). The seton 12 ensures that the outer leading coil is centred around the outside of the fistula tract. Tension may be applied to the seton 12 as the coil is advanced into the tissue to aid in advancement and to maintain a centred position around the fistula tract.
The seton 12 is attached to the central portion of the coil 11. With the coil knitting together the sphincteric muscle and closing the fistula tract's internal opening the seton 12 maintains the proximal portion of the fistula tract's patency to facilitate drainage of any abscess, pus, and new accumulation of bodily fluids to prevent infection occurrence. The seton 12 prevents the tract from closing in on itself proximal of any fluid accumulation and acts as a conduit allowing material drainage between the wall of the tract and the outer wall of the seton 12. The seton 12 may also have a central lumen with tangential drainage holes entering from the external wall of the seton 12. The seton 12 may be constructed with a multi surface external wall to create channels and optimize the fluid drainage and prevent the fistula tract wall from occluding drainage around the seton. The seton 12 may be constructed of part or all elements as described and illustrated in
The seton 12 is constructed of materials that are strong enough to allow for surgical placement in the fistula tract. The seton 12 may be constructed of materials that are non-absorbable and meant to be removed at a later time. Alternatively, the seton 12 may be made of materials that bioabsorb throughout and upon completion of the fistula tract healing processes (examples include magnesium, PLA, PLGA). The seton 12 may be constructed of or include anti-infection agents to prevent infection of the fistula tract (silver ions, antibacterial agents). The seton 12 may be constructed of materials that aid in tissue growth (stem cell, collagen matrix). The seton 12 may be constructed of part or all elements as described.
The seton may be of any suitable shape in cross section such as round, oval, cross shape, star or braid as illustrated in
As noted above, one or other or both of the coil and seton may comprise bioabsorbable materials.
Typical materials for the coil include:
Synthetic bioabsorbable materials may include PLA and PLGA (poly (lactic-co-glycolic acid)) (PLGA, PCL, Polyorthoesters, Poly(dioxanone), Poly(anhydrides), Poly(trimethylene carbonate), Polyphosphazenes), and or natural bioabsorbable materials may include fibrin, collagen, chitosan, gelatin, Hyaluronan are bioabsorbable polymers and would be a material of choice as they are commonly used bioabsorbable materials and have been well studied and used in medical products for over 70 years.
For example, companies such as Ethicon market a number of such products with different absorption rates such as http://www.ethicon.com/healthcare-professionals/products/. Absorbable polymer materials are also available from medical material companies such as Zeus, see http://www.zeusine.com/advanced-products/absory-bioabsorbables.
Typical materials for the seton include:
In one case both the coil and the seton are bioabsorbable, and the seton degrades prior to the degradation of the coil. This may be achieved in a number of different ways, such as the seton being of a different bioabsorbable material to the coil.
For example the coil implant may be constructed of PLLA which degrades slowly, typically within 18 to 36 months depending on formulation, cross section, and surface modifications, and the Seton drain may be constructed of PLGA (85L/15G) which typically degrades “faster” in 1 to 2 months depending on formulation, cross section, and surface modifications
Another method of altering the time of degradation (degradation (absorption) properties) is by providing a reduced cross sectional area, more porosity, less crystallinity, more reactive hydrolytic groups in the backbone, more hydrophilic end groups, and/or more hydrophilic backbone.
In one case, the seton begins to absorb 5 weeks post-surgical implantation. This is variable depending upon the healing time of the patient, with full healing usually occurring within a 5 to 10 week period. By way of example the coil implant may remain for a period of at least 10 weeks after healing and may degrade over a 6 to 18 month time period from the date of implantation.
Advantageously, the closure mechanism of the device is maintained during the entire healing process. In some cases the coil remains in situ to withstand rectal pressures and maintain closure of internal tract opening for at least 10 weeks to prevent re-opening of the tract.
The coil implant may remain in place longer to allow full healing of the internal opening of the fistula tract. The seton drain may degrade at a faster rate compared to the coil implant so long as the seton drain is in place for a long enough time for all remaining abscess and infection, to drain from the fistula tract and any side branches. It is advantageous that the seton drain absorbs faster than the coil so that the patient does not have any visually remnant feature of the device or thoughts of fistula. The seton is not needed for as long a period as the coil implant, with the seton drain absorbing faster than the implant, the patient will not have to return to the surgeon for removal during the internal opening healing process.
