Treatment method

In the treatment method of the present invention, the operation is performed in the following steps: an apparatus is perorally inserted in the stomach, a distal end portion of the apparatus inserted in the stomach is introduced from the stomach into the peritoneal cavity, a membrane of part of the outer wall of the abdominal esophagus is removed by the distal end portion of the apparatus which is introduced in the peritoneal cavity, the distal end portion of the apparatus which is introduced in the peritoneal cavity is returned therefrom into the stomach, the stomach fundus is perorally pulled to the part of the outer wall of the abdominal esophagus, and the pulled stomach fundus is fixed to the part of the outer wall of the abdominal esophagus.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention relates to a treatment method for gastroesophageal reflux disease.

2. Description of the Related Art

Conventionally, it is well known as gastroesophageal reflux disease (hereinafter referred to as GERD) that acid in the stomach flows back toward the esophagus side. It is thought that the GERD occurs when the reflux preventing function of the cardiac region lowers due to abnormality of a lower esophageal sphincter.

As a treatment method for the GERD, a Nissen surgical operation which is a surgical treatment is well known. In the Nissen surgical operation, the stomach fundus is surgically wound around the esophagus in the pertitoneal cavity, thereby re-forming the cardiac region. The esophagus is squashed and closed when the stomach fundus wound around the esophagus expands. Consequently, the reflux of acid in the stomach is prevented.

Another treatment method for the GERD is disclosed in U.S. Pat. No. 5,088,979. In this treatment method, the esophagus is pushed into the stomach, and is then fixed to the stomach such that the pushed part of the esophagus is kept inside of the stomach. The pushed part of the esophagus is squashed due to expansion of part of the stomach which is close to the gastroesophageal junction, thereby preventing the reflux of acid in the stomach.

A further treatment method for the GERD is disclosed in U.S. Pat. No. 6,312,437. In this treatment method, tissues of the gastroesophageal junction are pulled down into the stomach, and the stomach fundus is pulled and fixed to an outer wall of the pulled tissues of the gastroesophageal junction. The pulled tissues of the gastroesophageal junction are squashed due to expansion of part of the stomach which is close to the gastroesophageal junction, thereby preventing the flux of acid in the stomach.

U.S. Pat. No. 5,297,536 discloses a treatment method in which an incision is formed in the body wall, a surgical instrument is inserted into the peritoneal cavity through the incision, and a surgical treatment is carried out. Furthermore, U.S. patent application No. 2001/0049497 discloses an apparatus having an endoscope and an overtube into which the endoscope is to be inserted. The apparatus is perorally inserted into the stomach, and is then projected into the peritoneal cavity through the gastric wall. Thereafter, the endoscope is inserted into the peritoneal cavity along the overtube, clip forceps, etc. are projected from a distal end portion of the endoscope through an instrument channel thereof, and then placement of clips, etc. are carried out.

BRIEF SUMMARY OF THE INVENTION

A treatment method according to an embodiment of the present invention comprises: perorally inserting an apparatus into a stomach; introducing a distal end portion of the apparatus inserted in the stomach from the stomach into a peritoneal cavity; removing a membrane of part of an outer wall of an abdominal esophagus; returning the distal end portion of the apparatus introduced in the peritoneal cavity into the stomach; perorally pulling a stomach fundus to the part of the outer wall of the abdominal esophagus; and perorally fixing the pulled stomach fundus to the part of the outer wall of the abdominal esophagus.

DETAILED DESCRIPTION OF THE INVENTION

An embodiment of the present invention will be explained with reference toFIGS. 1 to 19. In a treatment method according to the embodiment, a reflux preventing valve for preventing occurrence of a reflux from the stomach of a living body to the esophagus is formed to the abdominal esophagus. To be more specific, in this treatment method, an apparatus is perorally introduced from the stomach into the peritoneal cavity, and the peritoneum and fat, etc. of part of an outer wall of the abdominal esophagus are removed through the peritoneal cavity by using the apparatus. Then, the stomach fundus is pulled and fixed to the above part of the outer wall of the abdominal esophagus. The above two steps will be explained in detail.

First, the step in which the apparatus is perorally introduced from the stomach into the peritoneal cavity, and the peritoneum and fat, etc. of part of an outer wall of the abdominal esophagus are removed through the peritoneal cavity by using the apparatus will be explained with reference toFIGS. 1 to 12. The devices used in the process will be explained with reference toFIGS. 1 to 4.FIG. 1shows an endoscope2. The endoscope2has substantially the same structure as an endoscope known as an electronic endoscope or a fiber type endoscope.

