US 7,678,068 B2Grant
Atraumatic delivery devices
Issue Date:2010-03-16
•24 Claims
•35 Drawing Sheets
Abstract
Methods and apparatus for delivering an implant device within the digestive system of an animal are presented. An delivery device includes an outer sheath, or container, for storing a proximal portion of the implant device. The outer sheath is moveable relative to the stored portion of the implant device to release the proximal portion from within the outer sheath. The delivery device also includes an inner sheath defining a lumen therein that extends distal to the outer sheath, a moveable element adapted to secure the distal end of the implant to the inner sheath, and a release mechanism coupled to the moveable element for releasing the distal end of the implant. The device also includes a atraumatic tip, or ball, coupled at its distal end to facilitate guiding the delivery device through the gastrointestinal tract.
Metadata
Assignee
- GI Dynamics, Inc.
Inventors
- Andy H. Levine
- John F. Cvinar
- David A. Melanson
- John C. Meade
Application Information
Application Number:US 11/302,977
Filing Date:2005-12-13
Priority Date:2002-12-02
Art Unit:3774
Classifications
IPC:
A61M5/00A61F2/04
Patent Drawings (35 sheets)
Description
Related Applications
[0001] This application is a continuation-in-part of U.S. application Ser. No. 10/999,846, now U.S. Pat. No. 7,329,285, filed Nov. 30, 2004, which is a divisional of U.S. application Ser. No. 10/339,786, now U.S. Pat. No. 7,025,791, filed Jan. 9, 2003, which claims the benefit of U.S. Provisional Application No. 60/430,321, filed on Dec. 2, 2002. The entire teachings of the above applications are incorporated herein by reference.
Background of the Invention
[0002] According to the Center for Disease Control (CDC), over sixty percent of the United States population is overweight, and almost twenty percent are obese. This translates into 38.8 million adults in the United States with a Body Mass Index (BMI) of 30 or above. The BMI is defined as a person's weight (in kilograms) divided by height (in meters), squared. To be considered clinically, morbidly obese, one must meet one of three criteria: BMI over 35, 100 lbs. overweight or 100% above ideal body weight. There is also a category for the super-obese for those weighing over 350 lbs.
[0003] Obesity is an overwhelming health problem. Because of the enormous strain associated with carrying this excess weight, organs are affected, as are the nervous and circulatory systems. In 2000, the National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK) estimated that there were 280,000 deaths directly related to obesity. The NIDDK further estimated that the direct cost of healthcare in the US associated with obesity is $51 billion. In addition, Americans spend $33 billion per year on weight loss products. In spite of this economic cost and consumer commitment, the prevalence of obesity continues to rise at alarming rates. From 1991 to 2000, obesity in the US grew by 61%. Not exclusively a US problem, worldwide obesity ranges are also increasing dramatically.
[0004] One of the principle costs to the healthcare system stems from the co-morbidities associated with obesity. Type-2 diabetes has climbed to 7.3% of the population. Of those persons with Type-2 diabetes, almost half are clinically obese, and two thirds are approaching obese. Other co-morbidities include hypertension, coronary artery disease, hypercholesteremia, sleep apnea and pulmonary hypertension.
[0005] Although the physiology and psychology of obesity are complex, the medical consensus is that the cause is quite simple—an over intake of calories combined with a reduction in energy expenditures seen in modern society. While the treatment seems quite intuitive, the institution of a cure is a complex issue that has so far vexed the best efforts of medical science. Dieting is not an adequate long-term solution for most people. Once an individual has slipped past the BMI of 30, significant changes in lifestyle are the only solution.
[0006] There have been many attempts in the past to surgically modify patients' anatomies to attack the consumption problem by reducing the desire to eat. Stomach saplings, or gastroplasties, to reduce the volumetric size of the stomach, therein achieving faster satiety, were performed in the 1980's and early 1990's. Although able to achieve early weight loss, sustained reduction was not obtained. The reasons are not all known, but are believed related to several factors. One of which is that the stomach stretches over time increasing volume while psychological drivers motivate patients to find creative approaches to literally eat around the smaller pouch.
[0007] There are currently two surgical procedures that successfully produce long-term weight loss; the Roux-en-Y gastric bypass and the biliopancreatic diversion with duodenal switch (BPD). Both procedures reduce the size of the stomach plus shorten the effective-length of intestine available for nutrient absorption. Reduction of the stomach size reduces stomach capacity and the ability of the patient to take in food. Bypassing the duodenum makes it more difficult to digest fats, high sugar and carbohydrate rich foods. One objective of the surgery is to provide feedback to the patient by producing a dumping syndrome if they do eat these food products. Dumping occurs when carbohydrates directly enter the jejunum without being first conditioned in the duodenum. The result is that a large quantity of fluid is discharged into the food from the intestinal lining. The total effect makes the patient feel light-headed and results in severe diarrhea. For reasons that have not been determined the procedure also has an immediate therapeutic effect on diabetes.
[0008] Although the physiology seems simple, the exact mechanism of action in these procedures is not understood. Current theory is that negative feedback is provided from both regurgitation into the esophagus and dumping when large volumes of the wrong foods are eaten. Eventually, patients learn that to avoid both these issues they must be compliant with the dietary restrictions imposed by their modified anatomy. In the BPD procedure, large lengths of jejunum are bypassed resulting in malabsorption and therefore, reduced caloric uptake. In fact, the stomach is not reduced in size as much in the BPD procedure so that the patient is able to consume sufficient quantities of food to compensate for the reduced absorption. This procedure is reserved for the most morbidly obese as there are several serious side effects of prolonged malabsorption.
[0009] Unfortunately, these procedures carry a heavy toll. The morbidity rate for surgical procedures is alarmingly high with 11% requiring surgical intervention for correction. Early small bowel obstruction occurs at a rate of between 2-6% in these surgeries and mortality rates are reported to be approximately 0.5-1.5%. While surgery seems to be an effective answer, the current invasive procedures are not acceptable with these complication rates. Laparoscopic techniques applied to these surgeries provide fewer surgical complications but continue to expose these very ill patients to high operative risk in addition to requiring an enormous level of skill by the surgeon. Devices to reduce absorption in the small intestines have been proposed (See U.S. Pat. No. 5,820,584 (Crabb), U.S. Pat. No. 5,306,300 (Berry) and U.S. Pat. No. 4,315,509 (Smit)). However, these devices have not been successfully implemented.
Summary of the Invention
[0010] The present invention provides methods and apparatus for implanting a device within the gastrointestinal tract of an animal. More particularly the methods and apparatus of the invention provide for implanting a device through the nose or mouth of a patient and into the intestine.
[0011] A delivery system for placing a gastrointestinal implant device in a body includes an outer sheath, or container, for storing a proximal portion of the implant device, and an inner sheath within the outer sheath, and an atraumatic feature such as a ball coupled to the distal end of the inner sheath to guide the delivery system through the alimentary canal. The ball can be dimensioned to permit it to be pulled-back through a central lumen of the implant device. The outer sheath is moveable relative to the stored portion of the implant device to release the proximal portion of the device from within the outer sheath.
[0012] The inner sheath defines a lumen therein and extends distal to the outer sheath. The delivery system also includes a moveable element, such as an elongated wire moveable within the lumen of the inner sheath. The moveable element is adapted to secure the distal end of the implant, such as a sleeve, to the inner sheath. A release mechanism is coupled to the moveable element for releasing the distal end of the implant. In some embodiments, the inner sheath of the delivery system defines a second lumen for passing the outer sheath over a guidewire.
[0013] The delivery system can be used to implant a device, such as an elongated sleeve having a collapsible sleeve anchor coupled to its proximal end. In some embodiments, the sleeve, or liner, is open at both ends and adapted to extend into the duodenum. In some embodiments, the sleeve is extended to a length of about 1 foot or more when implanted. The desired result using the implanted sleeve can include one or more of: limiting the absorption of nutrients; delaying the mixing of chyme with digestive enzymes; providing negative feedback; reducing hormone triggers; and treating diseases, such as diabetes.
[0014] The sleeve anchor is adapted to be retained within the digestive system and can include a stent having a network of struts. In some embodiments, the delivery system is used to anchor the implant device distal to the pylorus. In other embodiments, the delivery system can be used to anchor the implant within the pyloric orifice or proximal to the pylori orifice, such as in the stomach.
[0015] In operation, the anchor release mechanism pulls the outer sheath toward the proximal end of the delivery system to remove the outer sheath from the sleeve anchor. Similarly, the sleeve release mechanism pulls the moveable element toward the proximal end of the delivery system to release the distal end of the sleeve after the sleeve anchor has been released. The moveable element can be a sleeve retention wire, exiting the lumen of the inner sheath and piercing the distal end of the sleeve. Alternatively, the moveable element can be a snare wire capturing the distal end of the sleeve.
Brief Description of the Drawings
[0016] The foregoing and other objects, features and advantages of the invention will be apparent from the following more particular description of preferred embodiments of the invention, as illustrated in the accompanying drawings in which like reference characters refer to the same parts throughout the different views. The drawings are not necessarily to scale, emphasis instead being placed upon illustrating the principles of the invention.
[0017] FIG. 1 is a sectional view of a portion of the digestive tract in a body;
[0018] FIG. 2 is a perspective view of a gastrointestinal implant device according to the principles of the present invention;
[0019] FIG. 3A is a plan view of the proximal portion of the gastrointestinal implant device shown in FIG. 2 ;
[0020] FIG. 3B is a cross-sectional view as taken along line A-A of FIG. 3A showing the stent and first inner layer and second outer layer of the sleeve shown in FIG. 2 ;
[0021] FIG. 4 is a perspective view of the gastrointestinal implant device with the second outer layer of the sleeve removed;
[0022] FIG. 5A is a sectional view of a body showing one embodiment of the gastrointestinal implant device implanted in the digestive system;
[0023] FIG. 5B is a sectional view of a body showing an alternative embodiment of the gastrointestinal implant device implanted in the digestive system;
[0024] FIG. 6 is a perspective view of a collapsible self-expanding stent in the gastrointestinal implant device;
[0025] FIG. 7 is a perspective view of the stent shown in FIG. 6 when compressed;
[0026] FIG. 8 is a perspective view of another embodiment of a stent when compressed;
[0027] FIG. 9 is a perspective view of the stent shown in FIG. 8 with the strut ends bent to provide opposed barbs;
[0028] FIG. 10 is a perspective view of the stent shown in FIG. 8 when expanded;
[0029] FIG. 11 illustrates the gastrointestinal device shown in FIG. 1 including an anti-buckling mechanism;
[0030] FIG. 12 is a perspective view of a catheter system for delivery of the gastrointestinal implant device;
[0031] FIG. 13 is a cross-sectional view of the inner shaft taken along line E-E of FIG. 12 ;
[0032] FIG. 14A is an expanded perspective view of the dead-bolt mechanism shown in FIG. 12 ;
[0033] FIG. 14B is a sectional view of the dead-bolt mechanism shown in FIG. 13A illustrating the sleeve retention wire threaded through the sleeve;
[0034] FIG. 15 is sectional view of a portion of the catheter system illustrating the collapsed stent stored inside the outer sheath;
[0035] FIG. 16A is a plan view of the catheter system illustrating the collapsed stent stored inside the outer sheath of the gastrointestinal implant device;
[0036] FIG. 16B is a plan view of the catheter system illustrating the gastrointestinal implant device after release of the stent from the outer sheath;
[0037] FIG. 16C is a plan view of the catheter system illustrating the expanded gastrointestinal implant device after the sleeve retention wire has been released;
[0038] FIG. 17 is a perspective view of another embodiment of the catheter system shown in FIG. 12 ;
[0039] FIG. 18 is a sectional view of an everting catheter system for delivery of a longer length sleeve;
[0040] FIG. 19 is a perspective view of a retrieval device for removing the gastrointestinal implant device from the digestive tract;
[0041] FIG. 20 is a perspective view of the removal device engaged with the stent;
[0042] FIG. 21 is a perspective view of another embodiment of a gastrointestinal implant device;
[0043] FIG. 22 is a perspective view of the anchoring ring shown in FIG. 21 ;
[0044] FIG. 23 is a perspective view of the anchoring ring shown in FIG. 21 in a collapsed position for insertion and removal;
[0045] FIG. 24 is a perspective view of an anchor for anchoring the collapsible ring shown in FIG. 23 to the muscular tissue of the pyloric section of the stomach;
[0046] FIG. 25A is a perspective view of a delivery system for delivering the anchor after the gastrointestinal implant device has been placed in the stomach;
[0047] FIG. 25B is a plan view of the delivery system shown in FIG. 25A ;
[0048] FIG. 25C is a cross-sectional view of the distal end of the catheter as taken along line B-B of FIG. 25A ;
[0049] FIG. 25D is a perspective view of the gastrointestinal implant device illustrating the anchor engaged with the tissue;
[0050] FIG. 25E is a perspective view illustrating the barb engaging the tissue after delivery;
[0051] FIG. 26A is a plan view of the delivery system including a snare wire for holding the distal end of the sleeve in position;
[0052] FIG. 26B is a cross-sectional view taken along line CC of FIG. 26A through the inner sheath;
[0053] FIG. 26C is a cross-sectional view taken along line DD of FIG. 26A through the outer sheath showing the inner sheath within the outer sheath;
[0054] FIG. 26D is a cross-sectional view through the distal portion of the catheter showing the snare capturing the distal end of the sleeve;
[0055] FIG. 26E is a sectional view through the distal portion of the catheter showing the snare locking mechanism;
[0056] FIG. 27 is a perspective view of the distal portion of the gastrointestinal implant device including texturing at the distal end;
[0057] FIG. 28 is a plan view of an alternative embodiment of the gastrointestinal implant device of FIG. 2 ; and
[0058] FIGS. 29A-C are a series of sequential diagrams illustrating the delivery of a gastrointestinal implant using an alternative embodiment of a delivery device.