Also, the implant remains in place for a long enough period of time (e.g. greater than 1 week) to allow remodelling of the defect in the mucosa and formation of a mucosal layer. This mucosal layer acts as a bacterial seal preventing reinfection of the tract from entering of fasces. The re-formation of the musical layer in conjunction with the sphincter muscle closure mechanism prevents fasces entering the tract.
The implant coil and draining seton may be doped or loaded with healing and antimicrobial agents (such as stem cell, silver ions, silver particles, antibiotics, antibacterial agents and the like).
The seton may be of differential bioabsorption wherein the seton is absorbed at a different rate along its length.
The seton may be of differential bioabsorption wherein the distal portion of the drain absorbs more quickly than the proximal portion. This differential absorption of the seton results in the seton remaining attached to the coil via the proximate portion until fully absorbed. Advantageously, this allows for the external opening to close and remove the chance of the seton being pulled out through the external opening.
The seton may also be of differential bioabsorption wherein the proximal portion of the seton absorbs more quickly—in this case the anchoring mechanism of the closure device with relation to the seton could be broken at an earlier time than the full seton absorption allowing the seton to be removed (by the patient or doctor or naturally fall out) through the external opening.
In both differential absorption embodiments, the entire seton would have to remain in place for full healing (and drainage) time of the tract (e.g. 10 weeks).
The bioabsorbable materials used in the construction of the implant coil, or drainage seton, or both, can be both natural or synthetic polymers such as those listed below.
Natural Polymers
Synthetic Polymers
The selection of the material used can be made whilst taking the following factors into account.
Factors that Accelerate Polymer Degradation:
The implant coil of the invention may be delivered by a number of techniques. In one case the coil is delivered by a coil delivery mechanism. In this case, the implant coil may have an interface region for interfacing with the delivery mechanism.
A perianal fistula treatment device may comprise an implant coil having a tapered portion which is configured for insertion into bulk tissue surrounding a fistula. The implant coil may have a driver interface portion which is configured for engagement with a driver implement for rotation of the coil to draw tissue surrounding a fistula inwardly. The advantages of such an implant coil are:
One such implant coil 200 is illustrated in
The implant is a coiled body structure. The leading end of the implant is the largest coil and initially surrounds the tissue defect with appropriate margin. As the implant is advanced the leading end provides a large surface area to effectively anchor the implant. Each subsequent coil provides (adds to) the anchoring and compression function. The smallest coil towards the trailing end provides the highest amount of tissue compression. As the implant is turned into the tissue each coil further compresses the captured tissue toward the center of the tissue defect, thus effectively completely compressing the surrounding tissue inwardly. The close approximation of tissue allows for the tissue to heal together. This compression provides an effective seal against the pressures generated in the rectum and prevents entering of passing faeces into the fistula tract thus preventing re-infection. The smaller diameters of the implant coils retain the captured tissue from separating and prevents the breakdown of the healing process or foreign material from entering the tissue defect. This is a major advantage over sutures and suture based surgical techniques such as the advancement flap (dermal flap) and the LIFT procedures.
The compression ensures close approximation of tissue throughout the center of the implant. At the most proximal surface the close approximation of tissue provides support to the healing mucosal lining of the rectum over the implant and tissue defect. Thus the healing tissue is fully supported by the implant during the healing process and is capable of surviving pressures of 150 mmHg and upwards of 200 mmHg which can be generated in the rectum.
The coil is delivered submucosal (at a predetermined depth) below the surface of the mucosa. This ensures that there is a full mucosal seal at the rectal mucosa surface to provide for a bacterial seal barrier. With the implant just below the surface the tissue is drawn inwards for complete compression and supports the mucosa healing process.
As the implant is turned into the tissue the compression becomes greater along the depth of the coil (progressive compression) and the length of the tract captured internal of the implant is compressed completely. This close approximation of tissue aids in the healing process.
In this and other embodiments the implant body is in the form of an open tapered coil body (for example, without a cross bar or other centering feature) in which the leading edge, (into the muscle) is of a larger diameter than the trailing edge, (rectum surface). The trailing portion is of smaller diameter than the leading portion. The coil is of open form, therefore there is no inward protrusion at either the proximal nor distal end of the body. This open form factor enables the implant to be driven into the tissue body to a pre-determined depth (depending on the taper) which results in progressive tissue compression.