The endoscope2includes an elongated endoscope insertion portion4to be inserted into a body cavity. The endoscope insertion portion4is formed by connecting an endoscope distal end structural portion6, an endoscope bending portion8and an endoscope flexible tube portion10in this order from its distal end. At a proximal end portion of the endoscope insertion portion4, an endoscope control section12is provided. The endoscope control section12includes an endoscope operating handle, not shown, for bending operation of the endoscope bending portion8. The endoscope bending portion8can be bent in four directions.

Furthermore, in the endoscope insertion portion4, an instrument channel14, into which medical instrument such as forceps are to be inserted, is formed in the longitudinal direction of the endoscope insertion portion4. A distal end portion of the instrument channel14is open at the distal end portion of the endoscope insertion portion4, and a proximal end portion of the instrument channel14is open at the endoscope control section12.

A universal code16is provided to extend from the endoscope control section12. In the universal code16, a light guide of an illuminating optical system and a transmission cable of an observing optical system, etc. are inserted. Also, a connector18is provided at an extension end portion of the universal code16. At the connector18, a light guide connector20is provided, and is connected to a light source device22. The light source device22includes a lamp24and a condensing lens26. From the connector18, a scope cable28is extended, and is connected to a video processor30. The video processor30is connected to a monitor30, a VTR deck34, a video printer36and a video disk38, etc.

An endoscope apparatus including the endoscope2and a bending-overtube40will be explained with reference toFIG. 2. As shown inFIG. 2, the bending-overtube40is provided with an insertion portion42which has the same structure as the endoscope2. To be more specific, the insertion portion42is formed by connecting a distal end structural portion44, a bending portion46and a flexible tube portion48in this order from its distal end side. At a proximal end portion of the insertion portion42, a branch portion50is provided. The bending-overtube40is branched into an insertion opening portion52and a branch end portion54at the branch portion50. The insertion opening portion52is projected in the direction of the central axis of the insertion portion42, and the branch end portion54is extended inclined backwards with respect to the central axis of the insertion portion42. To the branch end portion54, a soft connection flexible tube56is connected. To a terminal portion of the connection flexible tube56, a control section58is provided for bending operation of the bending portion46.

In the bending-overtube40, an insertion hole60is formed to extend through the insertion portion42, the branch portion50and the insertion opening portion52. A distal end portion of the insertion hole60is open at the distal end structural portion44, and a proximal end portion of the insertion hole60is open at the insertion opening portion52. The bending portion46of the bending-overtube40can be bent, with the endoscope2inserted in the bending portion46.

In the embodiment, the bending direction of the bending portion46will be defined as follows: in a plane including both of the central axis of the insertion portion42and a central axis of the branch end portion54, bending of the bending portion46toward the branch end portion54is “upward” bending, and bending of the bending portion46in a direction opposite to the upward bending is “downward” bending. Also, in a plane vertical to the above plane, bending of the bending portion46toward one side direction is “rightward” bending, and bending of the bending direction46in a direction opposite to the rightward bending is “leftward” bending.

The outer diameter of the flexible tube portion48is set such that the flexible tube portion48can be inserted into the esophagus without great resistance. For example, it is set at approximately 20 mm or less. Furthermore, the length of the flexible tube portion48is set at an appropriate value to enable a step, which will be described later, to be carried out. For example, the length from the proximal end portion of the bending portion46to the terminal portion of the insertion opening portion52is approximately 400 to 800 mm. The bend radius of the bending portion46is set within a range of approximately 40 to 70 mm. If it is smaller than the range, and then, for example, if a conventional endoscope having an outer diameter of approximately 10 mm is used, the endoscope receives a great resistance when it is inserted into the insertion hole60of the bending-overtube40, as a result of which it is difficult to push the endoscope forwards. In addition, the maximum bend angle of the bending portion46in each of upper, lower and right and left directions is set at an appropriate angle more than 180°, with the endoscope2inserted in the bending portion of the bending-overtube40.

The above-mentioned values of the bending-overtube40are specified as examples. That is, the dimensions of the bending-overtube40are not limited to the values. For example, the above bend radius can be changed in accordance with the outer diameter of the insertion portion42and the flexibility of the flexible tube portion48, etc.

