Abstract:
A combination tissue apposition and suture capturing device ( 100 ) for performing endoscopic procedures typically in the gastro-esophageal tract. The device ( 100 ) is particularly adapted for forming multiple plications used in a gastroplasty procedure devised to cure or ameliorate gastro-esophageal reflux disease. The device include a tissue sewing capsule ( 102 ) attached to the distal end of an endoscope having a needle ( 120 ) that is deposited in a capsule ( 102 ) distal tip cavity following the suturing of a tissue fold and retrieved to enable the suturing of a subsequent tissue fold without the need for multiple intubations. A suture clip delivery device ( 200 ) is also disclosed that is adapted to fit within the capsule to enable suture capture without the need for multiple intubations. The combination device eliminates the need for an overtube and maximizes the speed efficiency of the gastroplasty procedure. A method for using the combination device is also disclosed.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application is a continuation of U.S. patent application Ser. No. 11/803,956, filed May 16, 2007, which is a continuation of U.S. patent application Ser. No. 10/275,534, filed Nov. 6, 2002, which is the U.S. National Stage of International Application No. PCT/US01/16025, filed May 19, 2001, which claims the benefit to U.S. Provisional Applications Nos. 60/205,741, filed May 19, 2000, 60/205,444, filed May 19, 2000, and 60/253,970, filed Nov. 29, 2000, and International Application No. PCT/US01/07349, filed Mar. 5, 2001, the entire contents of which are incorporated herein by reference. 
    
    
     FIELD OF THE INVENTION 
     The present invention relates to a novel combination of endoscopic tissue apposition devices and suture clip delivery devices. Specifically, the invention provides an endoscopic apposition device configured to collect and secure a plurality of tissue portions with a single intubation of the device. The invention is applicable to both flexible and rigid endoscopy. 
     BACKGROUND OF THE INVENTION 
     Endoscopic apposition devices are devices that can be used in the body of a patient without the need to make an external incision in the patient, the device being controlled externally of the patient by endoscopic means. Apposition devices may comprise a sewing or stapling device for use in flexible endoscopy, though it is also applicable to devices for use in rigid endoscopy. 
     Endoscopic tissue apposition devices are useful to help perform a gastroplasty procedure to correct a condition known as gastro-esophageal reflux disease (GERD). This condition, believed to afflict as many as 15,000,000 individuals in the United States alone, results from the inability of the sphincter muscle (known as the lower esophageal or cardiac sphincter), at the junction between the stomach and the esophagus to function properly. Such malfunction enables reflux of stomach acid into the esophagus. The object of the gastroplasty procedure is to stitch together portions of stomach tissue into plications in a region proximal to the malfunctioning sphincter to reduce the cross-sectional area of the gastro-esophageal juncture and mimic the valve-like function of the sphincter. 
     To perform the procedure, an apposition device, such as a sewing capsule is attached to the end of a viewing endoscope and is inserted through a patient&#39;s esophagus to form a plurality of stitches in stomach tissue slightly below the sphincter. The sewing capsule has an aspiration port for generating negative pressure to suction stomach wall tissue into the sewing capsule. A first stitch is made through the stomach tissue to one side of the esophagus, and a second stitch is made, with the same suture thread, in stomach tissue adjacent to the first stitch. The two stitches then are drawn together to pull together the diametrically opposed, stitched stomach portions. In a preferred procedure, a tubular configuration having a somewhat figure-eight cross-sectional configuration is formed. 
     In accordance with what has been, until now, the conventional procedure followed, after the sutures are applied, the endoscope is removed from the patient and a knot is tied with the free ends of the suture thread that extend outside of the patient to maintain the figure-eight configuration. The knot is pushed down to the site of the sutures by a thread guide device that has been positioned at the distal end of the endoscope. To help navigate the knot to a location where it will effectively hold the tissue, the knot is viewed through the viewing channel of the endoscope as it is guided to the stomach. To be visible through the endoscope, the knot must be maintained in front of the viewing channel port at the distal face of the endoscope while positioning the thread guide device so as not to block the viewing channel. 
     The suturing and knotting procedure is repeated several times at longitudinally spaced intervals to create a plurality of figure-eight configurations extending longitudinally of the esophagus into the stomach. Suturing the stomach tissue in this manner essentially lengthens the esophageal passage and defines a structure having a valving action that is proven effective to prevent gastro-esophageal reflux. After a sufficient number of knots and sutures have been placed, a thread cutter, also operable through the endoscope, may be employed to cut the suture thread at points that are close to the tissue. 