At least the driver interface portion of the implant coil is solid and in some cases all of the implant coil is solid. Alternatively, as described above and below, the implant coil or at least part thereof may be hollow.
In this embodiment, preferably the treatment device also includes a seton of the type described above. In some cases the seton is not mounted or attached to the implant coil during delivery but may be attached so as to extend from the coil when the coil is in situ. In some cases the seton may be embedded in the sphincter muscle complex and lead so that the end of the seton protrudes through the external opening of the fistula tract.
The implant is delivered using any suitable delivery device as described. In one case the delivery device comprises a driver implement which interfaces with the implant coil and is used to rotate the coil to draw tissue surrounding a fistula inwardly. The driver implement preferably interfaces with the driver interface of the implant coil.
In some cases the driver implement comprises a driver coil which is configured for engagement with the driver interface of the implant coil. The driver coil may have a substantially uniform lateral extent along a length thereof for engagement with the corresponding driver interface portion of the implant coil.
In one embodiment as illustrated in
The hollow sections of the delivery coil in all cases may comprise a single turn, multiple turns or part thereof or the entire construct.
The straight sections of the coil in all cases may comprise a single turn, multiple turns or part thereof.
The hollow sections of the implant coil in all cases may comprise a single turn, multiple turns or part thereof or the entire construct.
The delivery system has the following advantages:
These delivery mechanisms may be coupled to a manually operated, trigger operated user interface or similar.
In current techniques for treating a fistula a surgeon identifies the external opening of the fistula tract and carefully inserts a probe through the external opening, through the fistula tract and through the internal opening of the fistula. The probe is then extended back through the rectum and a localisation seton or suture is attached to the end of the probe which is then drawn back through the rectum and the fistula tract until it exits through the external opening of the fistula tract. The localisation seton loop is then tied off.
The implant and delivery system of the invention is compatible with this known current technique. In the invention the probe or the localisation seton may be used to guide the leading end of the implant coil and/or the drainage seton.
The implant body in some cases is in the form of an “open” tapered coil body in which the distal edge (leading edge, into the muscle) is of a larger diameter than the proximal edge (trailing edge, rectum surface), the proximal portion is of smaller diameter than the distal portion. The coil is of open form, therefore there is no inward protrusion at either the proximal nor distal end of the body. The open form factor enables the implant to be driven into the tissue body to a pre-determined depth (depending on the taper which results in progressive tissue compression).
The open coil design allows for the mucosal layer to heal over the top of the implant, and the implant supports the healing of the mucosal layer, by preventing the pressure from opening the tract, and compromise freshly healed mucosa layer. With the implant below the mucosa it does not interfere with external rectal surface and interact with faeces that may drag the implant out of its purchase or lend to tract infection along its body. Thus, the implant is suitable for submucosal delivery which facilitates the formation of a continuous mucosal surface over the site of implantation.
The implant in some cases has anti-movement (anti-rewind) features to prevent the rotational movement of the implant in the counter-clockwise motion. Typically, the implant is driven into the tissue body in a clockwise motion consistent with the usual direction of driving fixation medical devices. However, it will be appreciated that the implant may also be driven into the tissue in the counter clock-wise direction. The anti-rewind features facilitate the forward driving motion into the tissue body in a clock-wise motion to be effortless during delivery but provide resistance to prevent the implant from working itself out or unwinding during the course of natural wound healing and normal physiological forces experienced day to day of the patient's life.
The anti-rewind features may include one or more of:
As described above, a driver coil may be used to insert the implant. The driver coil (such as the coil 404 illustrated in
In addition, the driver coil surface 405 may be constructed so as to have a lubricious nature (e.g. by means of a coating or surface treatment or other) in order to minimise the torque requirement associated with the tissue friction during delivery of the implant coil and during retraction of the delivery coil.
The coiled section of the delivery coil may include features to temporarily lock or fasten to the implant prior to and during implant delivery. This provides a positive interface between the implant and the delivery mechanism, to prevent premature implant detachment and related delivery issues.
When the implant has been delivered to the correct location and depth the delivery mechanism detaches/disengages from the implant and is removed from the anatomy.