Detailed Description of the Invention
[0059] A description of preferred embodiments of the invention follows.
[0060] FIG. 1 is a sectional view of a portion of the digestive tract in a body. Food to be digested enters the stomach 102 through the cardiac orifice 110 from the esophagus. Chyme, a semi-fluid, homogeneous creamy or gruel-like material produced by gastric digestion in the stomach exits the stomach through the pyloric orifice (pylorus) 108 and enters the small intestine 112. The pylorus 108 is a distal aperture of the stomach 102 surrounded by a strong band of circular muscle. The small intestine, about nine feet in length, is a convoluted tube, extending from the pylorus to the ileo-caecal valve where it terminates in the large intestine. The small intestine has three sections, the duodenum 104, jejunum 106 and the ileum (not shown). The first eight to ten inch section of the small intestine, the duodenum, is the shortest, widest and most fixed part of the small intestine.
[0061] The duodenum has four sections: superior, descending, transverse and ascending which typically form a U-shape. The superior section is about two inches long and ends at the neck of the gall bladder. The descending section is about three to four inches long and includes a nipple shaped structure (papilla of vater) 114 through which pancreatic juice from the pancreas and bile produced by the liver and stored by the gall bladder enter the duodenum from the pancreatic duct. The pancreatic juice contains enzymes essential to protein digestion and bile dissolves the products of fat digestion. The ascending section is about two inches long and forms the duodenal-jejunal flexure 116 where it joins the jejunum 106, the next section of the small intestine. The duodenal-jejunal flexure 116 is fixed to the ligament of Treitz 118 (musculus supensionus duodeni). The juices secreted in the duodenum break the partially digested food down into particles small enough to be absorbed by the body. The digestive system is described in Gray's Anatomy (“Anatomy of the Human Body”, by Henry Gray) and “Human Physiology”, Vander, 3rd Ed, McGraw Hill, 1980, the contents of which are incorporated herein by reference in their entirety.
[0062] FIG. 2 is a perspective view of a gastrointestinal implant device 200 according to the principles of the present invention. The gastrointestinal implant device 200 includes an elongated open-ended flexible sleeve or tube 202 having a first proximal opening 204 and a second distal opening 206. Within the sleeve 202 is a passageway that extends from the first proximal opening 204 to the second distal opening 206 for transporting the chyme exiting the stomach 102 (FIG. 1 ). The surface of the passageway (the interior surface of the implant device 200) is smooth to enable the chyme to easily pass through. The exterior surface of the implant device 200 is smooth to prevent tissue in-growth and to be non-irritating to the bowel.
[0063] Within the implant device 200 at the proximal end including the first proximal opening 204 is a collapsible self-expanding stent 208. The stent 208 includes a plurality of opposed barbs 210 for anchoring the implant device 200 to the muscular pylorus in the stomach 102. The diameter of the stent 208 is dependent on the diameter of the pyloric orifice 108 (FIG. 1 ) about 0.8″ to 1.1″ based on human anatomy variations. In one embodiment, the length l of the stent 208 is selected to extend through the pylorus 108 and keep the pylorus 108 permanently open to induce “dumping syndrome.” In an alternate embodiment, a stent with a shorter length l allows the pylorus 108 to open and close normally.
[0064] The sleeve material is thin and conformable so that it collapses in the intestine to a small volume to minimize bowel irritability. It has a low coefficient of friction (<0.20) so that chyme slides easily through it and the bowel slides easily around it. It is of low permeability to fluids so that the chyme does not touch the bowel wall and the digestive enzymes do not significantly breakdown the chyme. It is biologically inert and non-irritating to the tissues. One such material is expanded polytetrafluoroethylene (ePTFE), a fluoropolymer, with a wall thickness of about 0.006″ and an internodal distance of 20 microns. This material is hydrophobic but is slightly porous. However, these very small pores may plug over time. The porosity may be reduced by coating the material on the inside, outside or in the pores with dilute solutions of silicone or polyurethane. Another material is polyethylene with a wall thickness of less than 0.001″. Rubber-like materials typically have friction coefficients of 1-4, significantly stickier than these materials. However, in alternate embodiments other materials having similar characteristics can be used.
[0065] The sleeve 202 includes two layers of material at least at the proximal end. A first outer layer covers the exterior of the stent. The second inner layer covers the interior surface of the stent 208. The barbs 210 protrude from the exterior surface of the stent 208 through the first outer layer of the sleeve 208. The holes in the first outer layer through which the barbs 210 protrude are filled with an impervious material such as silicone or urethane to limit mixing of digestive juices with the chyme flowing through the passageway. The diameter of the sleeve 208 is selected such that the first outer layer of the sleeve 208 fits over the stent 208.
[0066] The sleeve length 212 ranges from about one foot to about five feet. The typical length of the sleeve 208 is about 1.5 feet from the anchor (barbs 210) in the pyloric region of the stomach to below the ligament of Treitz 118 (FIG. 1 ). The length 212 of the sleeve 202 is selected to bypass the duodenum 104 (FIG. 1 ) and a portion of the jejunum. The length is increased to further decrease absorption by bypassing a longer section of the jejunum 106 (FIG. 1 ). The length 212 of the sleeve 202 is variable and dependent on the patient's Body Mass Index (BMI). The procedure is a less invasive alternative to surgery for the treatment of obesity and morbid obesity and also provides a new treatment approach for type 2 diabetes.
[0067] The covered stent 208 can be collapsed into a sheath having a diameter less than ¼ inches to enable endoscopic delivery. Covering the exterior surface of the stent 208 with the first outer layer of the sleeve 202 permits endoscopic removal of the implant device 200 by preventing tissue in-growth on the exterior surface of the stent 208.
[0068] Markings can be added to the exterior surface of the sleeve 202 to detect the position and orientation of the sleeve on a fluoroscopic image and whether the sleeve is twisted. For example, a stripe can be painted down the length of the device 200 using tantalum impregnated ink, or tantalum bands can be bonded to the exterior surface of the device. If the sleeve 202 is twisted, the sleeve 202 can be untwisted by inserting a balloon into the proximal end of the device thereby sealing it, and then injecting water into the sleeve at low pressure.
[0069] FIG. 3A is a plan view of the proximal portion of the gastrointestinal implant device shown in FIG. 2 . FIG. 3B is a cross-sectional view as taken along line AA of FIG. 3A showing the stent 208 and the first outer layer 300 and the second inner layer 302 of the sleeve 202 shown in FIG. 2 . As described in conjunction with FIG. 2 , the sleeve 202 includes a first outer layer 300 and a second inner layer 302. The first outer layer 300 is bonded to the second inner layer 300 at positions 306 below the distal end of the stent 208 and at positions 308, above the proximal end of the stent 208. A passageway 304 inside the second inner layer 302 of the sleeve 202 allows passage of chyme through the sleeve 202. The stent 208 is sandwiched between the first outer layer 300 and the second inner layer 302 at the proximal end of the sleeve 202 and is free to move at the distal end within the first outer layer 300 and the second inner layer 302 of the sleeve 202. The covered exterior surface of the stent 208 prevents tissue growth to allow removal of the implant device 200. The covered interior surface of the stent 208 provides a smooth passageway for chyme to bypass the duodenum 104.
[0070] FIG. 4 is a perspective view of the gastrointestinal implant device 200 with the first outer layer 300 of the sleeve 202 removed. The interconnecting struts which form the mesh (a network of struts) with diamond spaced openings are sufficiently flexible to allow the stent to be collapsed inside a delivery catheter and have sufficient elasticity to hold the pylorus open once the catheter is withdrawn. The force needed to hold the pylorus open is about 1-2 lbs. of radial force outward when the stent is compressed from its full diameter by 25%.
[0071] FIG. 5A is a sectional view of a body showing one embodiment of the gastrointestinal implant device 200 implanted in the digestive system. The first proximal end 204 of the implant device 200 is anchored to muscle in the pyloric portion of the stomach 102. The barbs 210 grip onto the muscle to anchor the implant device 200 in place so that the implant device 200 can not be dragged into the stomach or down into the intestines with movement of the stomach and the intestines. FIG. 5B is a sectional view of a body showing an alternative embodiment of the gastrointestinal implant device 200′ implanted distal to the pylorus 108.
[0072] The sleeve 202 extends over the ligament of Treitz 118 beyond the proximal jejunum. Extending the sleeve below the ligament of Treitz reduces the likelihood that the sleeve will move back through the duodenum 104 toward the stomach 102.
[0073] After the gastrointestinal implant device 200 has been placed in the body and anchored in either the pyloric portion of the stomach or distal to the pylorus 108, chyme leaving the stomach passes through passageway 304 (FIG. 3B ) inside the sleeve 202 and bypasses the duodenum 104 and proximal jejunum 106. By directing the chyme through the sleeve 202 the digestion and the absorption process in the duodenum 104 is interrupted. By interrupting mixing of the chyme with juices in the duodenum 104, partially digested food material is not broken down into particles small enough to be absorbed by the body. Further, there is no mixing of bile with the chyme until the chyme reaches the jejunum 106. The absorption of fats and carbohydrates is reduced by delaying the mixing of bile with the chyme.
[0074] The pyloric valve opens periodically to allow chyme to exit the stomach 102 to the duodenum 104. In one embodiment of the invention the length of the stent 208 is selected to keep the pyloric valve permanently open to induce “dumping syndrome.” By keeping the pylorus 108 open, the chyme empties rapidly into the sleeve 202 and passes down through the sleeve 202 and into the jejunum 106 with minimal digestion. This results in a “dumping syndrome” which is a reaction to excessive rapid dumping of chyme into the jejunum 106 causing the patient to feel ill, dizzy and nauseated. This syndrome is particularly enhanced when sugars and carbohydrates are eaten and passed directly into the jejunum 106.
[0075] To hold the pyloric valve open, the length of the stent 208 should be at least 1.5 inches so that the stent 208 extends from the anchoring position in the pyloric portion of the stomach through the pyloric orifice 108 (the opening from the stomach while the pyloric valve is open). The length of the stent is selected so that the distal end of the stent is above the papilla of Vater 114 (FIG. 1 ). As shown, the stent 208 extends through the pyloric orifice 108 to hold the pyloric valve permanently open. In an alternative embodiment, the length of the stent 208 is selected such that the stent 208 ends at the stomach side of the pyloric orifice 108 allowing the pyloric valve to operate normally.
[0076] The sleeve 202 provides weight loss mechanisms by providing negative feedback, reduced fat digestion and reduced desire for food. The reduced fat digestion occurs because the sleeve 202 delays the mixing of bile and pancreatic juices with chyme from the stomach until after the chyme leaves the sleeve. The reduced desire for food may occur because the sleeve 202 blocks hormonal release from the duodenum.
[0077] After the chyme from the stomach has passed through the sleeve, the sleeve becomes extremely thin and floppy, permitting the sleeve to contour to the inner walls of the intestine. The sleeve is non-compliant and drapes away from the intestinal walls thereby permitting the pancreatic juice to flow unimpeded into the duodenum through the papilla of vater. The normal peristalsis of the bowel is used to propel the chyme through the intestines.