At the outer surface of a boundary portion between the bending portion46and the flexible tube portion48, first and second balloon62aand62b, which are annularly formed, are arranged closely in the axial direction of the insertion portion42. To the first and second balloons62aand62b, tubes63are connected. The first and second balloons62aand62bcan be expanded and contracted by injecting and sucking fluid into and from terminal portions of the tubes63. The first and second balloons62aand62bare formed such that they are each formed in a shape of a doughnut around the central axis of the insertion portion42when they are expanded.

The structure of the control section58will be explained in detail with reference toFIGS. 2 and 3. In the operation portion58, a UD bending knob64aand an RL bending knob64bare provided coaxial with each other. When the UD bending knob is rotated, the bending portion46is bent in the upward or downward direction. Similarly, the RL bending knob64bis rotated, the bending portion46is bent in the leftward or rightward direction. At the bending knobs64aand64b, engagement levers66aand66bare provided, respectively. The engagement levers66aand66bare operated to fix the bending knobs64aand64bin desired rotation positions, respectively. That is, the bending portion46can be fixed at a desired angle. Furthermore, it should be noted that the bending-overtube40does not have a connection member like the universal code16connecting the control section58and another device (seeFIG. 1), since it does not have an observing function or the like.

The structure of the distal end portion of the insertion portion42will be explained in detail with reference toFIGS. 2 to 4. The distal end structural portion44is substantially cylindrical, and has a taper68which extends from its proximal end in such a manner as to be gradually thinner toward the distal end. Furthermore, the bending portion46is formed by rotatably connecting substantially cylindrical bending pieces70to each other in their axial direction. To the distal end structural portion44, distal end portions of plurality of pull wires72are fixed. The pull wires72are connected to the control section58through the insertion portion42, the branch portion50and the connection flexible tube56. When the bending knobs64aand64bof the control section58are operated, the pull wires72are pulled to bend the bending portion46. Furthermore, the bending portion46is covered with an elastic cover74formed of elastic material in order to prevent a liquid from entering the bending-overtube40.

In the bending portion46, a tube member76is inserted. A distal end portion of the tube member76is fixed to the distal end structural portion44. A bore of the distal end structural portion44and that of the tube member76defines the insertion hole60into which the endoscope insertion portion4of the endoscope2is to be inserted.

The structure of the branch portion50will be explained with reference toFIG. 5. As stated above, the insertion portion42is connected to the distal end side of the branch portion50, and the insertion opening portion52and the branch end portion54are branched from the branch portion50. Further, the insertion opening portion52is projected in the direction of the central axis of the insertion portion42. The insertion hole60linearly extends from the insertion portion42to the insertion opening portion52. In the insertion opening portion52, a plurality of valves78are removably provided. The valves78are annular elastic members each of which has an inner diameter slightly smaller than the outer diameter of the endoscope insertion portion4(seeFIG. 2), which are provided coaxially with the central axis of the insertion hole60, and which are formed of, e.g., rubber. The endoscope2(seeFIG. 2) can be inserted into the insertion hole60through center holes of the valves78. When the endoscope2(seeFIG. 2) is inserted in the insertion hole60, the valves78operate to prevent air, etc. in the insertion hole60from flowing therefrom to the outside, and keep the inside of the body cavity leaktight as long as the pressure of the inside of the body cavity is a predetermined value or less.

The branch end portion54is extended inclined backwards with respect to the central axis of the insertion portion42, and the soft connection flexible tube56is connected to the branch end portion54. In the connection flexible tube56, coil pipes79are inserted which extends from the flexible tube portion48, and in each coil pipe79, a pull wire (not shown) is inserted which extends from the flexible tube portion48.

Referring toFIGS. 2 and 3, in the embodiment, the bending-overtube40, which can be bent in the upward, downward, leftward and rightward directions, is used. However, the structure of the bending-overtube40is not limited to the above structure. That is, a bending-overtube40which can be bent only in the upward and downward directions, i.e., the two directions, may be used. As the structure of the bending-overtube bendable in the two directions only, it can be considered that the RL bending knob64bis fixed and unworkable, or the RL bending knob64bis not provided.

Furthermore, a bending-overtube which can be bent in only one direction from its linear state may be used. As the structure of the bending-overtube bendable in only one direction, it can be considered that the bending-overtube is bent through an angle more than 180° when the UD bending knob64ais rotated in one direction, and it is returned to its linear state when the UD bending knob64ais rotated in the opposite direction. Even when the bending-overtube bendable in only one direction is applied, a step, which will be described later, can be carried out as in the case of applying the bending-overtube bendable in the two directions and the bending-overtube bendable in the four directions.