The driver coil may have an interface to the implant which allows positive (interlocking) when the driver coil is turned in a clockwise direction and negative (i.e. disengagement) interaction when the driver coil is turned in an anti-clockwise direction (or vice versa). Thus when the implant has been delivered to the tissue by means of a clockwise driver coil motion, the driver coil may then turn in an anti-clockwise direction, disengage from the implant, and exit (or ‘back out’) from the tissue.
The implant may be attached to the delivery coil by a mechanism that prevents the implant becoming dislodged from the delivery coil prior to complete delivery. Thus, the implant coil is prevented from prematurely detaching from delivery coil.
The internal support structure of the implant coil may have a positive feature (peak) that locks into a negative (valley) feature on the implant. There maybe be several features of this type to enhance the locking grip.
The inverse of this arrangement may also be implemented in which a positive feature is provided on the implant and a negative feature is a part of the driving mechanism.
Alternatively or additionally, the implant may be attached to the internal opening of the implant driver by friction/interference fit/surface roughness. The driver col may be hollow and accept a solid implant or the driver may be solid and inserted into the hollow portion of the implant.
The cross section of the driver coil may be a channel or slot rather than closed circular. A coil with such a cross section may be more easily manufacturable. It may also allow the incorporation of internal (to the driver coil) locking features to interface with the implant.
The implant is interfaced to the driving mechanism such as a driver coil. In one case the interface comprises a flare or step that abuts against the driving mechanism. One such flare or step 301 is illustrated in
The flare may also act as a barb or anti-rewind feature allowing only one way (e.g. clockwise) motion which in one case is forward motion (clockwise motion driven into the tissue body) and prevents the implant from moving in a backwards motion (unwinding/counter clockwise).
Such a barb feature may be achieved by having the flare surface area greater than the driving coil interface surface area.
The flare may be positioned anywhere along the implant body that is optimal for the implant driving force, driver attachment coupling, and/or anti motion control (anti-rewind can be clockwise or anti clockwise).
It will be appreciated that as an alternative to such locking features on the implant coil similar features may be provided on the engagement surfaces of the delivery coil.
The implant is in some cases in the form of a coiled body structure. The distal end of the implant is the largest coil, and the distal end initially surrounds the tissue defect with appropriate margin. As the implant is advanced the distal portion provides a large surface area to effectively anchor the implant (each subsequent coil provides (adds to) the anchoring and compression function).
The smallest proximal coil provides the highest amount of tissue compression. As the implant is turned into the tissue each coil further compresses the captured tissue toward the centre of the tissue defect, thus effectively completely compressing the surrounding tissue inwardly. The close approximation of tissue allows for the tissue to heal together. This compression provides an effective seal against the pressures generated in the rectum and prevents entering of passing faeces into the fistula tract thus preventing re-infection. The smaller diameters of the implant coils retain the captured tissue from separating and prevents the breakdown of the healing process or foreign material from entering the tissue defect. This is the advantage over sutures and suture based surgical techniques such as the advancement flap (dermal flap) and the LIFT procedures.
The compression ensures close approximation of tissue throughout the centre of the implant. At the most proximal surface the close approximation of tissue provides support to the healing mucosal lining of the rectum over the implant and tissue defect. Thus the healing tissue is fully supported by the implant during the healing process and is capable of surviving pressures of 150 mmHg and upwards of 200 mmHg which are generated in the rectum.
Preferably, the coil is delivered submucosal (at a predetermined depth) below the surface of the mucosa. This ensures there is a full mucosal seal at the rectal mucosa surface to provide for a bacterial seal barrier. With the implant just below the surface the tissue is draw inwards for complete compression and supports the mucosa healing process.
As the implant is turned into the tissue the compression becomes greater along the depth of the coil (progressive compression) and the length of the tract captured internal of the implant is compressed completely, the close approximation of tissue aids in the healing process.
The implant and delivery system is compatible with current surgical technique.
Upon completion of the surgeon preparing the tissue tract, the device drain is attached to the rectal end of the fistula probe or seton/suture that was used to localize the tract.
The probe/seton is pulled toward the surgeon through the fistula tract out of the external opening until the large distal portion of the implant is abutted against the rectal wall. The Implant coil is aligned to be concentric to the internal tract opening.
The device drain is tied to the fistula probe or localization seton.
In one embodiment the drain seton runs distal of the implant and through the length of the handle and may be anchored in the proximal portion of the drive shaft or handle.