[0078] FIG. 6 is a perspective view of a collapsible self-expanding stent 600 in the gastrointestinal implant device 200 shown in FIG. 2 when expanded. The stent 600 is non-woven, collapsible and self-expanding, allowing endoscopic insertion and removal of the implant device 200. The stent 600 includes a plurality of flat struts 602 forming an open space pattern to ease collapsing while ensuring self-expansion. The open space pattern allows for collapsing into a catheter for endoscopic delivery and removal. The struts 602 may be manufactured from heat-treated spring steel, or from an alloy such as a nickel-titanium, a shape-memory alloy commonly referred to as nitinol. Other alloys include nickel-cobalt-chromium-molybdenum alloys possessing a unique combination of ultrahigh tensile strength, such as MP35N, available from Asahi Intecc Co., Ltd. of Newport Beach, Calif.
[0079] In the embodiment shown, the stent has a length L of about 1.5 inches and has a diameter D of about 1 inch. The struts 602 are flat, about 0.010 inches wide and about 0.004 to 0.010 inches thick. The stent can be formed from a tube of material by laser cutting followed by expansion and heat setting, or other methods well known to those skilled in the art.
[0080] In an alternate embodiment, the struts 602 can be formed separately and the strut intersections can be welded or attached by other means well known to those skilled in the art. Visually the struts form sections 604 around the circumference of the stent. Each section has a series of triangles with each triangle defined by one distal strut connection 606 and two proximal strut connections 608, 610. The ratio of the collapsed diameter to the expanded diameter of the stent is roughly 1:4.
[0081] When expanded, the angle α between divergent strut sections is about 45-50 degrees and the diameter of the stent is about one inch. When compressed, the angle β between divergent strut sections is about 5-6 degrees to reduce the diameter of the stent to about 0.21 inch for endoscopic delivery and removal. The elasticity of the struts permits this compression. When the radial compression is released, the elasticity of the struts causes the stent to expand to diameter D. The stent assumes its desired diameter as the elastic restoring forces seek their minimum stress.
[0082] The ends of the struts at the proximal end of the stent 600 are elongated and shaped to provide barbs 612 to anchor to the muscle in the pyloric portion of the stomach 102.
[0083] FIG. 7 is a perspective view of the stent 600 shown in FIG. 6 when compressed. The stent 600 is compressed until the angle β between divergent strut sections is about 5-6 degrees to reduce the diameter D of the stent 600 to about 0.21 inch for endoscopic delivery and removal. The barbs 704 at the proximal end of the stent are elongated. The barbs 704 can be shaped to anchor the stent to the muscular pylorus.
[0084] FIG. 8 is a perspective view of another embodiment of a stent 800 when compressed. Pairs of barbs 802 at the proximal end of the stent 800 are elongated and can be shaped to provide opposed barbs to anchor the stent 800 in the muscle of the pylorus.
[0085] FIG. 9 is a perspective view of the compressed stent 800 shown in FIG. 8 with the strut ends 902, 900 bent to provide opposed barbs 904, 906. The barbs 904,906 engage the muscle of the pylorus to anchor the gastrointestinal implant device in the pylorus portion of the stomach. As shown in FIG. 2 , the strut ends 900, 902 protrude outward from the outer surface of the stent 800 in opposite directions. They may be perpendicular to each other. The barbs 904, 906 at the ends of the respective opposed strut ends 900, 902 dig into the pylorus muscle to anchor the stent. The barbs 904, 906 at the end of the protruding opposed strut ends 900, 902 prevent movement of the stent 800 in either direction; that is, they prevent movement of the stent 800 into the stomach and prevent movement of the stent 800 down through the duodenum.
[0086] FIG. 10 is a perspective view of the stent 800 shown in FIG. 8 when expanded. As discussed in conjunction with FIG. 9 , the barbs 904, 906 engage the muscle of the pylorus while the stent 800 is expanded. In the engaged position, the barbs 904, 906 spread radially outward from the longitudinal axis of the stent 800 such that the tips of the barbs come into contact and engage the tissue.
[0087] FIG. 11 illustrates the gastrointestinal device 1100 shown in FIG. 1 including an anti-buckling mechanism 1102. A flexible, anti-rotation, anti-buckling mechanism 1102 is attached to the sleeve 202 and extends from below the distal end of the stent along the length L of the sleeve to the distal end of the sleeve 202. In the embodiment shown, the anti-buckling mechanism 1102 is a guidewire device attached to the exterior surface of the outer layer of the flexible sleeve. Guidewire devices are well known to those skilled in the art. A first proximal end of the guidewire device 1104 is attached below the stent and a second distal end of the guidewire device 1106 is attached to the distal end of the flexible sleeve. The diameter of the guidewire ranges from about 0.010″ to about 0.016″.
[0088] The length of the sleeve 202 can be sized to just pass over the ligament of Treitz thereby bypassing only the duodenum and proximal jejunum 106. By doing this, it may not be necessary to provide any anti-buckling mechanisms in the sleeve 202 since the duodenum 104 is not very mobile compared to the jejunum 106. Typically, an anti-buckling mechanism 1102 is added to the exterior surface of a sleeve 202 having a length exceeding the length of the duodenum 104 and proximal jejunum 106.
[0089] The gastrointestinal implant device 200 is designed for endoscopic placement. FIG. 12 is a perspective view of a portion of a catheter system 1200 for delivery of the gastrointestinal implant device. The catheter system follows a guide wire 1212 through the esophagus and the stomach to the pylorus portion of the stomach. The guide wire 1212 enters a first inner lumen at the proximal end 1208 of the catheter system 1200 and exits the first inner lumen at the distal end 1222 of the catheter system 1200.
[0090] The catheter system 1200 includes an outer sheath 1202 for storing the stent 208 in collapsed form, a flange 1216 to pull back the outer sheath 1202 and a sleeve retention wire mechanism 1214 for releasing a sleeve retention wire 1210 from the proximal end of the flexible sleeve 202 after the stent has been released from the outer sheath 1202.
[0091] As described in conjunction with FIG. 2 , the distal portion of the gastrointestinal implant device includes a flexible sleeve 202 which can negotiate the duodenum and the jejunum. A sleeve retention wire 1210 travels through a second inner lumen and exits the second inner lumen to secure the distal end of the sleeve 202 to an inner sheath 1226. The sleeve retention wire 1210 is coupled to the sleeve retention wire release mechanism 1214 for releasing the sleeve retention wire 1210 after the gastrointestinal implant device has been positioned in the pyloric section of the stomach. The release mechanism 1214 will be described later in conjunction with FIG. 16B .
[0092] The sleeve 202 is secured temporarily outside the inner sheath 1226 allowing for proper positioning of the gastrointestinal implant device and then for release. As shown, the sleeve 202 is secured by the sleeve retention wire 1210 using a dead-bolt mechanism 1206. Non-stick coatings such as Teflon on the sleeve retention wire 1210 are preferred to make release easier to accommodate tortuous anatomical pathways. The sleeve retention wire 1210 extends through the second inner lumen from the release mechanism 1214 of the catheter system 1200 to the dead-bolt mechanism 1206. The dead-bolt mechanism 1206 is described later in conjunction with FIG. 13A . The sleeve retention wire 1210 holds the sleeve in position. The distal end of the folded sleeve is released by the release mechanism 1214 by pulling the sleeve retention wire 1210 backward from the proximal end 1208 of the catheter.
[0093] As described in conjunction with FIG. 1 , the proximal portion of the gastrointestinal device includes a covered stent. The covered stent does not enter the duodenum and thus is stiffer than the sleeve because it remains in the pylorus of the stomach. The stent in the gastrointestinal implant device is collapsed and stored in the outer lumen within the outer sheath 1202 between the flange 1216 and the distal end of the outer sheath 1202. The stent is supported in a collapsed form by the outer sheath 1202. The catheter 1200 is inserted into the digestive system through the esophagus to the pyloric section of the stomach. The proximal end of the outer sheath 1202 is positioned in the stomach, in the pylorus through the use of positioning ring 1224. After the outer sheath 1202 has been positioned, the stent is retracted from the outer lumen of the catheter by pulling flange 1216 toward the proximal end of the catheter system 1200. Upon release, the stent self-expands by its own elastic restoring force to engage the anchor portion with the stomach muscle at the pyloric section of the stomach.
[0094] FIG. 13 is a cross-sectional view of the inner shaft 1226 taken along line E-E of FIG. 12 . The sleeve retention wire 1210 passes through a second inner lumen 1314 in the inner sheath 1226. The sleeve retention wire 1210 exits the second inner lumen 1314 and is threaded through folds of the sleeve 202 at 1302 in FIG. 14A . The sleeve retention wire 1210 re-enters the second inner lumen 1314 at 1302 (FIG. 14A ). The guidewire 1212 passes through the first inner lumen 1310.
[0095] FIG. 14A is an expanded perspective view of the dead-bolt mechanism 1206 shown in FIG. 12 . The sleeve 202 has been folded for delivery. The sleeve is wrapped around the inner sheath 1226 and bunched above the inner sheath 1226. The sleeve is held in folded position around the inner sheath 1226 by threading the sleeve retention wire 1210 through the folds of the sleeve 202. The sleeve retention wire 1210 exits the second inner lumen 1314 through an opening 1306 and pierces through folds of the sleeve 202 at 1304. Threading the sleeve retention wire 1210 through the folds of the sleeve 202 results in a plurality of small holes at the distal end of the sleeve 202. The holes are reinforced with silicone or urethane to avoid tears in the material. The sleeve retention wire 1210 re-enters the second inner lumen through a second hole 1302 and advances a sufficient distance within the second inner lumen toward the distal end of the second inner lumen to resist pulling out of the second inner lumen.
[0096] FIG. 14B is a sectional view of the dead-bolt mechanism 1206 shown in FIG. 14A illustrating the sleeve retention wire 1210 threaded through the sleeve. The sleeve retention wire 1210 exits the second inner lumen 1314 at 1306 and pierces through folds in the sleeve 202 at 1304. The sleeve retention wire 1210 re-enters the second inner lumen 1314 at 1302.
[0097] FIG. 15 is a sectional view of a portion of the catheter system shown in FIG. 12 illustrating the collapsed stent 208 stored inside the outer sheath 1202. The stent 208 is pre-compressed and held in a collapsed form inside the outer sheath 1202 of the catheter. The outer sheath 1202 is pulled back by the flange 1216 toward the proximal end of the catheter system 1200 to release the self-expanding stent 208. The stent radially expands under its own elastic restoring force. The guidewire 1212 is directed through the first inner lumen 1310 and the sleeve retention wire 1210 is directed through the second inner lumen in the inner sheath 1226. The inner sheath includes a first lumen through which the guidewire passes and a second lumen through which the sleeve retention wire passes.
[0098] FIGS. 16A-C illustrate a method for delivery of the gastrointestinal implant device. FIG. 16A is a plan view of the catheter system illustrating the collapsed stent stored inside the outer sheath 1202 of the gastrointestinal implant device. As described in conjunction with FIG. 12 , the stent 208 is stored inside the outer sheath and the distal end of the sleeve 202 is secured outside the inner sheath 1226 by a sleeve retention wire 1210.
[0099] FIG. 16B is a plan view of the catheter system 1200 illustrating the gastrointestinal implant device after release of the stent 208 from the outer sheath 1202. The flange 1216 has been pulled back toward the proximal end of the catheter system 1200 to pull back the outer sheath 1202 from the stent and the stent 208 has self-expanded. The sleeve retention wire 1210 holds the distal end of the sleeve 202.
[0100] Once in place, the sleeve retention wire 1210 can be removed. As described previously in conjunction with FIG. 12 , the sleeve retention wire 1210 is coupled to locking mechanism 1224. Handle 1600 in the locking mechanism 1214 acts as a pivot device to pull the sleeve retention wire 1210 from the dead-bolt mechanism 1206. The distal end of the gastrointestinal implant device is released by moving handle 1600 in a clockwise direction 1604. As the handle 1600 is moved in direction 1604, the sleeve retention wire 1210 threaded through the folds of the sleeve is pulled back through the second inner lumen 1314 and disengages from the sleeve at the distal end of the gastrointestinal implant device. The sleeve retention wire 1210 extends from the distal end of the gastrointestinal implant device through the second inner lumen 1314. The wire is connected to the handle 1600 at the proximal end of the catheter.
[0101] FIG. 16C is a plan view of the catheter system illustrating the expanded gastrointestinal implant device after the sleeve retention wire has been released. The handle 1600 has been moved in a clockwise direction and the sleeve retention wire 1210 has been pulled back through the second inner lumen 1314 to release the distal end of the sleeve 202.