In addition, an indicator for indicating the bending direction of the bending portion46may be provided at the branch portion50or the control section58, etc.

Next, the step in which the endoscope is perorally introduced into the peritoneal cavity from the stomach, and peritoneum and fat, etc. of part of the outer wall of the esophagus are stripped off through the peritoneal cavity will be explained with reference toFIGS. 6 to 11. First, the stomach80, the esophagus82and peripheral parts of a human body will be explained with reference toFIG. 6. The esophagus82extends from the thorax84to the peritoneal cavity86through a hiatus of the diaphragm87, and is connected with the stomach80through a gastroesophageal junction88in the peritoneal cavity86. The peritoneum90extends from the diaphragm87to the gastroesophageal junction88to cover the abdominal esophagus92, and the abdominal esophagus92barely exposes to the peritoneal cavity86.

The above step will be specifically explained with reference toFIG. 7. The endoscope2is inserted into the insertion hole60of the bending-overtube40, and is then projected from the distal end portion of the bending-overtube40. Then, the endoscope2is pushed forwards through the bending-overtube40, and the distal end portion of the endoscope2is inserted into a pharynx portion, the esophagus82and the stomach80in this order. Thereafter, the bending-overtube40is inserted into the pharynx portion, the esophagus82and the stomach80in this order along the endoscope insertion portion4.

In this state, e.g., an electrosurgical knife94is inserted into the instrument channel14of the endoscope2, and is then projected from the opening of the endoscope structural portion6. Then, as shown inFIG. 7, an anterior wall96of the greater curvature of the stomach is cut by using the electrosurgical knife94by a length which is nearly equal to the diameter of the distal end of the endoscope2. The entire layer, or both mucous membrane and muscle layer of the anterior wall96, is incised, while pushing the endoscope distal end structural portion6against the anterior wall96. Consequently, an opening portion100is formed through which the stomach80and the peritoneal cavity86communicate with each other.

Thereafter, the endoscope2is pushed toward the opening portion100, and its distal end portion is introduced from the stomach80into the peritoneal cavity through the opening portion100. Furthermore, the endoscope2is pushed forwards, and the endoscope bending portion8is located in the peritoneal cavity86. Then, as shown inFIG. 8, the endoscope bending portion8is reversed in such a way as to be bent through an appropriate angle more than 180° and the posture of the endoscope2is adjusted so that the opening portion100is located within the field of view of the endoscope2,

While checking the state of the opening portion100by using the endoscope2, the bending-overtube40is pushed forwards along the endoscope2, and the distal end portion of the bending-overtube40is introduced from the stomach80into the peritoneal cavity86through the opening portion100. The distal end portion of the bending-overtube40is introduced from the stomach80into the peritoneal cavity86, while pushing and opening the opening portion100by means of the taper68. Furthermore, under observation using the endoscope2, the bending-overtube40is pushed forwards along the endoscope2, and the bending portion46is introduced into the peritoneal cavity86by a distance nearly half the entire length of the bending portion46.

Thereafter, as shown inFIG. 9, the bending portion46is bent through approximately 90° in the upward direction. The posture of the bending-overtube40is adjusted such that the bending portion46is bent in a plane parallel to the anterior and posterior walls of the stomach8. Under observation using the endoscope2, the posture of the endoscope2can be grasped based on the arrangement of internal organs in the peritoneal cavity86. Also, it should be noted that in the case where the indicator indicating the bending direction of the bending portion46is provided at the control section58or the branch portion50, etc., the bending direction of the bending portion46can be grasped based on the positional relationship between the position of a patient and the indicator or the like.

Under observation with the endoscope2, the bending-overtube40is further pushed into the peritoneal cavity86, and only the first balloon62awhich is located closer to the distal end side than the second balloon62bis introduced into the peritoneal cavity86. Then, fluid is injected into the first and second balloons62aand62bfrom the terminal portion of the tube63which is located outside the body of the patient, thereby expanding the first and second balloons62aand62b. As a result, as shown inFIG. 10, the anterior wall96is held by the first and second balloons62aand62b, thus fixing the insertion portion42to the anterior wall96.

Moreover, the bending portion46is bent until its bend angle reaches approximately 180°, while grasping the positional relationship between the endoscope apparatus and the internal organs using the endoscope2. The bend radius of the bending portion46falls within a range of approximately 40 to 70 mm, and is relatively small with respect to the inner space of the peritoneal cavity86. Thus, even when the bending-overtube40introduced in the peritoneal cavity86is bent, there is a slight possibility that the bending-overtube40may contact an internal organ, abdominal wall or the like, and receive a resistance. Thus, the bending-overtube40can be reliably bent.