     Endoscopic sewing devices are described in, for example, U.S. Pat. Nos. 5,080,663 and 5,792,153. Those patents disclose a sewing device for passing a thread through a tissue portion, which comprises a hollow needle movable between a first position in which it is out of the said tissue portion and a second position in which it passes through the said tissue portion, and a thread carrier adapted to be attached to the thread and being receivable within the hollow needle. The sewing device comprises a body, which defines a cavity within which the tissue portion can be held by means of suction, and the hollow needle is mounted for movement in the body between the first and second positions. 
     U.S. Pat. No. 5,792,153 discloses two suturing device embodiments: a single stitch sewing device and a multiple stitch sewing device. In the single stitch device, a thread carrier is transported by the needle through the tissue as the latter passes from its first position to its second position. When the needle returns to its first position, the thread carrier is left behind in the distal end of the sewing capsule. In the multiple stitch device, the same procedure occurs, but it is followed by a further step in which the hollow needle travels from its first position to its second position, picks up the thread carrier, and returns it. A second stitch may be formed during the next step. The whole sequence of steps is repeated as many times as may be required to form the desired number of stitches. 
     Similar advancements have been made with respect to the suture securing step that follows the stitching step. One such improvement is disclosed in U.S. Pat. No. 5,584,861 to Swain. The Swain patent discloses a suture clip and suture clip delivery device that is used in place of half hitch knots. The disclosed suture clip is a cylinder with a plug that can be releasably secured in the cylinder. The disclosed suture clip delivery device includes a tube, the distal end of which has a recess for receiving the suture clip. An axially movable stirrup is provided at the distal end that has the capacity to be moved from a first position that secures the suture clip to the tube and a second position that allows for the suture clip to be removed from the recess. 
     An aperture is provided in the cylinder to receive the suture. The cylinder is advanced over the suture that exits from a proximal end of the cylinder and enters the tube. An aperture in a sidewall of the tube provides egress for the suture. The plug is then advanced down the tube and into the cylinder. The interfacing walls of the cylinder and plug capture the suture. A pusher is used to force the plug into the cylinder while the stirrup maintains the suture clip in the recess. Following plug insertion, the stirrup, which is offset from the center axis of the tube, is advanced distally from the distal end of the tube to release the suture clip from the tube. 
     With all the improvements provided by the sewing capsules and suture securing devices, significant problems persist with the described gastroplasty procedure. One of the significant problems is the time and number of intubations needed to perform the various procedural steps endoscopically. Due to a number of concerns, a patient is typically anesthetized for no more than approximately 40 minutes. In this period of time, procedures such as the gastroplasty procedure must be performed to completion. 
     Minimizing the number of intubations and reducing the procedure time during which the patient must be kept under conscious sedation are significant considerations in any endoscopic procedure. In the gastroplasty procedure, several intubations have to be performed to create several plications. The prior art suturing devices must be withdrawn from the patient for each successive stitch made with single-stitch embodiments and must otherwise be repositioned for each stitch made with multi-stitch embodiments. The same is true of the suture securing devices. The devices must be withdrawn and repositioned between successive suture securing steps. The use of such devices is invariably long and cumbersome. There is a need to provide an endoscopic tissue apposition device and suture securing device that minimizes procedure time and the number of intubations while still joining the same number of tissue plications together during the procedure. 
     To reduce the trauma experienced by a patient having multiple devices intubated numerous times for one gastroplasty procedure, an overtube is placed in the gastro-esophageal tract. Although an overtube provides a barrier between the devices used to perform the procedure and the luminal walls of the tract, the act of inserting the relatively large diameter tube into the tract and the presence of the tube in the tract are perhaps the most significant sources of patient discomfort. There is a need to eliminate the requirement for an overtube to perform the described gastroplasty procedure. The invention disclosed herein provides such an improvement. 
     It is among the general objects of the invention to provide a tissue apposition device and suture securing device that, in combination, eliminate the need to use an overtube when performing a gastroplasty procedure. A further object is to provide a tissue apposition device that is adapted to receive a secure securing device to eliminate the need for multiple intubations to secure a plurality of tissue plications required to attach or repair internal tissue by a tissue securement mechanism comprising suture or staples. It is another object of the invention to provide an endoscopic apposition device that is simple and economical to fabricate by injection molding techniques. It is another object of the invention to provide a tissue apposition device having longitudinal flexibility to be easily navigable through a natural body lumen while mounted at the distal end of an endoscope. It is another object of the invention to provide a simplified tissue suture means having an anchor at one end which can remain on the through side of tissue during the process of tissue securement. These and other objects of the invention will become apparent from a reading of the following sections. 