[0102] FIG. 17 is a perspective view of another embodiment of the catheter system shown in FIG. 16 . The catheter includes a ball 1800 coupled to the distal end 1222 of the inner sheath 1226 for guiding the catheter through the alimentary canal (e.g., to the pyloric portion of the stomach). The ball 1800 is small enough so that it can be pulled back through the gastrointestinal implant device after the gastrointestinal device has been delivered, the stent expanded and the sleeve retention wire 1210 has been released. The sleeve is shown uniformly folded 1204. However, the sleeve may not necessarily be uniformly folded.
[0103] FIG. 18 is a cross-section of an everting catheter system 1900 for delivery of a longer flexible sleeve. The gastrointestinal implant device 200 is shown with the stent sleeve anchor 1901 and the attached sleeve 1902 shown as delivered into the anatomy. The delivery catheter previously described is then removed. A balloon catheter 1906 is introduced into the stent sleeve anchor 1901 and the balloon 1908 inflated to seal the lumen of the stent 1901. The sleeve 1902 is folded inside itself and an elastic band 1912 is used to seal the end of the sleeve. Fluid is then injected through the balloon catheter shaft 1906 into the sleeve lumen 1910, filling the lumen and pressurizing it. The pressure of the fluid is used to push the inner sleeve distally towards 1904. When the sleeve 1902 has fully deployed distally, the elastic band 1912 falls off of the closed end of the sleeve 1902 and passes distally in the intestine until it is excreted. This mechanism permits deployment of a sleeve that is double the length of the delivered device. This may be needed as it is difficult to access the distal parts of the intestine with guidewires. This everting catheter system enables delivery of longer sleeves than are possible using only the delivery catheter described in conjunction with FIG. 12 .
[0104] FIG. 19 is a perspective view of a retrieval device 2000 for removing the gastrointestinal implant device 200 from the digestive tract. As already described, the exterior surface of the stent 208 is covered with a material that prevents cellular in-growth allowing the stent 208 to be easily removed. The retrieval device 2000 includes an inner sheath 2004 and an outer sheath 2006. A plurality of fingers 2002 extend from the proximal end of the inner sheath 2004. The fingers 2002 engage the exterior surface of the gastrointestinal device. As the inner sheath 2004 is moved down over the fingers, the fingers 2002 pull radially inward to reduce the proximal stent diameter and pull the collapsed device into the outer sheath 2006.
[0105] FIG. 20 is a perspective view of the retrieval device 2000 engaged with the stent 208. The fingers 2002 of the retrieval device are positioned around the stent 208. As the inner sheath 2004 is pushed over the fingers 2002, the fingers pull radially inward on the proximal end of the stent 208 and the proximal end of the stent 208 is collapsed. After the stent 208 has been collapsed sufficiently such that the proximal stent diameter is less than the diameter of the outer sheath 2006, the stent is drawn into the outer sheath 2006. The entire gastrointestinal implant device can then easily be removed from the patient by pulling retrieval device 2000 through the stomach and the esophagus.
[0106] FIG. 21 is a perspective view of another embodiment of a gastrointestinal implant device 2200. The gastrointestinal implant device 2200 includes a sleeve 202 and an anchoring ring 2204. The distal end of the anchoring ring 2204 is bonded to the proximal end of the sleeve 202. A plurality of eyelets 2206 are distributed around the circumference of the proximal end of the ring for anchoring the device to the pyloric muscle using anchors shown in FIG. 24 . The anchoring ring 2204 is made from a flexible material such as silicone allowing the ring 2204 to be collapsed for endoscopic insertion and removal.
[0107] The anchoring ring 2204 does not hold the pylorus open. However, in an alternate embodiment, the anchoring ring 2204 can be bonded to a stent with sufficient length and diameter to hold the pylorus open as described in conjunction with FIG. 2 . The anchoring ring 2204 anchors the device and the stent holds the pylorus open.
[0108] FIG. 22 is a perspective view of the anchoring ring 2204 shown in FIG. 21 in the expanded position. The sleeve is bonded to the outer surface 2300 of the proximal end of the anchoring ring whose diameter is 0.8″ or about the same as the diameter of the sleeve. The anchoring ring 2204 includes at least four eyelets to anchor the device in place. The outer most diameter of the ring is about one inch. In an alternate embodiment there can be more than four eyelets.
[0109] FIG. 23 is a perspective view of the anchoring ring 2204 shown in FIG. 21 in a collapsed position for insertion and removal. The circular ring 2204 shown in FIG. 21 has been compressed to an oval shape allowing the anchoring ring to be inserted into the lumen of a catheter for delivery.
[0110] FIG. 24 is a perspective view of an anchor 2500 for anchoring the collapsible ring shown in FIG. 23 to the muscular tissue of the pyloric orifice. The anchor 2500 includes an anchor pin 2504 coupled to a second pin 2506 by a flexible shaft 2502. The anchor pin 2504 includes a shaped barb 2508 for locking the anchor 2500 into the tissue. The anchor 2500 is delivered after the collapsible ring has been positioned in the pyloric orifice. The anchor is guided so that the anchor pin 2504 is directed through a respective eyelet with the barbed portion of the anchor pin 2504 guided toward the tissue. After the barb 2508 has been locked into the tissue, the second pin 2506 sits inside the gastrointestinal implant device while the barbed portion 2508 of the anchor pin 2504 sits inside the pylorus muscle tissue. For removal of the gastrointestinal implant device from the body, the flexible shaft 2502 of the anchor 2500 is cut.
[0111] FIG. 25A is a perspective view of a delivery system 2600 for delivering the anchor 2500 after the gastrointestinal implant device has been placed in the pyloric orifice. The anchor 2500 is loaded in the distal end of a catheter having a single lumen tube 2600. The hollow, distal end of the delivery device is a sharp needle made to penetrate the pylorus muscle. In an alternate embodiment, the distal end of the delivery device can be formed in an arc to improve access to the eyelets 2206 through an endoscopic approach. The catheter 2600 includes a pusher 2604 for releasing the anchor 2500. The pusher 2604 is moved in a longitudinal direction 2602 to release the anchor 2500 from the lumen.
[0112] FIG. 25B is a plan view of the delivery system 2600 shown in FIG. 25A . FIG. 25C is a cross-sectional view of the distal end of the catheter 2600 as taken along line B-B of FIG. 25B . As described in conjunction with FIG. 24 , the anchor 2500 includes pins 2504, 2506 coupled by a flexible shaft 2502. The anchor 2500 is loaded in the lumen at the distal end of the catheter 2600. The anchor pin 2504 is placed in the distal end of the tube 2600 and the second pin 2506 in the proximal end. The barb 2508 on the anchor pin 2504 is pointed toward the proximal end of the tube 2506 to engage with the tissue upon release in the muscle tissue. The catheter is advanced to the center of the ring positioned in the pyloric orifice. The sharp end 2510 is then pushed through an eyelet and into the muscle tissue. The pusher 2506 is pushed in longitudinal direction 2602 to release the distal anchor 2506. Once the distal anchor is released, the delivery system is pulled back, dragging the proximal part of the anchor out of the delivery device with the flexible shaft going through the eyelet, and the proximal anchor portion resting on the inside of the device. In the embodiment of the ring shown in FIG. 22 , four anchors 2506 are delivered to anchor the gastrointestinal implant device through the four eyelets.
[0113] FIG. 25D is a perspective view illustrating the sharp end 2510 of the needle inserted through an eyelet 2206 for delivery of the anchor 2500 to the tissue 2512. The distal end of the catheter is formed in an arc 2520 to improve access the eyelets 2206. The sharp end 2510 of the catheter is inserted through the eyelet 2206 into the tissue 2516. The anchor pin 2504 of the anchor has been pushed out from the lumen into the tissue 2512.
[0114] FIG. 25E is a perspective view illustrating the barb 2508 engaging the tissue 2512 after delivery. The catheter has been removed from the eyelet 2206 leaving the anchor pin 2504 engaging the tissue 2512.
[0115] FIGS. 26A-E illustrate an alternative embodiment of a locking mechanism for holding the distal end of the sleeve 202 in position during delivery of the gastrointestinal implant device. A snare wire 2656 is passed through one of the lumens of a catheter 2650 to the distal end. At the distal end, the end of the snare wire 2650 is looped back and attached to or anchored inside the catheter 2650. The folds of the sleeve 202 are advanced through this snare loop. The snare handle 2664 pulls and releases the snare wire 2656 to lock and release the distal end of the sleeve 202. The delivery system includes a pull tap 2666 for releasing a drawstring holding the stent in a collapsed position.
[0116] FIG. 26B is cross-sectional view taken along line C-C of FIG. 26A through the inner sheath 2650. The inner sheath has two lumens 2654, 2662 and has a diameter of about 0.078 inches. The first inner lumen 2564 is for passing a guidewire through the inner sheath and is about 0.04 inches in diameter. The second inner lumen 2662 is for passing the snare wire through the inner sheath and is about 0.02 inches in diameter. The end of the snare wire 2658 is anchored inside the inner sheath 2650.
[0117] FIG. 26C is a cross-sectional view taken along line DD of FIG. 26A through the outer sheath 2600 showing the inner sheath 2650 within the outer sheath 2600. The outer sheath has an inner diameter of about 0.1 inches and an outer diameter of about 0.143 inches. The open space inside the outer sheath can be used for passing a drawstring through the outer sheath.
[0118] FIG. 26D is a cross-sectional view through the distal portion of the catheter 2650 showing the snare capturing the distal end of the sleeve 202. The distal end of the sleeve 202 is captured by the snare wire 2656 by pulling the distal end of the sleeve through a loop formed by the snare wire 2656.
[0119] FIG. 26E is a sectional view through the distal portion of the catheter showing the snare locking mechanism. The distal end of the sleeve is locked by pulling the snare wire 2656 in a longitudinal direction 2664 toward the proximal end of the delivery system to capture the sleeve folds against the inner shaft. After the gastrointestinal implant device is properly positioned in the body, the snare wire is advanced in a longitudinal direction 2662 toward the distal end of the delivery system. This opens the snare wire 2656 and releases the sleeve 202.
[0120] FIG. 27 is a perspective view of the distal portion of the gastrointestinal implant device including texturing 2700. Texturing of the distal end of the sleeve can be added to ensure that the actions of peristalsis do not advance the sleeve proximally, towards the stomach, but keep the sleeve pulled taught in the intestine. At the distal end of the sleeve, texturing 2700 is added with a directional aspect to it. The texturing 2700 can be molded into the sleeve material or added by adhesive or thermal bonding methods. The texturing material contains includes fibril shapes that are directed proximally so that any peristaltic waves that travel proximally, will have less force on the sleeve than distal peristaltic waves.
[0121] The gastrointestinal implant device offers a new alternative where other means of weight loss and efforts at behavior modification have failed. Because the gastrointestinal implant device is endoscopically introduced, there is a reduced risk at insertion compared to surgery. The procedure is also completely reversible, making this approach an ideal solution for patients who are desperate to reverse behavioral patterns that have lead to weight gain.
[0122] When inserted in the body, the gastrointestinal implant device mimics the duodenal bypass of the Roux-en-Y procedure. The implanted device reduces caloric absorption by delaying enzyme mixing with food and provides the feedback produced by the Roux-en-Y procedure by producing dumping syndrome when high sugar meals are ingested. Rapid stomach emptying is encouraged by inserting a stent in the pylorus to hold the pylorus open and all food bypasses the duodenum and passes rapidly into the jejunum. The implant device is an improvement on the Roux-en-Y procedure because it is minimally invasive and reversible. In the treatment of the super-obese where aggressive weight loss is not achieved, the length of the implant device below the stent can be further increased to drive the patient close to the point of malabsorption.
[0123] The gastrointestinal implant device can be used to reduce Type 2 diabetes symptoms by bypassing the duodenum. Following gastric bypass surgery, patients commonly experience complete reversal of Type 2 diabetes. While the exact mechanism of this remarkable effect is not understood, the clinical result is reported in a high percentage of cases. Reversal of Type 2 diabetes after gastric bypass is described in “Potential of Surgery for Curing Type 2 Diabetes Mellitus” by Rubino et al. incorporated herein by reference in its entirety. Since the gastrointestinal implant device provides equivalent blockage of duodenal processes, a similar effect is elicited but without the trauma of surgery. In patients who are not obese but suffer Type 2 diabetes, a modified gastrointestinal implant device is inserted. This gastrointestinal implant device provides the necessary effect to hinder pancreatic processes and receptors without blocking absorption.
[0124] In the embodiment of the gastrointestinal implant device for treating diabetes, the length of the stent is selected to allow the pylorus to operate normally. The length of the sleeve is also reduced to mimic the duodenum bypass. The sleeve extends to just below the ligament of Treitz but does not extend further into the jejunum, thus allowing absorption to occur in the jejunum.