At the interface of the implant and driver a cutting mechanism (such as a snip, guillotine or the like) may be provided to automatically cut the drainage seton once the implant is delivered. The handle/delivery system may then be readily removed from the surgical field.
In another embodiment the drain seton is locked to the handle/driver mechanism during implantation (delivery of implant) to maintain traction. Once the implant is fully implanted the handle is decoupled (automatically or manually) from the drain seton. The excess drain seton material may be trimmed at the external surface of the closed tissue tract site at the surface of the rectum.
Referring to
The drain is fixed in place due to the compression forces of the internal tissue tract being compressed inwardly by the radial forces applied by the implant.
To further enhance fixation of the drain seton and prevent the drain seton from moving out of the tract distally or proximally the drain seton may be constructed with locking features 906 along the entire length, partial length, and defined/predetermined compression zone at the site of the implant tissue compression, or any combination of these.
Referring to
Referring to
Referring to
To enhance the anchoring of the drain seton quills such as 801, 802, 804 (
The drain seton maybe be constructed to act purely as a drain and/or as a scaffold to enhance tissue healing.
To provide enhanced drainage, the seton may have a plurality of peripheral holes and may include (pores). The shape of the seton in cross section may be selected from one or more of round, oval, star and cross. The drain/seton is constructed to be bioabsorable.
An example of potential materials include: PLA and PLGA (poly(lactic-co-glycolic acid)) (PLGA, PCL, Polyorthoesters, Poly(dioxanone), Poly(anhydrides), Poly(trimethylene carbonate), Polyphosphazenes), and or natural bioabsorbable materials may include fibrin, collagen, chitosan, gelatin, Hyaluronan are bioabsorbable polymers and would be a material of choice as they are commonly used bioabsorbable materials.
The shape is designed to enhance the drainage of the residual tract. The shape may also act as a scaffold to improve/enhance the healing of the tract.
The plurality of peripheral holes/pores enhance drainage of the tract to prevent the drain/seton from blockage.
To enhance scaffolding, the plurality of peripheral holes/pores may serve as a structure of a scaffold that enhances tissue integration and improves wound healing of the tract.
A variety of materials may be used as a tissue scaffold that enhance and improve tissue wound healing. Many of these materials are bioabsorable polymers or natural tissue materials. An example of potential materials include: PLA and PLGA (poly(lactic-co-glycolic acid)) (PLGA, PCL, Polyorthoesters, Poly(dioxanone), Poly(anhydrides), Poly(trimethylene carbonate), Polyphosphazenes), and or natural bioabsorbable materials may include fibrin, collagen, chitosan, gelatin, Hyaluronan are bioabsorbable polymers and would be a material of choice as they are commonly used bioabsorbable materials.
The invention also provides a mechanism to stabilise the tissue during the delivery of the implant to prevent bunching and twisting of the mucosal layer during delivery of the implant. By preventing such tissue interaction, the delivery forces may be reduced and a more reliable and repeatable depth of delivery may be achieved.
One mechanism of stabilising the mucosal tissue is achieved by utilising a hollow ‘trumpet, cone, shield or pyramid’ type element that is attached to the delivery mechanism and surrounds the undelivered implant. One such stabiliser 952 is illustrated in
The ‘trumpet’ interfaces onto the surface of the mucosal lining and may stabilise the tissue prior to and during the delivery of the implant using one or more of the following mechanisms:
Referring to
The guide coil 1101 has a distal diameter that is larger than the tissue defect such that, in use, the guide 1101 surrounds the internal opening of the fistula track
With the guide 1101 removed from the tissue and the implantable element 1102 anchored in the tissue, the implantable element 1102 is activated in this case by pulling in the direction of the arrow 1106. The implant 1102 is anchored distally in the tissue and collapses and compresses the tissue tract closed (like a purse string or boa constrictor snake)
The guide coil 1101 may be a straight or tapered coil. The coil may be hollow or a rail type support or an internal support (such as a removable wire internal to a hollow implant element).