Thereafter, as shown inFIG. 10, the endoscope bending portion8is returned to the linear state. Then, with an operator's operation on the proximal end side of the apparatus, the endoscope2is pushed forwards in the insertion hole60of the bent bending-overtube40, and the distal end portion of the endoscope2is pushed forwards in the peritoneal cavity86. The posture of the bending-overtube40is adjusted as occasion demands, so that the distal end portion of the endoscope2is moved to reach the vicinity of the abdominal esophagus92. Then, the electrosurgical knife94is projected from the instrument channel14of the endoscope2, and the peritoneum90covering the abdominal esophagus92from the diaphragm87to gastroesophageal junction88is incised from the peritoneal cavity side, and is ablated. In such a manner, the abdominal esophagus92is sufficiently exposed to the peritoneal cavity86.

Then, the endoscope2and the bending-overtube40are pulled back into the stomach80in the following manner. The endoscope bending portion8is bent to be reversed, and the distal end portion of the bending-overtube40is located in the field of view of the endoscope2and checked. Then, the endoscope2is pulled into the bending-overtube40as much as possible. In the case where the bending portion46is greatly projected in the peritoneal cavity86, when it is returned to the linear state, it is easily brought into contact with another internal organ. This is because when the bending portion46is bent with respect to its proximal end portion in the peritoneal cavity86, its bend radius is great. Accordingly, in the embodiment, the following operation is repeated: the bending portion46is slightly returned from its bent state toward the linear state, and the bending-overtube40is pulled from the peritoneal cavity86into the stomach80by several centimeters. In such a manner, since the bent state of the bending portion46is returned to the linear state by degrees, the bending portion46is not easily brought into contact with another internal organic. In the above manner, the bending portion46of the bending-overtube40is returned to the linear state.

On the other hand, the endoscope2is kept bent even after the bending portion is made in substantially the linear state. The bending-overtube40is completely pulled into the stomach80, while checking the distal end structural portion44of the bending-overtube40in the field of view of the endoscope2. The endoscope bending portion8is returned to the linear state after confirming that bending-overtube40is completely pulled from the peritoneal cavity86into the stomach80. Then, the endoscope2is pulled from the peritoneal cavity86into the stomach80, and the opening portion100is checked within the field of view of the endoscope2in the stomach80.

Thereafter, as shown inFIG. 11, clip forceps103are projected from the instrument channel14of the endoscope2, and a plurality of clips104are located to close the opening portion100formed in the anterior wall96. After the opening portion100is completely closed, the endoscope2and the bending-overtube40are pulled out from the human body.

In the above step, the peritoneum90covering the abdominal esophagus92is incised and ablated through the peritoneal cavity, as a result of which the abdominal esophagus92is sufficiently exposed to the peritoneal cavity86.

In the step, since the insertion hole60of the bending-overtube60, into which the endoscope2is inserted, is linearly shaped, except for the case where the bending portion46is bent, the endoscope2inserted in the insertion hole60of the bending-overtube60is also linearly shaped, and can be easily moved forwards/backwards. Furthermore, the endoscope2can be easily turned around its central axis within the bending-overtube40, since the insertion hole60of the bending-overtube40and the insertion portion42of the endoscope2are substantially coaxial with each other. In addition, the control section58of the bending-overtube40can be feely moved so as not to interfere with operations, since it is provided at the terminal portion of the soft connection flexible tube56connected to the branch portion50, thus improving the operability.

A modification of the above structural elements and steps will be explained with reference toFIG. 12. In the modification, the endoscope2includes first and second forceps channels14aand14b. The endoscope2is a multi-bending endoscope, and includes first and second endoscope bending portions8aand8bwhich are arranged adjacent to each other in the axial direction of the endoscope insertion portion4. The first endoscope bending portion8aon the distal end side of the endoscope2can be bent in four directions. The second endoscope bending portion8bcan be bent in two directions independent of the first endoscope bending portion8a. At the endoscope control section, operating knobs not shown are provided the number of which varies in accordance with the number of the endoscope bending portions and that of the bending directions thereof.