     It is to be appreciated that the combination tissue apposition and suture securing device disclosed herein has a potentially wide range of applications including, but not limited to, the attachment of devices, e.g., a pH monitor to the gastrointestinal wall, the closure of perforations or ulcers, the creation of anastomoses, plication formation to address severe obesity and polyp plications. The device can be used with an endoscope, can be formed as the terminus of a catheter in combination with a visualization device such as an fiberoptic eye wire as is known in the art. 
     SUMMARY OF THE INVENTION 
     The present invention pertains to improvements to endoscopic apposition device and suture clip delivery devices. The improvements may be embodied in a tissue apposition device similar to those disclosed in U.S. Pat. No. 5,792,153 or 5,080,663, or a stapling device such as is disclosed in U.S. Pat. No. 5,037,021. The disclosures of the above listed patents are incorporated by reference herein, in their entirety. The prior art endoscopic tissue apposition devices provided a mechanism for capturing only a single fold with one intubation. The present invention provides a tissue apposition device capable of capturing multiple tissue folds and securing the sutures used to capture the folds with one intubation. The elimination of the need for multiple intubations eliminates the need for an overtube with respect to endoscopic procedures performed in the gastro-esophageal tract. 
     The device is comprised of a generally cylindrically shaped capsule attachable to the distal end of an endoscope, preferably a flexible viewing endoscope. The capsule comprises, in one embodiment, a body having an arc shaped suction port into which can be captured portions of tissue. The suction port defines an opening to a vacuum chamber. The vacuum chamber is operated through a vacuum source line that can extend interiorly or exteriorly to the endoscope. 
     Application of vacuum pressure causes tissue to be suctioned into the suction port and into the vacuum where a needle assembly comprising a needle releasably locked to a pusher via mating surfaces and an outer locking sleeve is adapted to carry a suture in a distal axial direction through into and through the tissue and into a distal tip of the capsule. Formed in the distal tip of the capsule is a cavity adapted to receive the needle assembly. A pair of springs are oriented parallel in the cavity for receiving the needle assembly. Distal faces of the springs engage a proximal edge of the needle and provide a restraining force to retraction of the needle. The locking sleeve is proximally retracted which allows the pusher to disengage from the needle that remains restrained by the springs. The pusher is retracted to allow for the release of the sutured tissue fold. 
     Following release of the tissue fold, the pusher is re-advanced into the distal tip of the capsule. The locking sleeve is also advanced to lock the needle onto the pusher. Proximal retraction of the pusher in a locked condition with the needle overcomes the restraining force of the springs that flex radially outwardly to allow the needle to be retracted into the proximal end of the capsule. The needle assembly is now in a condition to implant a suture in a second tissue fold. The process can be continually repeated for virtually any selected number of tissue folds, all of which will be connected by a single suture, all with a single intubation. 
     The tissue apposition device of the present invention offers another advantage over previous designs in that the entire capsule body may be injection molded from a polymer material. A single piece injection molded unit is easier to produce than previous capsule designs, which were machined from metal and comprise several assembled components. 
     In another aspect of the invention, the tissue apposition capsule body is adapted to utilize and receive a novel tissue suturing device. One tissue securement mechanism embodiment comprises sutures having anchoring elements at one end that permit them to be passed through tissue and then become anchored behind the tissue layer to permit suturing and retention of the fold of tissue. The anchoring element of the special suture material, such as polypropylene, may comprise a cylindrical tube with detents formed in a sidewall of the tube. A needle having a longitudinal slot and a channel is adapted to receive the anchor or tag and deposit it in the distal tip of the capsule. In this embodiment, the needle is retrieved with the pusher and the tag is retained in the capsule distal tip by virtue of the interaction of the detents with the springs. To allow release of the tag from the needle, the locking sleeve is only partially retracted to allow the distal end of the needle to expand radially outwardly while the proximal end is radially restrained to maintain engagement with the pusher. Following release of the sutured tissue fold, the needle/pusher assembly is reintroduced into the distal tip and the locking sleeve fully advanced to retrieve the tag. In an alternate embodiment, the tag is released with the sutured tissue fold and the needle is retracted out of the endoscope for the loading of another anchor for insertion into another tissue fold. 