[0125] FIG. 28 is a perspective view of a gastrointestinal implant device with another embodiment of a collapsible self-expanding anchoring device. The gastrointestinal implant device 2800 includes a sleeve 202 and an anchoring device, or sleeve anchor, for anchoring the gastrointestinal implant 2800 device within the gastrointestinal tract. In some embodiments, the implant device 2800 includes a wave anchor 2810 coupled to a proximal portion of the sleeve 202. Wave anchors are described in more detail in co-pending U.S. patent application Ser. Nos. 10/858,851 and 10/858,852, both filed on Jun. 1, 2004, both claiming priority to U.S. Provisional Application Nos. 60/528,084 filed on Dec. 9, 2003 and 60/544,527 filed on Dec. 13, 2003; U.S. patent application Ser. No. 11/229,352, filed on Sep. 16, 2005, which claims priority to U.S. Provisional Application No. 60/611,038, filed on Sep. 17, 2004; and U.S. patent application Ser. No. 11/147,992, filed on Jun. 8, 2005, all incorporated herein by reference in their entirety.
[0126] The wave anchor 2810 includes a compliant, radial spring 2900 shaped into an annular oscillating pattern. For example, the pattern is a wave pattern, such as a sinusoidal pattern formed about a central axis. The anchor provides an outward radial force, while allowing substantial flexure about its perimeter. Such flexure is advantageous as it allows for minimally-invasive delivery and ensures that the device will substantially conform to the surrounding anatomical structure when implanted.
[0127] The annular wave element 2900 can be formed from one or more elongated resilient members radially-disposed about a longitudinal axis and joined together defining a lumen along its central axis formed between two open ends. When implanted, the central axis 2815 of the anchor is substantially aligned with the central axis of the lumen 2820 (e.g., duodenum 104), allowing chyme to pass through the interior of the device 2800. Additionally, the compliant wave anchor 2810 minimizes trauma to the tissue by providing sufficient flexibility and compliance, while minimizing the likelihood of tissue erosion and providing a solid anchoring point to the tissue.
[0128] In some embodiments, the wave anchor is adapted for placement within a region of the proximal duodenum referred to as the duodenal bulb 500 (FIG. 5B ). For these applications, the axial extent of the anchor is preferably less than the distance between the pyloric sphincter and the ampulla of Vater. Exemplary relaxed lengths can range from about 20 to 50 mm (i.e., from less than 1 to about 2 inches). The diameter of the wave anchor 2900 can have an initial installed diameter within the range of about 20-40 millimeters (i.e., between about ¾ and 1¾ inches).
[0129] The compliance of the anchor 2900, allows it to flex radially over a wide range according to natural contractions and expansions of the duodenum 104. In some embodiments, the relaxed diameter of the wave anchor 2900 can be about 50 mm (i.e., about 2 inches). In other embodiments, the relaxed diameter can exceed 50 mm, being up to 60 mm (i.e., 2.5 inches) or even more. In either case, the wave anchor 2900 can be temporarily collapsed to about 12 mm (i.e., about 0.5 inches) for endoscopic placement.
[0130] In some embodiments, the implant device includes a retrieval/repositioning feature. For example, the implant device 2800 includes a drawstring 2825. The drawstring 2825 can be selectively woven around the perimeter of the anchor 2900 through openings of opportunity in the anchor 2900. Alternatively or in addition, the drawstring 2825 can be selectively woven through dedicated openings, such as eyelets provided on the anchor 2900 or in the proximal sleeve 202. In operation, the drawstring 2825, when pulled, contracts about the perimeter of the anchor 2900 to reduce the diameter of the anchor 2900. Collapsing the anchor 2900 in this manner before removing or repositioning the anchor 2900 is advantageous in avoiding tissue damage, particularly when the implant device 2800 includes barbs.
[0131] In some embodiments, the gastrointestinal implant device 2800 can be inserted endoscopically in combination with a delivery catheter, such as any of the delivery catheters described herein (FIGS. 12 and 17 ) or any of the delivery catheters described in U.S. patent application Ser. No. 10/999,846, filed on Nov. 30, 2004, which is a divisional of U.S. patent application Ser. No. 10/339,786, filed on Jan. 9, 2003, which claims the benefit of U.S. Provisional Application No. 60/430,321 filed on Dec. 2, 2003; any of the delivery catheters described in U.S. patent application Ser. No. 10/726,011, filed on Dec. 2, 2003, which claims the benefit of U.S. Provisional Application No. 60/512,145, filed on Oct. 17, 2003; or any of the delivery catheters described in U.S. patent application Ser. No. 11/057,861, filed on Feb. 14, 2005, which claims the benefit of U.S. Provisional Application Nos. 60/586,521, filed on Jul. 9, 2004 and 60/610,614, filed on Sep. 19, 2004, all incorporated herein by reference in their entirety.
[0132] For example, a delivery device 2950 is directed into the duodenum, as illustrated in FIG. 29A . The leading or distal end of the delivery device 2950 includes an outer catheter 2955 that may include a capsule or container 2960. The capsule 2960 may be placed with the assistance of a guidewire (not shown) and its position confirmed within a desired location, such as partially or entirely through the pylorus 108 and into the small intestine, using fluoroscopy.
[0133] The container 2960 holds or houses parts or all of a gastrointestinal implant device (e.g., a gastrointestinal sleeve). The gastrointestinal implant device includes a distal portion and a proximal portion. The distal portion includes a gastrointestinal sleeve and the proximal portion of the device includes a collapsible sleeve anchor for securing the device within the gastrointestinal tract (e.g., in the proximal duodenum). In some embodiments, the container 2960 holds or houses at least the proximal portion of the gastrointestinal device. In other embodiments, the container 2960 holds or houses both the distal and proximal portions. In still further embodiments, the container 2960 holds or houses the entire gastrointestinal device. Some or all of the sleeve portion can be folded and stored in the container 2960 with the sleeve anchor.
[0134] After the container 2960 is positioned at the desired location, a distal portion 2965 of the sleeve is removed from the container and directed into a location in the gastrointestinal tract that is distal from the container, as illustrated in FIG. 29B . The outer catheter 2955 defines an inner catheter lumen (not illustrated) and an inner catheter (hidden under sleeve 2965) extending distal to the outer catheter 2955 or container 2960. The inner catheter can be advanced with respect to the container 2960 into locations of the gastrointestinal tract that are distal from container 2960 and pylorus 108.
[0135] The distal portion 2965 of the sleeve is releasably secured to the leading or distal portion of the inner catheter so that as the inner catheter is advanced through the intestine 112, distal portion 2965 is also advanced. In this manner, distal portion 2965 is directed to locations in the gastrointestinal tract that are distal from container 2960 and into the intestine 112 (e.g., into the jejunum). Throughout this procedure, the outer catheter 2955 is held in place to ensure that capsule 2960 remains in the duodenum and does not move proximally into the stomach.
[0136] The proximal portion of the gastrointestinal sleeve can be releasably secured within the container 2960 by a locking means (e.g., by an anchor locking wire) to ensure that the anchor does not emerge from container 2960 and deploy before the distal portion 2965 of the sleeve is extended to a desired location in the intestine 112.
[0137] In some embodiments, an atraumatic tip (e.g., atraumatic ball 2970) is attached to the distal end of the inner catheter, which minimizes or eliminates tissue trauma as the inner catheter is advanced into the intestine.
[0138] After the distal portion 2965 of the sleeve is advanced to a desired location in the intestine 112, the anchor is deployed from the container 2960 and secured to a desired position within the gastrointestinal tract, as illustrated in FIG. 29C . The anchor locking means (not shown) is released to allow the anchor to be subsequently removed from container 2960. For example, the anchor locking means can include a locking wire that releasably secures the anchor within container 2960 and pulling the locking wire proximally detaches the anchor so that the anchor can be removed from the container 2960 at some subsequent time.
[0139] Once the container 2960 is in the desired location, outer catheter 2955 is held in position and the inner catheter can be advanced further distally to pull the sleeve and anchor 2975 from container 2960. Optionally, the anchor 2975 is pushed out of the container 2960 using a means for displacing an anchor 2975 from the container assembly (e.g., an anchor plunger). In some embodiments, either the inner catheter or the means for displacing the anchor are used to hold the anchor 2975 in position, while the outer catheter 2955 is pulled proximally to release the anchor 2975 in place.
[0140] In some embodiments, the atraumatic tip or ball 2970 is dimensioned such that it can be pulled back through the sleeve. The inner catheter and outer catheter 2955 are removed by pulling the delivery device 2950 proximally, out of the patient.
[0141] In some embodiments, the gastrointestinal implant device can be repositioned and/or removed endoscopically in combination with a repositioning/removal device, such as any of the repositioning/removal devices described herein (FIG. 19 ) or any of the repositioning/removal devices described in U.S. patent application Ser. No. 11/001,812, filed on Nov. 30, 2004, which is a divisional of U.S. patent application Ser. No. 10/339,786, filed on Jan. 9, 2003, which claims the benefit of U.S. Provisional Application No. 60/430,321 filed on Dec. 2, 2003; or any of the repositioning/removal devices described in U.S. Provisional Application No. 60/645,287, filed on Jan. 19, 2005, all incorporated herein by reference in their entirety.
[0142] Various embodiments of the gastrointestinal implant device have been described herein. These embodiments are given by way of example and are not intended to limit the scope of the present invention. It should be appreciated, moreover, that the various features of the embodiments that have been described may be combined in various ways to produce numerous additional embodiments.
[0143] While this invention has been particularly shown and described with references to preferred embodiments thereof, it will be understood by those skilled in the art that various changes in form and details may be made therein without departing from the scope of the invention encompassed by the appended claims.
[0144] The appended claims are of a scope that covers the embodiments disclosed in priority application U.S. patent application Ser. No. 10/858,852 referenced herein, and thus have the benefit of priority of that filing date. The claims are also of a sufficient scope to cover more recent embodiments, including those described above and those disclosed in U.S. patent application Ser. Nos. 11/229,352 and 11/147,992, also referenced herein.
Claims
What is claimed is:
1. A method for delivering a gastrointestinal device in a body comprising the steps of:
providing a delivery system including an outer sheath and an inner sheath disposed therein,
securing a distal portion of a gastrointestinal device outside of the inner sheath, the distal portion being a floppy sleeve surrounding the inner sheath;
guiding the delivery system through the alimentary canal with a ball coupled to a distal end of the inner sheath distal to the sleeve, the outer sheath extending through the stomach and the inner sheath extending through the intestine.
2. The method of claim 1, wherein the delivery system is used for delivering the gastrointestinal device, a proximal portion of the gastrointestinal device comprising a self-expanding anchor and a distal portion comprising the sleeve.
3. The method of claim 2, wherein the proximal end of the device is stored within the outer sheath and outside of the inner sheath.
4. The method of claim 3, wherein the distal end of the device is secured outside of the inner sheath.
5. The method of claim 3 wherein the sleeve is releasably secured to the inner sheath using a sleeve retention device.
6. The method of claim 2, wherein the gastrointestinal device is anchored in the stomach.
7. The method of claim 2, wherein the gastrointestinal device is anchored distal to the pylorus.
8. The method of claim 2, wherein the gastrointestinal device is retained within the pyloric orifice.
9. The method of claim 2, further comprising the steps of selectively releasing a distal end of the sleeve.
10. The method of claim 2, further comprising releasing the anchor from the outer sheath and expanding the anchor to anchor the gastrointestinal device.
11. The method of claim 10, wherein expanding the anchor comprises the step of selectively releasing the anchor from the outer sheath.
12. The method of claim 11 wherein the step of selectively releasing the anchor from outer sheath comprises pulling the outer sheath toward the proximal end of the delivery system.
13. The method of claim 1, further comprising the step of passing the delivery system over a guidewire.
14. The method of claim 13 wherein the step of selectively releasing the distal end of the sleeve comprises pulling a moveable element toward the proximal end of the delivery system.
15. The method of claim 14, further comprising the step of retracting the ball through a central lumen of the gastrointestinal device after the distal end of the sleeve is released.
16. The method of claim 1, wherein the inner sheath defines a lumen.
17. A method for placing a gastrointestinal device in a body comprising the steps of:
providing a delivery system including an outer sheath and an inner sheath disposed therein;
storing a proximal portion of the gastrointestinal device within the outer sheath and outside of the inner sheath;
securing a distal portion of the gastrointestinal device outside of the inner sheath, the distal portion being a sleeve surrounding the inner sheath;
guiding through the alimentary canal a ball coupled to a distal end of the delivery system distal to the sleeve;
releasing the distal end of the gastrointestinal device from the inner sheath; and
releasing the proximal end of the gastrointestinal device from the outer sheath.