As shown inFIG. 12, in the case of ablating the peritoneum90, the first and second endoscope bending portions8aand8bare bent in opposite directions, and the posture of the endoscope insertion portion4is adjusted such that the endoscope distal end structural portion6is raised, whereby the endoscope distal end structural portion6is located in the front of the abdominal esophagus92. In this state, grasping forceps124are projected from the second forceps channel14b, and part of the peritoneum90which is to be incised is grasped and pulled by the grasping forceps124. Then, the electrosurgical knife94is projected from the first forceps channel14ato incise and ablate the pulled part of the peritoneum90. It should be noted that the grasping forceps124and the electrosurgical knife94can be vertically pushed against the peritoneum90, since the endoscope distal end structural portion6is located in the front of the abdominal esophagus92. Accordingly, the operability is improved.

In the operation for incising and ablating the peritoneum90, in the above embodiment, the electrosurgical knife94is used, and in the above modification of the embodiment, the grasping forceps124and the electrosurgical knife94are used in combination with each other. However, the above incising and ablating operation can also be carried out by another method.

Next, the step in which the stomach fundus is perorally pulled and fixed to the part of the outer wall of the gastroesophageal junction, from which the peritoneum, etc. are stripped off, will be explained. Also, the structural elements used in the step will be explained with reference toFIGS. 13A to 15B. As shown inFIG. 13A, the distal end portion of the endoscope2is fitted in a distal end hood105as a tube member and an abut member. In the distal end hood105, a side hole106is formed as a communication portion. In the embodiment, the side hole106is located in an upper position of the field of view of the endoscope2; however, it may be located in another position.

As shown inFIG. 13B, on a rear end side of the distal end hood105, a distal end tube passage108is formed to extend in the axial direction of the distal end hood105. A distal end opening portion of the distal end tube passage108is located in substantially the same position as the side hole106in a circumferential direction of the distal end hood105. At a rear end opening portion of the distal end tube passage108, a connecting pipe110is provided to be projected. To the connecting pipe110, a distal end portion of a distal end hood sheath112is connected. The distal end hood sheath112extends to the vicinity of the endoscope control section12(seeFIG. 15A). The distal end tube passage108, the connecting pipe110and the distal end hood sheath112define a distal end hood channel114. The distal end hood channel114permits any of kinds of medical instruments to be inserted thereinto from its proximal end portion, and also enables air and water to be sent and sucked through the distal end hood channel114.

A puncture needle116to be inserted into the distal end hood channel114is shown inFIG. 13C. The puncture needle116is formed as a hollow needle, and contains a placement member118at its distal end portion. The placement member118is formed by connecting first and second T-bars120aand120bwith a thread121. The first and second T-bars120aand120bare fitted in the puncture needle116, and the second T-bar120bis located in the rear of the first T-bar120a. Also, the puncture needle116contains a pusher122which is located in the rear of the placement member118. When the pusher122is moved forwards and backwards, the first and second T-bars120aand120bcan be separately ejected from the distal end portion of the puncture needle116.

As shown inFIG. 14A, the grasping forceps124can be inserted into the instrument channel14of the endoscope2. At the distal end opening portion of the instrument channel14, an elevator126is provided which can adjust the projecting direction of the grasping forceps124. Due to adjusting of the projecting direction of the grasping forceps124with the elevator126, the grasping forceps124can be projected to the outside of the distal end hood105through the side hole106.

As shown inFIG. 14B, the grasping forceps124include first and second grasping portions128aand128bwhich are openable/closable by an operation on the distal end side of the endoscope2. A sheath130extends from a journal portion of the first and second grasping portions128aand128b. The first and second grasping portions128aand128bcan be opened such that they can grasp tissues of the stomach fundus and tissues of the abdominal esophagus which are stacked together. Furthermore, sharp edges129for puncturing tissues of a living body are provided at the inner surfaces of the distal end portions of the first and second grasping portions128aand128b. Then, as shown inFIG. 14C, a center line between the first and second grasping portions128aand128bcan be inclined with respect to the sheath130, and the first and second grasping portions128aand128bcan be opened asymmetrical with respect to the sheath130.

As shown inFIGS. 15A and 15B, the distal end sheath hood112is fixed with a tape or the like to a protection boot131, which connecting the endoscope control section12and the endoscope insertion portion4and preventing folding of the endoscope insertion portion4, and other parts of the insertion portion4. At the proximal end portion of the distal end hood sheath112, a sheath handle132is provided which is to be gripped by an operator. At a proximal end portion of the sheath handle132, a needle handle134is provided for moving the puncture needle forwards/backwards. At a distal end portion of the needle handle134, a pusher handle136is provided for moving the pusher122forwards/backwards.