     Also described herein is a suture clip delivery device adapted for navigation through the working channel of an endoscope and through the capsule channel adapted to receive the needle assembly. The delivery device comprises a multi-coaxial catheter with a three or four finger collet jaw affixed at a distal end. The catheter has a distal end from which the collect fingers distally project. The collet fingers are made of a material such as stainless steel or an engineering grade of plastic that allow the collet fingers to flex or spring from a pre-biased first open position to a second closed position and back to the first position. Alternatively, the collet fingers can be designed to flex or spring from a pre-biased first closed position to a second open position and back to the first position. The collet fingers define a cage within which a suture clip assembly is premounted. The cage is defined proximally by a distal end of the collet body and distally by flanges extending radially inwardly from the distal ends of the collet fingers. In one embodiment, the case is sized so that a plurality of suture clip plugs can be preloaded into the cage along with a single suture clip ring. By biasing the collet fingers in an open position, the need for cam surfaces and cam followers is eliminated. 
     In one embodiment, a separate control surface provided coaxially about the collet cage is employed to slide the outer sliding sleeve relative to the collet cage and the pusher. With any of the embodiments, the outer sliding sleeve is provided to secure the collet fingers in a closed position when placed in a distally advanced position. The outer sliding sleeve performs the additional function of severing the suture at a point proximal to the suture clip after engagement of the suture upon proximal retraction. One or more suture slots are provided in the distal end of the outer sliding sleeve to provide suture exits. A distal end of the suture slots can be sharpened to sever the suture. Upon proximal retraction of the outer sliding sleeve, the distal end of suture slot engages the suture and severs it when the distal end of the suture slot travels proximally to a cutting edge formed at or near the proximal end of the collet fingers. The design of the delivery device enables the suture clip to be cinched in close proximity to the sutured tissue as well as allow for the severing of the suture tails and release of the suture from the delivery device in one step. 
     The suture clips adapted for use with the suture clip delivery device are comprised of a plug and a ring that are configured to allow a suture to inter-wind through the clip in such a manner that the clips move with minimal friction while in an open position. The plug is a headless design that reduces abrasion of the suture as it exists the suture clip ends. In a closed position, the clip captures the suture by frictional engagement. The ring and plug components of the clip can be provided with interlocking features for enhancing the suture capturing effect. 
     Once threaded into the ring and plug, the suture is passed through finger slots formed between adjacent collet fingers and out the suture slot of the outer sliding sleeve. This enables the suture tails to be channeled externally of the catheter for removal at the proximal end of the catheter outside the patient after the tails have been severed at a point proximal to the now assembled suture clip. The catheter operator may thread a suture through a clip and then load the clip into the tooling or thread the suture through a premounted clip. After positioning the delivery system at the sutured tissue site, the device operator activates the handle to apply a distally directed force to the clip, thereby locking it to the suture. The application of force secures the clip components thus capturing the suture material within the mating surfaces. A second, proximally directed force is applied to the sliding sleeve to release radial restraint on the collet fingers that allows the secured suture clip to be deployed and to sever the suture tails in close proximity to the suture clip. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       The foregoing and other objects and advantages of the invention will be appreciated more fully from the following further description thereof, with reference to the accompanying drawings wherein: 
         FIG. 1  is a perspective view of a suture capsule with a locking handle removed according to one embodiment of the invention. 
         FIG. 2  is a perspective view of a needle assembly adapted for use in a suture capsule according to one embodiment of the invention. 
         FIG. 3  is a partial sectional view of a capsule/locking sleeve/needle assembly according to one embodiment of the invention. 
         FIG. 4  is a partial sectional view of a capsule/needle assembly according to one embodiment of the invention. 
         FIG. 5  is a partial sectional view of a capsule/locking sleeve/needle assembly according to another embodiment of the invention. 
         FIG. 6  is a partial sectional view of a needle assembly with a suture secured to the needle disengaged from a pusher in a distal end of a suture capsule according to one embodiment of the invention. 
         FIG. 7  is a partial sectional view of a suture capsule vacuum chamber and distal cavity with a needle assembly lodged in the distal cavity according to one embodiment of the invention. 
         FIG. 8  is a partial sectional view of a needle assembly with a retracted locking sleeve according to one embodiment of the invention. 
         FIG. 9  is a top perspective view of the distal end of a needle assembly with a retracted locking sleeve according to one embodiment of the invention. 
         FIG. 10A  is a partial side elevational view of a suture capsule/endoscope assembly with tissue suctioned into the suction port/vacuum chamber according to one embodiment of the invention. 