18. The method of claim 17, wherein the proximal end of the gastrointestinal device is a self-expanding anchor.
19. The method of claim 17 wherein the sleeve is releasably secured to the inner sheath using a sleeve retention device.
20. The method of claim 17, wherein the gastrointestinal device is anchored in the stomach.
21. The method of claim 17, wherein the gastrointestinal device is anchored distal to the pylorus.
22. The method of claim 17, wherein the gastrointestinal device is retained within the pyloric orifice.
23. The method of claim 17, further comprising the step of passing the delivery system over a guidewire.
24. The method of claim 17, further comprising the step of retracting the ball through a central lumen of the gastrointestinal device after the distal end of device is released.
Patent Citations (408)
| Patent | Date | Inventor | Cited By |
|---|---|---|---|
| US1899781(A) | 1933-02-01 | Twiss | Applicant |
| US2464933(A) | 1949-03-01 | Kaslow | Applicant |
| US3516408(A) | 1970-06-01 | Montanti | Examiner |
| US3780740(A) | 1973-12-01 | Rhea | Applicant |
| US4133315(A) | 1979-01-01 | Berman et al. | Applicant |
| US4134405(A) | 1979-01-01 | Smit | Applicant |
| US4265694(A) | 1981-05-01 | Boretos et al. | Applicant |
| US4270542(A) | 1981-06-01 | Plumley | Applicant |
| US4279251(A) | 1981-07-01 | Rüsch | Applicant |
| US4315509(A) | 1982-02-01 | Smit | Applicant |
| US4341218(A) | 1982-07-01 | U | Applicant |
| US4403604(A) | 1983-09-01 | Wilkinson et al. | Applicant |
| US4416267(A) | 1983-11-01 | Garren et al. | Applicant |
| US4501264(A) | 1985-02-01 | Rockey | Applicant |
| US4580568(A) | 1986-04-01 | Gianturco | Applicant |
| US4607618(A) | 1986-08-01 | Angelchik | Applicant |
| US4617932(A) | 1986-10-01 | Kornberg | Applicant |
| US4641653(A) | 1987-02-01 | Rockey | Applicant |
| US4648383(A) | 1987-03-01 | Angelchik | Applicant |
| US4763653(A) | 1988-08-01 | Rockey | Applicant |
| US4768507(A) | 1988-09-01 | Fischell et al. | Applicant |
| US4823808(A) | 1989-04-01 | Clegg et al. | Applicant |
| US4846836(A) | 1989-07-01 | Reich | Applicant |
| US4878905(A) | 1989-11-01 | Blass | Applicant |
| US4905693(A) | 1990-03-01 | Ravo | Applicant |
| US4913141(A) | 1990-04-01 | Hillstead | Applicant |
| US4991594(A) | 1991-02-01 | Angelchik | Examiner |
| US4994070(A) | 1991-02-01 | Waters | Examiner |
| US5035706(A) | 1991-07-01 | Gianturco et al. | Applicant |
| US5037387(A) | 1991-08-01 | Quinn et al. | Applicant |
| US5041126(A) | 1991-08-01 | Gianturco | Applicant |
| US5057091(A) | 1991-10-01 | Andersen | Applicant |
| US5059166(A) | 1991-10-01 | Fischell et al. | Applicant |
| US5104399(A) | 1992-04-01 | Lazarus | Applicant |
| US5123917(A) | 1992-06-01 | Lee | Applicant |
| US5135516(A) | 1992-08-01 | Sahatjian et al. | Applicant |
| US5152756(A) | 1992-10-01 | Quinn et al. | Applicant |
| US5152782(A) | 1992-10-01 | Kowligi et al. | Applicant |
| US5176617(A) | 1993-01-01 | Fischell et al. | Applicant |
| US5190561(A) | 1993-03-01 | Graber | Applicant |
| US5234454(A) | 1993-08-01 | Bangs | Examiner |
| US5236423(A) | 1993-08-01 | Mix et al. | Applicant |
| US5254133(A) | 1993-10-01 | Seid | Applicant |
| US5279553(A) | 1994-01-01 | Winkler et al. | Applicant |
| US5282824(A) | 1994-02-01 | Gianturco | Applicant |
| US5306300(A) | 1994-04-01 | Berry | Applicant |
| US5314444(A) | 1994-05-01 | Gianturco | Applicant |
| US5314472(A) | 1994-05-01 | Fontaine | Applicant |
| US5318530(A) | 1994-06-01 | Nelson, Jr. | Applicant |
| US5322501(A) | 1994-06-01 | Mahmud-Durrani | Applicant |
| US5330500(A) | 1994-07-01 | Song | Applicant |
| US5364353(A) | 1994-11-01 | Corfitsen et al. | Applicant |
| US5387235(A) | 1995-02-01 | Chuter | Applicant |
| US5389090(A) | 1995-02-01 | Fischell et al. | Applicant |
| US5401241(A) | 1995-03-01 | Delany | Applicant |
| US5405378(A) | 1995-04-01 | Strecker | Applicant |
| US5417697(A) | 1995-05-01 | Wilk et al. | Applicant |
| US5423851(A) | 1995-06-01 | Samuels | Applicant |
| US5443498(A) | 1995-08-01 | Fontaine | Applicant |
| US5456713(A) | 1995-10-01 | Chuter | Applicant |
| US5458605(A) | 1995-10-01 | Klemm | Applicant |
| US5458615(A) | 1995-10-01 | Klemm et al. | Applicant |
| US5480423(A) | 1996-01-01 | Ravenscroft et al. | Applicant |
| US5492530(A) | 1996-02-01 | Fischell et al. | Applicant |
| US5507767(A) | 1996-04-01 | Maeda et al. | Applicant |
| US5507771(A) | 1996-04-01 | Gianturco | Applicant |
| US5562697(A) | 1996-10-01 | Christiansen | Applicant |
| US5569219(A) | 1996-10-01 | Hakki et al. | Applicant |
| US5605530(A) | 1997-02-01 | Fischell et al. | Applicant |
| US5607442(A) | 1997-03-01 | Fischell et al. | Applicant |
| US5611787(A) | 1997-03-01 | Demeter et al. | Applicant |
| US5620763(A) | 1997-04-01 | House et al. | Applicant |
| US5624430(A) | 1997-04-01 | Eton et al. | Applicant |
| US5630797(A) | 1997-05-01 | Diedrich et al. | Applicant |
| US5634928(A) | 1997-06-01 | Fischell et al. | Applicant |
| US5639274(A) | 1997-06-01 | Fischell et al. | Applicant |
| US5643312(A) | 1997-07-01 | Fischell et al. | Applicant |
| US5662713(A) | 1997-09-01 | Andersen et al. | Applicant |
| US5665064(A) | 1997-09-01 | Bodicky et al. | Applicant |
| US5669932(A) | 1997-09-01 | Fischell et al. | Applicant |
| US5690642(A) | 1997-11-01 | Osborne et al. | Applicant |
| US5693084(A) | 1997-12-01 | Chuter | Applicant |
| US5695516(A) | 1997-12-01 | Fischell et al. | Applicant |
| US5697971(A) | 1997-12-01 | Fischell et al. | Applicant |
| US5713948(A) | 1998-02-01 | Uflacker | Applicant |
| US5715832(A) | 1998-02-01 | Koblish et al. | Applicant |
| US5718973(A) | 1998-02-01 | Lewis et al. | Applicant |
| US5720776(A) | 1998-02-01 | Chuter et al. | Applicant |
| US5722984(A) | 1998-03-01 | Fischell et al. | Applicant |
| US5730698(A) | 1998-03-01 | Fischell et al. | Applicant |
| US5733325(A) | 1998-03-01 | Robinson et al. | Applicant |
| US5735859(A) | 1998-04-01 | Fischell et al. | Applicant |
| US5735892(A) | 1998-04-01 | Myers et al. | Applicant |
| US5743874(A) | 1998-04-01 | Fischell et al. | Applicant |
| US5749825(A) | 1998-05-01 | Fischell et al. | Applicant |
| US5755777(A) | 1998-05-01 | Chuter | Applicant |
| US5759174(A) | 1998-06-01 | Fischell et al. | Applicant |
| US5776186(A) | 1998-07-01 | Uflacker | Applicant |
| US5792144(A) | 1998-08-01 | Fischell et al. | Applicant |
| US5792172(A) | 1998-08-01 | Fischell et al. | Applicant |
| US5800456(A) | 1998-09-01 | Maeda et al. | Applicant |
| US5800526(A) | 1998-09-01 | Anderson et al. | Applicant |
| US5820584(A) | 1998-10-01 | Crabb | Applicant |
| US5830229(A) | 1998-11-01 | Konya et al. | Applicant |
| US5840009(A) | 1998-11-01 | Fischell et al. | Applicant |
| US5843164(A) | 1998-12-01 | Frantzen et al. | Applicant |
| US5855601(A) | 1999-01-01 | Bessler et al. | Applicant |
| US5876445(A) | 1999-03-01 | Andersen et al. | Applicant |
| US5879282(A) | 1999-03-01 | Fischell et al. | Applicant |
| US5879370(A) | 1999-03-01 | Fischell et al. | Applicant |
| US5895391(A) | 1999-04-01 | Farnholtz | Applicant |
| US5910145(A) | 1999-06-01 | Fischell et al. | Applicant |
| US5913895(A) | 1999-06-01 | Burpee et al. | Applicant |
| US5925063(A) | 1999-07-01 | Khosravi | Applicant |
| US5962620(A) | 1999-10-01 | Reich et al. | Applicant |
| US5964771(A) | 1999-10-01 | Beyar et al. | Applicant |
| US5976153(A) | 1999-11-01 | Fischell et al. | Applicant |
| US6013019(A) | 2000-01-01 | Fischell et al. | Applicant |
| US6013085(A) | 2000-01-01 | Howard | Applicant |
| US6025044(A) | 2000-02-01 | Campbell et al. | Applicant |
| US6027526(A) | 2000-02-01 | Limon et al. | Applicant |
| US6074673(A) | 2000-06-01 | Guillen | Applicant |
| US6086604(A) | 2000-07-01 | Fischell et al. | Applicant |
| US6099552(A) | 2000-08-01 | Adams | Applicant |
| US6102887(A) | 2000-08-01 | Altman | Applicant |
| US6113607(A) | 2000-09-01 | Lau et al. | Applicant |
| US6120533(A) | 2000-09-01 | Fischell | Applicant |
| US6120534(A) | 2000-09-01 | Ruiz | Applicant |
| US6132471(A) | 2000-10-01 | Johlin, Jr. | Applicant |
| US6146323(A) | 2000-11-01 | Fischell | Applicant |
| US6152956(A) | 2000-11-01 | Pierce | Applicant |
| US6179868(B1) | 2001-01-01 | Burpee et al. | Applicant |
| US6190403(B1) | 2001-02-01 | Fischell et al. | Applicant |
| US6200336(B1) | 2001-03-01 | Pavcnik et al. | Applicant |
| US6221043(B1) | 2001-04-01 | Fischell et al. | Applicant |
| US6221102(B1) | 2001-04-01 | Baker et al. | Applicant |
| US6241757(B1) | 2001-06-01 | An et al. | Applicant |
| US6251132(B1) | 2001-06-01 | Ravenscroft et al. | Applicant |
| US6270521(B1) | 2001-08-01 | Fischell et al. | Applicant |
| US6293960(B1) | 2001-09-01 | Ken | Applicant |
| US6302891(B1) | 2001-10-01 | Nadal | Applicant |
| US6302917(B1) | 2001-10-01 | Dua et al. | Applicant |
| US6315708(B1) | 2001-11-01 | Salmon et al. | Applicant |
| US6322538(B1) | 2001-11-01 | Elbert et al. | Applicant |
| US6331190(B1) | 2001-12-01 | Shokoohi et al. | Applicant |
| US6332877(B1) | 2001-12-01 | Michels | Applicant |
| US6355056(B1) | 2002-03-01 | Pinheiro | Applicant |
| US6356782(B1) | 2002-03-01 | Sirimanne et al. | Applicant |
| US6375660(B1) | 2002-04-01 | Fischell et al. | Applicant |
| US6383214(B1) | 2002-05-01 | Banas et al. | Applicant |
| US6387114(B2) | 2002-05-01 | Adams | Applicant |
| US6402779(B1) | 2002-06-01 | Colone et al. | Applicant |