As shown inFIG. 15B, the sheath handle132is substantially cylindrical, and the puncture needle116is inserted in an inner hole of the sheath handle132. Also, the needle handle134is substantially cylindrical, and its distal end is fitted from the proximal end side of the sheath handle132in the inner hole thereof such that it is movable forwards/backwards. A proximal end portion of the puncture needle116is connected to a distal end portion of the needle handle134. A proximal end side of the needle handle134has a diameter larger than that of the distal end side, and is provided as part to be gripped by the operator. A distal end side of the pusher handle136is fitted from the proximal end side of the needle handle134in an inner hole thereof such that it is movable forwards/backwards. The pusher122is inserted in the inner holes of the puncture needle116and needle handle134, and its proximal end portion is connected to the distal end portion of the pusher handle136. The distal end portion of the pusher handle136is provided as part to be pushed by the operator.

Next, the step in which the stomach fundus is perorally pulled and fixed to the part of the outer wall of the abdominal esophagus92, from which the peritoneum, etc. are stripped off, will be explained with reference toFIGS. 16 to 18. The endoscope2on which the distal end hood15is set is inserted perorally from the esophagus82into the stomach82. The posture of the endoscope2is adjusted such that the side hole106of the distal end hood105faces the greater curvature. Then, as shownFIG. 16, the endoscope bending portion8is bent such that the distal end portion of the distal end hood105is moved from a position under a lower end of the esophagus82toward the stomach fundus102, and the distal end portion of the distal end hood105is abutted against an inner surface of the stomach fundus102. The side hole106of the distal end hood105faces the stomach fundus102and toward the abdominal esophagus. In the embodiment, the side hole106is located in the upper position of the field of view of the endoscope2, and the endoscope bending portion8of the endoscope2is bent upwards in above step.

Then, the endoscope bending portion8is further bent to pull and bring the stomach fundus102into contact with the part of the outer wall of the abdominal esophagus92, from which the peritoneum90, etc. are stripped off, as shown inFIG. 17A. Thereafter, as shown inFIG. 17B, the grasping forceps124are projected from the instrument channel14of the endoscope2. The projecting direction of the grasping forceps124is adjusted by the elevator126provided at the opening portion of the instrument channel14, and the grasping forceps124are projected from the side hole106of the distal end hood105to the outside thereof. Then, the grasping forceps124are pressed against tissues of the stomach fundus102to make the sharp edges129of the first and second grasping portions128aand128bsubstantially vertically puncture the tissues of the stomach fundus102, and then the first and second grasping portions128aand128bare closed to grasp the tissues of the stomach fundus102and the tissues of the abdominal esophagus92, with those tissues stacked together. In this state, the stacked tissues of the stomach fundus102and abdominal esophagus92are pulled into the distal end hood105by pulling the grasping forceps124.

Thereafter, the needle handle134and the pusher handle136are pushed together with each other toward the sheath handle132, and the puncture needle116is projected from the distal end portion of the distal end hood channel114, and is pushed forwards. Then, the puncture needle116is made to puncture the tissues of the stomach fundus102and those of the abdominal esophagus92. Furthermore, after being once inserted into the esophagus82, the puncture needle116is made to re-puncture the tissues of the abdominal esophagus92and those of the stomach fundus102.

In this state, the pusher handle136is pushed toward the needle handle134to eject the first T-bar120afrom the puncture needle116into the stomach80. Then, the needle handle134and the pusher handle136are pulled together with each other in a direction away from the sheath handle132to pull out the puncture needle116from the tissues of the stomach fundus102and those of abdominal esophagus92. In this state, the second T-bar120bis ejected from the puncture needle116into the stomach80.

Thereafter, the first and second grasping portions128aand128bare opened to release the tissues of the stomach fundus102and those of the abdominal esophagus92. Then, the endoscope bending portion8is bent to pull out the tissues of the stomach fundus102and those of the abdominal esophagus92from the distal end hood105. In such a manner, as shown inFIG. 17C, the stomach fundus102is fixed to the part of the outer wall of the abdominal esophagus92, from which the peritoneum90, etc. are stripped off.

The step in which the stomach fundus102is wound around the abdominal esophagus92will be explained with reference toFIGS. 18A to 18C. As shown inFIG. 18A, first, the stomach fundus102is fixed to part of the abdominal esophagus92. Then, the endoscope2is moved forwards and backwards to move the distal end hood105in the axial direction of the esophagus82, and parts of stomach fundus102is fixed to corresponding parts of the esophagus82which are arranged apart from each other in the axial direction of the esophagus82. The above parts of the stomach fundus102may be successively fixed to the parts of the abdominal esophagus92from the diaphragm side toward the vicinity of the gastroesophageal junction88. Alternatively, those parts may be successively fixed from the vicinity of the gastroesophageal junction88toward the diaphragm side.