The implant element 1102 may be anchored in various ways. A single, (or multiple), barb 1107 or locking feature may be located at the distal end of the implant element 1102. The barb(s) 1107 allow the implant element 1102 to penetrate the tissue in one direction
The anchor can be an “umbrella shape” or “parachute” shape element 1108 that is attached to the distal end of the implant element 1102. The “parachute” is initially stowed during delivery (
Multiples of small “hair” like filaments 1110 may be provided along a length of the distal surface covering the full circumference, specific quadrants, and or intermittently covering the distal surface of the implant element 1102. This quill-like configuration increases the surface area of the distal end and anchors the implant element 1102 in the tissue. The bristles or quills 1110 are initially collapsed/compressed when stowed in the driver guide (
In some cases the implant element 1102 does not have an anchor. In this case the implant element 1102 may be positioned by a pusher 1111 during removal of the guide mechanism after delivery to the desired location (
The implantable element 1102 may be at least partially bioabsorbable. The element may comprise a suture which is anchored distally into tissue. When the guide 1101 is removed, the suture can be pulled proximally and will then cinch the tract closed, similar to a purse string.
The implant element can be made of a shape memory material such as Nitinl or a shape memory polymer. It can be active (requires a stimulus such as electrical, mechanical, light, magnetism or the like) or passive (heat set).
The implant element 1102 may be stowed in the guide element 1101 for delivery into the tissue. Once the guide/driver element reaches the desired depth, the guide element is unwound from the tissue. As the guide is unwound from the tissue the anchored implant is no longer supported by the guide and the exposed portion(s) of the implant is free to compress the tissue tract. The passive shape set implantable element compresses the tissue tract as the guide element 1101 is unwound from the tissue. The implantable element 1102 may be preset in shape before stowage in the guide element 1101. For example, a Nitinol coil is shape set into the compressed state and is then inserted into the guide 1101.
The implantable element 1102 may be stowed in the driver/guide element 1101 for delivery into the tissue. Once the guide element reaches the appropriate depth the guide 1101 is unwound from the tissue leaving the implant element 1102 anchored in tissue. With the guide element 1101 removed from the tissue the implantable element 1102 is then activated by any suitable means such as heat, light, electrical signal, changing the state of the implantable element and activating the implantable element to be transformed to the compression state, thus compressing the tissue tract closed. The patient's body heat may passively activate the implant element to transform to the compressive state.
A sharp tip may be provided at the distal tip to penetrate into the tissue as the guide/delivery mechanism is advanced into the tissue.
In one configuration the distal tip and leading edge of the coil guide/driver element 1101 has a sharp tip that facilitates the penetration of tissue upon insertion and during advancement throughout the tissue
In another configuration (
A sharp tip in some cases may be incorporated into both the driver element and the implant element.
In some cases the implant element is an activatable element which may have a collapsed delivery configuration, a deployed configuration, and an activated configuration. The activatable implant element in some cases is an expansile element such as a balloon.
The balloon 1201 may be mounted in a rail of memory alloy or similar which assists in forming the spiral balloon shape, on deployment.
In one embodiment the balloon 1201 forms a straight coiled structure after delivery around the fistula tract.
In another embodiment the balloon 1201 forms a tapered coiled structure after delivery whereby the larger coil of the balloon is positioned deeper in the tissue than the narrow end.
The balloon 1201 may be delivered using a hollow delivery coil which locates the balloon in place. The balloon is then pushed out of the delivery coil and left in place.
Once in place, the balloon 1201 is inflated with saline, or other liquid or gas 1203 (
The balloon may be comprised of a bioabsorbable material or similar. After a period of time corresponding to the healing of the fistula tract, the balloon material may degrade to a sufficient extent that the fluid with which it is filled (e.g. saline) is exposed to the tissue and is also absorbed. In time the entire balloon is absorbed.
The delivery mechanism may have a sharp tip to facilitate progression through the tissue.
The balloon may be dragged behind a coiled solid needle type delivery mechanism and detached to deploy the balloon.
In another embodiment the balloon is made from a non-bioabsorbable material, and is removed at an appropriate time frame post healing of the fistula tract.
The pressure to which the balloon is inflated may be variable. The balloon may be inflated to a pressure that corresponds to sufficient closing of the tract opening thereby overcoming the variability in delivery, anatomy and tract diameter.
A programmable electronic controller may be used to automatically inflate the balloon to the appropriate pressure.
Alternatively an analog or digital pressure gauge may be provided to indicate the balloon pressure to the clinician.
The activatable compressive element (balloon) may similarly be formed from a foam, pre formed structure (e.g. Nitinol cage or stent-like structure), or collapsible coil or other similar structure.