| US6406792(B1) | 2002-06-01 | Briquet et al. | Applicant |
| US6428558(B1) | 2002-08-01 | Jones et al. | Applicant |
| US6450989(B2) | 2002-09-01 | Dubrul et al. | Applicant |
| US6458074(B1) | 2002-10-01 | Matsui et al. | Applicant |
| US6485409(B1) | 2002-11-01 | Voloshin et al. | Applicant |
| US6485515(B2) | 2002-11-01 | Strecker | Applicant |
| US6508833(B2) | 2003-01-01 | Pavcnik et al. | Applicant |
| US6520985(B1) | 2003-02-01 | Burpee et al. | Applicant |
| US6524268(B2) | 2003-02-01 | Hayner et al. | Examiner |
| US6524335(B1) | 2003-02-01 | Hartley et al. | Applicant |
| US6524336(B1) | 2003-02-01 | Papazolgou et al. | Applicant |
| US6530951(B1) | 2003-03-01 | Bates et al. | Applicant |
| US6537247(B2) | 2003-03-01 | Shannon | Applicant |
| US6540775(B1) | 2003-04-01 | Fischell et al. | Applicant |
| US6540789(B1) | 2003-04-01 | Silverman et al. | Applicant |
| US6544291(B2) | 2003-04-01 | Taylor | Applicant |
| US6547817(B1) | 2003-04-01 | Fischell et al. | Applicant |
| US6558400(B2) | 2003-05-01 | Deem et al. | Applicant |
| US6558429(B2) | 2003-05-01 | Taylor | Applicant |
| US6565597(B1) | 2003-05-01 | Fearnot et al. | Applicant |
| US6572646(B1) | 2003-06-01 | Boylan et al. | Applicant |
| US6589213(B2) | 2003-07-01 | Reydel | Applicant |
| US6589275(B1) | 2003-07-01 | Ivancev et al. | Applicant |
| US6623518(B2) | 2003-09-01 | Thompson et al. | Applicant |
| US6635069(B1) | 2003-10-01 | Teoh et al. | Applicant |
| US6635079(B2) | 2003-10-01 | Unsworth et al. | Applicant |
| US6645239(B1) | 2003-11-01 | Park et al. | Applicant |
| US6652555(B1) | 2003-11-01 | VanTassel et al. | Applicant |
| US6656194(B1) | 2003-12-01 | Gannoe et al. | Applicant |
| US6669722(B2) | 2003-12-01 | Chen et al. | Applicant |
| US6675809(B2) | 2004-01-01 | Stack et al. | Applicant |
| US6676692(B2) | 2004-01-01 | Rabkin et al. | Applicant |
| US6695875(B2) | 2004-02-01 | Stelter et al. | Applicant |
| US6699263(B2) | 2004-03-01 | Cope | Applicant |
| US6699278(B2) | 2004-03-01 | Fischell et al. | Applicant |
| US6706061(B1) | 2004-03-01 | Fischell et al. | Applicant |
| US6716240(B2) | 2004-04-01 | Fischell et al. | Applicant |
| US6736840(B2) | 2004-05-01 | Fischell et al. | Applicant |
| US6740121(B2) | 2004-05-01 | Geitz | Applicant |
| US6755869(B2) | 2004-06-01 | Geitz | Applicant |
| US6764518(B2) | 2004-07-01 | Godin | Applicant |
| US6773440(B2) | 2004-08-01 | Gannoe et al. | Applicant |
| US6776791(B1) | 2004-08-01 | Stallings et al. | Applicant |
| US6821291(B2) | 2004-11-01 | Bolea et al. | Applicant |
| US6845776(B2) | 2005-01-01 | Stack et al. | Applicant |
| US6860899(B1) | 2005-03-01 | Rivelli, Jr. | Examiner |
| US6860901(B1) | 2005-03-01 | Baker et al. | Applicant |
| US6936065(B2) | 2005-08-01 | Khan et al. | Applicant |
| US6960233(B1) | 2005-11-01 | Berg et al. | Applicant |
| US6989024(B2) | 2006-01-01 | Hebert et al. | Applicant |
| US7011654(B2) | 2006-03-01 | Dubrul et al. | Applicant |
| US7011671(B2) | 2006-03-01 | Welch | Applicant |
| US7011673(B2) | 2006-03-01 | Fischell et al. | Applicant |
| US7025791(B2) | 2006-04-01 | Levine et al. | Applicant |
| US7037327(B2) | 2006-05-01 | Salmon et al. | Applicant |
| US7037344(B2) | 2006-05-01 | Kagan et al. | Applicant |
| US7081132(B2) | 2006-07-01 | Cook et al. | Applicant |
| US7087088(B2) | 2006-08-01 | Berg et al. | Applicant |
| US7121283(B2) | 2006-10-01 | Stack et al. | Applicant |
| US7122058(B2) | 2006-10-01 | Levine et al. | Applicant |
| US7146984(B2) | 2006-12-01 | Stack et al. | Applicant |
| US7152607(B2) | 2006-12-01 | Stack et al. | Applicant |
| US7160312(B2) | 2007-01-01 | Saadat | Applicant |
| US7211114(B2) | 2007-05-01 | Bessler et al. | Applicant |
| US7220237(B2) | 2007-05-01 | Gannoe et al. | Applicant |
| US7220284(B2) | 2007-05-01 | Kagan et al. | Applicant |
| US7267694(B2) | 2007-09-01 | Levine et al. | Applicant |
| US7314489(B2) | 2008-01-01 | McKenna et al. | Examiner |
| US7329285(B2) | 2008-02-01 | Levine et al. | Applicant |
| US7338520(B2) | 2008-03-01 | Bailey et al. | Applicant |
| US7347875(B2) | 2008-03-01 | Levine et al. | Applicant |
| US7354454(B2) | 2008-04-01 | Stack et al. | Applicant |
| US7476256(B2) | 2009-01-01 | Meade et al. | Applicant |
| US7507218(B2) | 2009-03-01 | Aliski et al. | Examiner |
| US7513914(B2) | 2009-04-01 | Schurr | Examiner |
| US7621886(B2) | 2009-11-01 | Burnett | Examiner |
| US2001/0020190(A1) | 2001-09-01 | Taylor | Applicant |
| US2002/0022853(A1) | 2002-02-01 | Swanson et al. | Applicant |
| US2002/0032487(A1) | 2002-03-01 | Dua et al. | Applicant |
| US2002/0065545(A1) | 2002-05-01 | Leonhardt et al. | Applicant |
| US2002/0091439(A1) | 2002-07-01 | Baker et al. | Applicant |
| US2002/0120277(A1) | 2002-08-01 | Hauschild et al. | Applicant |
| US2002/0143387(A1) | 2002-10-01 | Soetikno et al. | Applicant |
| US2002/0147489(A1) | 2002-10-01 | Hong et al. | Applicant |
| US2002/0151953(A1) | 2002-10-01 | Chobotov et al. | Applicant |
| US2002/0183768(A1) | 2002-12-01 | Deem et al. | Applicant |
| US2002/0183786(A1) | 2002-12-01 | Girton | Applicant |
| US2002/0188344(A1) | 2002-12-01 | Bolea et al. | Applicant |
| US2002/0193828(A1) | 2002-12-01 | Griffin et al. | Applicant |
| US2003/0032941(A1) | 2003-02-01 | Boyle et al. | Applicant |
| US2003/0040804(A1) | 2003-02-01 | Stack et al. | Applicant |
| US2003/0040808(A1) | 2003-02-01 | Stack et al. | Applicant |
| US2003/0050684(A1) | 2003-03-01 | Abrams et al. | Applicant |
| US2003/0069539(A1) | 2003-04-01 | Gandhi et al. | Examiner |
| US2003/0109892(A1) | 2003-06-01 | Deem et al. | Applicant |
| US2003/0109931(A1) | 2003-06-01 | Geitz | Applicant |
| US2003/0109935(A1) | 2003-06-01 | Geitz | Applicant |
| US2003/0120265(A1) | 2003-06-01 | Deem et al. | Applicant |
| US2003/0149467(A1) | 2003-08-01 | Linder et al. | Applicant |
| US2003/0153927(A1) | 2003-08-01 | DiPoto et al. | Applicant |
| US2003/0191476(A1) | 2003-10-01 | Smit | Examiner |
| US2003/0199989(A1) | 2003-10-01 | Stack et al. | Applicant |
| US2003/0199990(A1) | 2003-10-01 | Stack et al. | Applicant |
| US2003/0199991(A1) | 2003-10-01 | Stack et al. | Applicant |
| US2003/0208260(A1) | 2003-11-01 | Lau et al. | Applicant |
| US2003/0216749(A1) | 2003-11-01 | Ishikawa et al. | Applicant |
| US2003/0233140(A1) | 2003-12-01 | Hartley et al. | Applicant |
| US2004/0024386(A1) | 2004-02-01 | Deem et al. | Applicant |
| US2004/0039452(A1) | 2004-02-01 | Bessler | Applicant |
| US2004/0044357(A1) | 2004-03-01 | Gannoe et al. | Applicant |
| US2004/0082963(A1) | 2004-04-01 | Gannoe et al. | Applicant |
| US2004/0092892(A1) | 2004-05-01 | Kagan et al. | Applicant |
| US2004/0092974(A1) | 2004-05-01 | Gannoe et al. | Applicant |
| US2004/0093065(A1) | 2004-05-01 | Yachia et al. | Applicant |
| US2004/0098079(A1) | 2004-05-01 | Hartley et al. | Applicant |
| US2004/0107004(A1) | 2004-06-01 | Levine et al. | Applicant |
| US2004/0117004(A1) | 2004-06-01 | Osborne et al. | Applicant |
| US2004/0117031(A1) | 2004-06-01 | Stack et al. | Applicant |
| US2004/0122452(A1) | 2004-06-01 | Deem et al. | Applicant |
| US2004/0122453(A1) | 2004-06-01 | Deem et al. | Applicant |
| US2004/0133147(A1) | 2004-07-01 | Woo | Applicant |
| US2004/0136971(A1) | 2004-07-01 | Scharp et al. | Applicant |
| US2004/0138525(A1) | 2004-07-01 | Saadat et al. | Applicant |
| US2004/0138529(A1) | 2004-07-01 | Wiltshire et al. | Applicant |
| US2004/0138760(A1) | 2004-07-01 | Schurr | Applicant |
| US2004/0138761(A1) | 2004-07-01 | Stack et al. | Applicant |
| US2004/0143342(A1) | 2004-07-01 | Stack et al. | Applicant |
| US2004/0148034(A1) | 2004-07-01 | Kagan et al. | Applicant |
| US2004/0153167(A1) | 2004-08-01 | Stack et al. | Applicant |
| US2004/0158229(A1) | 2004-08-01 | Quinn | Applicant |
| US2004/0158331(A1) | 2004-08-01 | Stack et al. | Applicant |
| US2004/0172063(A1) | 2004-09-01 | Li et al. | Applicant |
| US2004/0172141(A1) | 2004-09-01 | Stack et al. | Examiner |
| US2004/0172142(A1) | 2004-09-01 | Stack et al. | Applicant |
| US2004/0172143(A1) | 2004-09-01 | Geitz | Applicant |
| US2004/0181242(A1) | 2004-09-01 | Stack et al. | Applicant |
| US2004/0193093(A1) | 2004-09-01 | Desmond, III | Applicant |
| US2004/0220682(A1) | 2004-11-01 | Levine et al. | Applicant |
| US2004/0236363(A1) | 2004-11-01 | Kieturakis et al. | Examiner |
| US2004/0236401(A1) | 2004-11-01 | Shin et al. | Applicant |
| US2004/0249362(A1) | 2004-12-01 | Levine et al. | Applicant |
| US2005/0004681(A1) | 2005-01-01 | Stack et al. | Applicant |
| US2005/0043601(A1) | 2005-02-01 | Kilcoyne et al. | Applicant |
| US2005/0043817(A1) | 2005-02-01 | McKenna et al. | Applicant |
| US2005/0049718(A1) | 2005-03-01 | Dann et al. | Applicant |
| US2005/0055039(A1) | 2005-03-01 | Burnett et al. | Applicant |
| US2005/0060017(A1) | 2005-03-01 | Fischell et al. | Applicant |
| US2005/0075622(A1) | 2005-04-01 | Levine et al. | Applicant |
| US2005/0080395(A1) | 2005-04-01 | Levine et al. | Applicant |
| US2005/0080431(A1) | 2005-04-01 | Levine et al. | Applicant |
| US2005/0080491(A1) | 2005-04-01 | Levine et al. | Applicant |
| US2005/0085787(A1) | 2005-04-01 | Laufer | Applicant |
| US2005/0090873(A1) | 2005-04-01 | Imran | Applicant |
| US2005/0096750(A1) | 2005-05-01 | Kagan et al. | Applicant |
| US2005/0125020(A1) | 2005-06-01 | Meade et al. | Applicant |
| US2005/0125075(A1) | 2005-06-01 | Meade et al. | Applicant |
| US2005/0149114(A1) | 2005-07-01 | Cartledge et al. | Applicant |