         FIG. 10B  is a partial side elevational view of a suture capsule/endoscope assembly with tissue suctioned into the suction port/vacuum chamber with a suture/tag assembly piercing the tissue according to one embodiment of the invention. 
         FIG. 10C  is a partial side elevational view of a suture capsule/endoscope assembly with a released first tissue mound with embedded suture and distal anchor tag and a second tissue mound suctioned into the suction port/vacuum chamber with a suture/tag assembly piercing the second tissue mound according to one embodiment of the invention. 
         FIG. 10D  is a partial side elevational view of a suture capsule/endoscope assembly with released first and second tissue mounds with a single suture embedded in each tissue mound with separate distal anchor tags. 
         FIG. 11  is a side elevational view of a tissue plication with a suture piercing the plication mound halves and secured with a suture clip. 
         FIG. 12  is a schematic view of a suture capsule/endoscope assembly according to one embodiment of the invention. 
         FIG. 13  is a tissue plication secured with a suture clip according to one embodiment of the invention. 
         FIG. 14  is a tissue plication secured with a suture clip according to another embodiment of the invention. 
         FIG. 15A  is a top view of a needle/pusher assembly according to one embodiment of the invention. 
         FIG. 15B  is a side elevational view of the needle/pusher assembly shown in  FIG. 15A . 
         FIG. 16  is a sectional view of the needle/pusher assembly shown in  FIGS. 15A and 15B . 
         FIG. 17  is a perspective view of a needle assembly according to one embodiment of the invention. 
         FIG. 18A  is a side elevational view of a suture capsule/endoscope assembly with tissue suctioned into the suction port and vacuum chamber according to one embodiment of the invention. 
         FIG. 18B  is a side elevational view of a suture capsule/endoscope assembly with tissue suctioned into a suction port and vacuum chamber and with a needle assembly advanced to a proximal end of the tissue according to one embodiment of the invention. 
         FIG. 18C  is a side elevational view of a suture capsule/endoscope assembly with a needle/suture/tag assembly advanced distally through the tissue according to one embodiment of the invention. 
         FIG. 18D  is a side elevational view of a suture capsule/endoscope assembly with a partially retracted needle and a suture tag assembly releasably locked into a distal end of the suture capsule according to one embodiment of the invention. 
         FIG. 18E  is a side elevational view of a suture capsule/endoscope assembly with a fully retracted needle and a released tissue mound pierced by a suture. 
         FIG. 18F  is a side elevational view of a suture capsule/endoscope assembly with a released tissue mound pierced by a suture and a distally advanced needle encompassing a suture anchoring tag according to one embodiment of the invention. 
         FIG. 18G  is a side elevational view of a suture capsule/endoscope assembly with a released tissue mound and a retracted needle/tag assembly according to one embodiment of the invention. 
         FIG. 18H  is a side elevational view of a suture capsule/endoscope assembly with a released tissue mound pierced by a suture and a second tissue mound suctioned into a suction port and vacuum chamber with a needle/tag assembly partially piercing the second mound according to one embodiment of the invention. 
         FIG. 18I  is a side elevational view of a suture capsule/endoscope assembly with two released tissue mounds pierced by a suture with a needle/tag assembly in a retracted position according to one embodiment of the invention. 
         FIG. 18J  is a side elevational view of a suture capsule/endoscope assembly with two released tissue mounds pierced by a suture with a suture clip delivery device partially advanced in the suture capsule according to one embodiment of the invention. 
         FIG. 18K  is a side elevational view of a suture capsule/endoscope assembly with two released tissue mounds pierced by a suture with a suture clip delivery device fully advanced in the suture capsule in a pre-cinched state according to one embodiment of the invention. 
         FIG. 18L  is a side elevational view of a suture capsule/endoscope assembly with two released tissue mounds pierced by a suture and cinched with a suture clip secured to the suture and being deployed by a suture clip delivery device according to one embodiment of the invention. 
         FIG. 18M  is a side elevational view of a suture capsule/endoscope assembly with a cinched plication and a partially retracted suture clip delivery device according to one embodiment of the invention. 
         FIG. 18N  is a side elevational view of a suture capsule/endoscope assembly with a tag retention detent in the capsule distal end according to one embodiment of the invention. 
         FIG. 18O  is a side elevational view of a suture capsule/endoscope assembly without a tag retention detent in the capsule distal end according to one embodiment of the invention. 