Referring to
Once the implant element 1301 is delivered to the desired depth by an appropriate delivery/guide element 1302 (
A compression coil may be delivered by placing a delivery tube 1401 a specified distance from the internal opening of the tissue tract (
In another embodiment (
The coil can be made of a shape memory material. It is delivered as a straight coil and upon activation it compress the tissue tract.
In another method, the implant material is not shape set and not of a shape memory material but is formed by a die built into the delivery tube (
Referring to
In some cases the implant may comprise a plurality of elements 1500. One such implant is illustrated in
Each element may be preformed, or formed on delivery, or be activatable as previously described. The elements may be the same size in the preformed, or activated state. Alternatively the leading element may be larger in diameter and the following elements progressively smaller.
The clinician may determine the number of elements to deploy to attain adequate closure of the tract.
The device is capable of one or more of the following:
The perianal fistula treatment device ensures sparing of the sphincter, occluding of the fistula tract internal opening, and promotion of drainage and tissue healing.
The anchoring and sealing mechanism of the device may consist of a tapered coil. The coil geometry is designed to pull tissue together as it is deployed into the sphincter muscle complex, resulting in a strong anchor but also, importantly, an effective compressive seal preventing reinfection of the fistula tract and close tissue approximation to enhance tissue healing.
The perianal fistula treatment device preserves sphincteric and anatomical conditions and functions, prevents re-fistulisation, and improves healing time over the current treatment methods. The implant closes the fistula internal opening by compressing the tract's surrounding tissue inwardly such that the tissue is brought within close approximation creating a seal impermeable to foreign materials and promoting tissue growth across the closely approximated fistula tract.
A drain may be used to provide a conduit to drain any abscess and remaining or newly formed exudate and fluids from the fistula tract throughout the time of the healing process. Such a drain or seton may be any of those described above.
The implant may be of any suitable shape in transverse cross section. For example, the implant cross-section may be round, oval, triangular, multifaced or ribbon-like. In some cases the implant may be hollow.
The implant may be intended for subsequent removal or may be bioabsorbable.
Typical materials for the implant include
A bioabsorbable implant would be beneficial to treatment of perianal fistulas due to the body's natural tendency to reject foreign materials.
The closure implant of the device may be maintained during the entire healing process. In some cases the implant remains in situ to withstand rectal pressures and maintain closure of internal tract opening for at least 10 weeks to prevent re-opening of the tract.
The implant may remain in place longer to allow full healing of the internal opening of the fistula tract.
The implant remains in place for a long enough period of time (e.g. greater than 1 week) to allow remodelling of the defect in the mucosa and formation of a mucosal layer. This mucosal layer acts as a bacterial seal preventing reinfection of the tract from entering of fasces. The re-formation of the musical layer in conjunction with the sphincter muscle closure mechanism prevents fasces entering the tract.
The implant may be doped or loaded with healing and antimicrobial agents (such as stem cell, silver ions, silver particles, antibiotics, antibacterial agents and the like).
Modifications and additions can be made to the embodiments of the invention described herein without departing from the scope of the invention. For example, while the embodiments described herein refer to particular features, the invention includes embodiments having different combinations of features. The invention also includes embodiments that do not include all of the specific features described.
The invention is not limited to the embodiments hereinbefore described, which may be varied in construction and detail.
| Number | Date | Country | Kind |
|---|---|---|---|
| 15169640 | May 2015 | EP | regional |
| 16174951 | Jun 2016 | EP | regional |
| 16201270 | Nov 2016 | EP | regional |
This is a request for filing a continuation application under 37 CFR § 1.53(b) of pending prior U.S. application Ser. No. 15/595,619, filed May 15, 2017, which is a continuation-in-part application under 37 CFR § 1.53(b) of pending International Application No. PCT/EP2016/061944, filed May 26, 2016, which claims the benefit of priority of European Application No. 15169640.8, filed May 28, 2015. Prior U.S. application Ser. No. 15/595,619, filed May 15, 2017, to which this application claims priority, also claims the benefit of priority of European Application No. 16201270.2, filed Nov. 29, 2016, and European Application No. 16174951.0, filed Jun. 17, 2016. All of the aforementioned applications are incorporated by reference herein in their entireties.
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| Number | Date | Country | |
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| Child | 15595619 | US |