| US2005/0221072(A1) | 2005-10-01 | Dubrow et al. | Applicant |
| US2005/0240279(A1) | 2005-10-01 | Kagan et al. | Applicant |
| US2005/0256587(A1) | 2005-11-01 | Egan | Applicant |
| US2005/0267499(A1) | 2005-12-01 | Stack et al. | Applicant |
| US2005/0283107(A1) | 2005-12-01 | Kalanovic et al. | Examiner |
| US2006/0009858(A1) | 2006-01-01 | Levine et al. | Applicant |
| US2006/0064120(A1) | 2006-03-01 | Levine et al. | Applicant |
| US2006/0106332(A1) | 2006-05-01 | Knudson et al. | Applicant |
| US2006/0155312(A1) | 2006-07-01 | Levine et al. | Applicant |
| US2006/0161139(A1) | 2006-07-01 | Levine et al. | Applicant |
| US2006/0161172(A1) | 2006-07-01 | Levine et al. | Applicant |
| US2006/0161187(A1) | 2006-07-01 | Levine et al. | Applicant |
| US2006/0161265(A1) | 2006-07-01 | Levine et al. | Applicant |
| US2006/0212042(A1) | 2006-09-01 | Lamport et al. | Applicant |
| US2006/0265082(A1) | 2006-11-01 | Meade et al. | Applicant |
| US2006/0287734(A1) | 2006-12-01 | Stack et al. | Applicant |
| US2007/0005147(A1) | 2007-01-01 | Levine et al. | Applicant |
| US2007/0010864(A1) | 2007-01-01 | Dann et al. | Applicant |
| US2007/0027548(A1) | 2007-02-01 | Levine et al. | Applicant |
| US2007/0032879(A1) | 2007-02-01 | Levine et al. | Applicant |
| US2007/0049801(A1) | 2007-03-01 | Lamport et al. | Applicant |
| US2007/0083271(A1) | 2007-04-01 | Levine et al. | Applicant |
| US2007/0282453(A1) | 2007-12-01 | Weitzner et al. | Examiner |
| US2007/0293885(A1) | 2007-12-01 | Binmoeller | Examiner |
| US2008/0071383(A1) | 2008-03-01 | Levine et al. | Applicant |
| US2008/0097466(A1) | 2008-04-01 | Levine et al. | Applicant |
| US2008/0103604(A1) | 2008-05-01 | Levine et al. | Applicant |
| US2008/0208239(A1) | 2008-08-01 | Annunziata | Examiner |
| US2008/0208240(A1) | 2008-08-01 | Paz | Examiner |
| US2008/0208357(A1) | 2008-08-01 | Melanson et al. | Applicant |
| US2008/0221575(A1) | 2008-09-01 | Betts | Examiner |
| US2008/0223476(A1) | 2008-09-01 | Stinson | Applicant |
| US2008/0234834(A1) | 2008-09-01 | Meade et al. | Applicant |
| US2009/0012553(A1) | 2009-01-01 | Swain et al. | Examiner |
| US2009/0024077(A1) | 2009-01-01 | Zeiner et al. | Examiner |
| US2009/0062717(A1) | 2009-03-01 | Laufer | Examiner |
| US2009/0281563(A1) | 2009-11-01 | Newell et al. | Examiner |
| EP480667(B1) | 1992-04-01 | Applicant | |
| EP278937(B1) | 1993-10-01 | Applicant | |
| EP506918(B1) | 1996-01-01 | Applicant | |
| EP754017(B1) | 1997-01-01 | Applicant | |
| EP843538(B1) | 1998-05-01 | Applicant | |
| EP857471(A2) | 1998-08-01 | Applicant | |
| EP935977(A2) | 1999-08-01 | Applicant | |
| EP935977(A3) | 1999-08-01 | Applicant | |
| EP1481649(A1) | 2004-12-01 | Applicant | |
| EP1504778(A2) | 2005-02-01 | Applicant | |
| EP1504778(A3) | 2005-02-01 | Applicant | |
| JP4212348 | 1992-08-01 | Applicant | |
| WO92/06734(A1) | 1992-04-01 | Applicant | |
| WO95/05132(A) | 1995-02-01 | Applicant | |
| WO97/03624(A1) | 1997-02-01 | Applicant | |
| WO98/22045(A) | 1998-05-01 | Applicant | |
| WO99/23953(A) | 1999-05-01 | Applicant | |
| WO99/44536(A) | 1999-09-01 | Applicant | |
| WO/12027 | 2000-03-01 | Applicant | |
| WO/32137 | 2000-06-01 | Applicant | |
| WO/42945 | 2000-07-01 | Applicant | |
| WO/42949 | 2000-07-01 | Applicant | |
| WO1/12256(A1) | 2001-02-01 | Applicant | |
| WO1/35861(A1) | 2001-05-01 | Applicant | |
| WO1/45485(A2) | 2001-06-01 | Applicant | |
| WO2/081019(A1) | 2002-10-01 | Applicant | |
| WO2/096327(A2) | 2002-12-01 | Applicant | |
| WO3/017882(A2) | 2003-03-01 | Applicant | |
| WO3/086246(A1) | 2003-10-01 | Applicant | |
| WO3/086247(A1) | 2003-10-01 | Applicant | |
| WO3/086360(A1) | 2003-10-01 | Applicant | |
| WO3/094785(A1) | 2003-11-01 | Applicant | |
| WO2004/000169(A1) | 2003-12-01 | Applicant | |
| WO2004/004542(A2) | 2004-01-01 | Applicant | |
| WO2004/004542(A3) | 2004-01-01 | Applicant | |
| WO2004/014237(A1) | 2004-02-01 | Applicant | |
| WO2004/019765(A2) | 2004-03-01 | Applicant | |
| WO2004/019765(A3) | 2004-03-01 | Applicant | |
| WO2004/021894(A1) | 2004-03-01 | Applicant | |
| WO2004/037064(A2) | 2004-05-01 | Applicant | |
| WO2004/037064(A3) | 2004-05-01 | Applicant | |
| WO2004/049982(A2) | 2004-06-01 | Applicant | |
| WO2004/064680(A1) | 2004-08-01 | Applicant | |
| WO2004/064682(A1) | 2004-08-01 | Applicant | |
| WO2004/064685(A1) | 2004-08-01 | Applicant | |
| WO2004/069331(A2) | 2004-08-01 | Applicant | |
| WO2004/069332(A1) | 2004-08-01 | Applicant | |
| WO2004/073782(A1) | 2004-09-01 | Applicant | |
| WO2004/087014(A2) | 2004-10-01 | Applicant | |
| WO2004/087233(A2) | 2004-10-01 | Applicant | |
| WO2004/093639(A2) | 2004-11-01 | Applicant | |
| WO2004/093639(A3) | 2004-11-01 | Applicant | |
| WO2005/011533(A1) | 2005-02-01 | Applicant | |
| WO2005/060869(A1) | 2005-07-01 | Applicant | |
| WO2005/060882(A1) | 2005-07-01 | Applicant | |
| WO2006/016894(A1) | 2006-02-01 | Applicant | |
| WO2006/034062(A1) | 2006-03-01 | Applicant | |
| WO2006/078781(A1) | 2006-07-01 | Applicant | |
| WO2006/078927(A1) | 2006-07-01 | Applicant | |
| WO2006/088578(A1) | 2006-08-01 | Applicant | |
| WO2006/102012(A1) | 2006-09-01 | Applicant | |
| WO2006/133311(A2) | 2006-12-01 | Applicant |
Non-Patent Literature (25)
- Yates III, M. R., et al., “Palliation of Malignant Gastric and Small Intestinal Strictures With Self-Expandable Metal Stents,” Endoscopy 30:266-272 (1998).Applicant
- Bethge, N., et al., “Human tissue responses to metal stents implanted in vivo for the palliation of malignant stenoses,” Gastrointestinal Endoscopy 43(6):596-602 (1996).Applicant
- Binkert, C. A., et al., “Benign and Malignant Stenoses of the Stomach and Duodenum: Treatment with Self-expanding Metallic Endoprostheses,” Radiology 199(2):335-338 (1996).Applicant
- Cwikiel, W., et al., “Self-expanding Stent in the Treatment of Benign Esophageal Strictures: Experimental Study in Pigs and Presentation of Clinical Cases,” Radiology 187(3):667-671 (1993).Applicant
- Dolan, K. et al., “Treating Diabetes in the Morbidly Obese by Laproscopic Gastric Band,” Obesity Surgery, vol. 13, pp. 439-443 (2003).Applicant
- Park, B.P. et al., Malignant Obstruction of Gastric Outlet and Duodenum: Palliation with Flexible Covered Metallic Stents, Radiology 219(3):679-683 (2001).Applicant
- Dormann, A.J. et al., “Self-expanding metallic stents for continous dilatation of benign stenosis in gastrointestinal tract—first results of long-term follow-up in interim stent application in pyloric and colonic obstructions,” Z Gastroenteral 39:957-960 (2001).Applicant
- Pories, W.J., “Why Does the Gastric Bypass Control Type 2 Diabetes Mellitus?” Obesity Surgery, 2:303-313 (1992).Applicant
- Pories, W.J., et al., “Etiology of Type II Diabetes Mellitus: Role of the Foregut,” World J. Surg., 25:527-531 (2001).Applicant
- Rubino, F., et al., “Potential of Surgery for Curing Type 2 Diabetes Mellitus,” Annals of Surgery 236(5): 554-559 (2002).Applicant
- Sandha, G. S. and Marcon, N. E., “Expandable Metal Stents For Benign Esophageal Obstruction,” Gastrointestinal Endoscopy Clinics of North America 9:(3)437-446 (1999).Applicant
- Feretis, C., et al., “Palliation of Malignant Gastric Outlet Obstruction with Self-Expanding Metal Stents,” Endoscopy 28:225-228 (1996).Applicant
- Rubino, F. and J. Marescaux, “Effect of Duodenal-Jejunal Exclusion in a Non-obese Animal Model of Type 2 Diabetes, A New Perspective for an Old Disease,” Annals of Surgery 239(1):1-11 (2004).Applicant
- Choostent™, Covered Esophageal Stent, Instructions, Retrieved from the Internet (http://mitech.co.kr/uploads/images/282/use guide esophachoo—english.pdf) on Jul. 26, 2005.Applicant
- Hwang, J.C., et al., “Covered Retrievable Tracheobronchial Hinged Stent: An Experimental Study in Dogs,” J. Vasc. Interv. Radiol., 12(12):1429-1436 (Dec. 2001).Applicant
- Irie, T., et al., “Relocatable Gianturco Expandable Metallic Stents1,” Radiology, 178:575-578 (1991).Applicant
- Lee, B.H., et al., “New Self-Expandable Spiral Metallic Stent: Preliminary clinical Evaluation in Malignant Biliary Obstruction,” J. Vasc Interv Radiol., 6(4):635-640 (Jul. 8, 1995).Applicant
- Lee, S.H., “The Role of Oesophageal Stenting in the Non-Surgical Management of Oesophageal Strictures,” British J. Radiology, 74:891-900 (Oct. 2001).Applicant
- Shim, C.S., et al., “Fixation of a Modified Covered Esophageal Stent: Its Clinical Usefulness for Preventing Stent Migration,” Endoscopy, 33(10):843-848 (Oct. 2001).Applicant
- Song, H.Y., et al., “Benign and Malignant Esophageal Strictures: Treatment with a Polyurethane-Covered Retrievable Expandable Metallic Stent1,” Radiology, 203(3):747-752 (Jun. 1997).Applicant
- Song, H.Y., et al., “Covered Retrievable Expandable Nitinol Stents in Patients with Benign Esophageal Strictures: Initial Experience1,” Radiology, 217:551-557 (Nov. 2000).Applicant
- Song, H.Y., et al., “Tracheobronchial Strictures: Treatment with a Polyurethane-Covered Retrievable Expandable Nitinol Stent—Initial Experience,” Radiology, 213:905-912 (Dec. 1999).Applicant
- Yoon, C.J., et al., “Removal of Retrievable Esophageal and Gastrointestinal Stents: Experience in 113 Patients,” American J. of Roentgenology, 183 :1437-1444 (Nov. 2004).Applicant
- U.S. Office Action in U.S. Appl. No. 12/001,365, mailed on Jul. 23, 2009.Applicant
- U.S. Office Action in U.S. Appl. No. 11/541,616, mailed on Mar. 17, 2009.Applicant