Subsequently, the control section58of the endoscope2is rotated to rotate the distal end portion of the endoscope2in the circumferential direction of the esophagus82as indicated by an arrow A inFIG. 18B. In this position, as mentioned above, parts of stomach fundus102is fixed to corresponding parts of the esophagus82which are arranged apart from each other in the axial direction of the esophagus82. Furthermore, the control section58of the endoscope2is rotated in the opposite direction to rotate the distal end portion of the endoscope2in the opposite direction along the circumferential direction of the esophagus82as indicated by an arrow B inFIG. 18C. In this position also, parts of stomach fundus102is fixed to corresponding parts of the esophagus82which are arranged apart from each other in the axial direction of the esophagus82. As a result, the stomach fundus102is kept to be wound around the abdominal esophagus92.

By the above step, as shown inFIG. 19, the stomach fundus102is wound around and fixed to the abdominal esophagus92, from which the peritoneum, etc. are stripped off.

In the embodiment, part of the peritoneum90, etc. covering the abdominal esophagus92is perorally removed. Then, the stomach fundus102is perorally pulled to the part of the abdominal esophagus92, from which the peritoneum90, etc. are removed. Then, the pulled stomach fundus102is perorally fixed to the part of the abdominal esophagus92, from which the peritoneum90, etc. are removed. That is, in the treatment method according to the embodiment, all the steps are perorally carried out. Thus, in the treatment method, the invasiveness is low, and the burden on a patient is small.

Furthermore, when the stomach fundus102wound around the abdominal esophagus92expands, the abdominal esophagus92is squashed and closed. It should be noted that the stomach fundus102expands and contracts to a sufficiently great degree, as compared with expanding and contacting of other portions of the stomach80, e.g., the gastroesophageal junction88and the vicinity thereof. Thus, when the treatment method according to the present invention is applied, the abdominal esophagus92is sufficiently squashed, compared with the case where other portions of the stomach80, e.g., the gastroesophageal junction88and the vicinity thereof, are fixed to the abdominal esophagus92, as a result of which reflux is effectively prevented.

From the anatomical point of view, the peritoneum90extends in such a way as to cover the abdominal esophagus92from the diaphragm87to the gastroesophageal junction88, and the abdominal esophagus92barely exposes to the inside of the peritoneal cavity86. Thus, in the case where the peritoneum90is not removed from the abdominal esophagus92, even if the stomach fundus102is pulled to the abdominal esophagus92, the outer wall of the stomach fundus102and that of the abdominal esophagus92cannot be directly fixed to each other. This is because the peritoneum90is present between the stomach fundus102and the abdominal esophagus92. Then, if the stomach fundus102is fixed to the peritoneum90between the abdominal esophagus92and the stomach fundus102, expanding and contracting of the stomach fundus102is absorbed by those of the peritoneum90, which is membranous and can expand and contract independent of other tissues. Thus, the expanding and contracting of the stomach fundus102are not transmitted to the abdominal esophagus92. Accordingly, it cannot be expected that it squashes the abdominal esophagus92.

In the embodiment, part of the peritoneum90, etc. of the abdominal esophagus92are removed through the peritoneal cavity, and the stomach fundus102is fixed to part of the abdominal esophagus92, from which the peritoneum90, etc. are removed. Thus, expanding and contacting of the stomach fundus102are not absorbed by the peritoneum90, and the abdominal esophagus92is sufficiently squashed, as compared with the case where the stomach fundus102is fixed to the peritoneum90. Accordingly, the reflux is effectively prevented.

Moreover, the bending portion46which is operated to be bent is provided at the bending-overtube40into which the endoscope2is to be inserted. Therefore, the peritoneum90, etc. can be stripped off by the following operation: the bending-overtube40is moved from the stomach80into the peritoneal cavity86through the opening portion100formed in the stomach80; the bending portion46is bent such that the distal end portion of the bending-overtube40faces the abdominal esophagus92; the endoscope2is pushed forwards within the bending-overtube40; and the distal end portion of the endoscope2is moved toward the abdominal esophagus92. That is, stripping off of the peritoneum90, which cannot be achieved simply by inserting the endoscope2into the peritoneal cavity86easily, can be appropriately performed by using the bending-overtube40including the bending portion46.