         FIG. 19  is a somewhat diagrammatic view of a suture capsule according to one embodiment of the invention. 
         FIG. 20  is a partial sectional somewhat diagrammatic view of a suture capsule suction port and distal end according to one embodiment of the invention. 
         FIG. 21  is a side perspective view of a suture clip delivery device distal collet cage with a suture threaded through the collet cage according to one embodiment of the invention. 
         FIG. 22  is a top plan view of a suture capsule with a suture clip delivery device advanced through the capsule. 
         FIG. 23  is a side partial sectional view of a suture clip delivery device collet cage with a disassembled suture clip plug and ring and a suture threaded through the delivery device according to one embodiment of the invention. 
         FIG. 24  is a side partial sectional view of a suture clip delivery device with a cinched suture clip according to one embodiment of the invention. 
         FIG. 25  is a side partial sectional view of a suture clip delivery device with a cinched suture clip and a severed suture according to one embodiment of the invention. 
         FIG. 26  is a side view of a suture clip delivery device including collet cage and handle assembly with a suture threaded through the collet cage and a sliding cutter handle in a distal position according to one embodiment of the invention. 
         FIG. 27  is a side view of a suture clip delivery device including collet cage and handle assembly with a suture threaded through the collet cage and severed and with a sliding clutter handle in a retracted position. 
         FIGS. 28A-30  show successive steps in the operation of a prior art single stitch sewing device. 
     
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT 
     A description of the embodiments of the present invention is best presented in conjunction with an explanation of the operation of a prior art tissue apposition device, which this invention serves to improve.  FIGS. 28A-30  depict a prior art endoscopic suturing device disclosed in U.S. Pat. No. 5,792,153.  FIG. 28A  shows the distal end of a flexible endoscope  90 , on which a sewing device  2  is attached. The endoscope is provided with a viewing channel, which is not shown, but which terminates at a lens on the distal face of the endoscope. The endoscope is further provided with a biopsy or working channel  3 , and a suction channel  4  the proximal end of which is connected to a source of vacuum (not shown). The suction channel  4  may comprise a separate tube that runs along the exterior of the endoscope, rather than an internal lumen as shown. The sewing device  2  has a tube  5 , which communicates with the suction pipe  4  and has a plurality of perforations  6  therein. These perforations communicate with an upwardly open vacuum chamber  7  formed in the sewing device. 
     A hollow needle  8  is mounted in the biopsy channel  3 , with its beveled tip extending into the sewing device. The needle has a channel  9  extending therethrough. A flexible, wire-wound cable  10  has its forward end attached to the rear of the needle  8 , and a center wire  11  runs within the cable  10 , along the entire length thereof, and is longitudinally movable with respect thereto. The diameter of the wire  11  is such that it is longitudinally movable within the channel  9  and, in the position shown in  FIG. 28A , the forward end portion of the wire  11  extends into the rear end portion of the channel  9 . A thread carrier in the form of a tag  12  is slidably and releasably mounted in the channel  9 . The tag is shown in detail in  FIG. 28B . The tag is hollow and has an aperture  13  extending through the sidewall thereof. As can also be seen in  FIG. 1 , one end of a thread  14  is secured to the tag by passing it through the aperture  13  and tying in the end of a knot  15  of sufficient size to prevent the thread escaping from the tag. The tag may be made from a relatively rigid material such as stainless steel. 
     At the distal end of the sewing device is defined a hollow head portion  16  defining a chamber  20  therein. Between the chamber  20  and the cavity  7  is a wall  17 , in which an aperture  18  is formed. The aperture  18  has a diameter that is marginally greater than the external diameter of the needle  8 , and is aligned therewith. The clearance between the needle  8  and the aperture  18  must be sufficiently small to prevent tissue being forced through the aperture and causing the needle to jam. Finally,  FIG. 28A  shows a portion of the patient&#39;s tissue  19 , in which a stitch is to be formed. 
     In operation, suction is applied to the suction pipe  4 , and thence, via the perforations  6  in the tube  5  to the cavity  7 . This sucks into the cavity a U-shaped portion  19   a  of the tissue  19 , as shown in  FIG. 29 . The hollow needle  8  is pushed through the U-shaped tissue portion  19   a  by extending distally the wire-wound cable  10  and associated needle  8 . After full advancement of the needle through both folds of the U-shaped tissue portion, the tip potion of the needle  8  is distal to the wall  17  and within the chamber  20  in the hollow head portion  16 . Distal movement of wire  11 , slidably received within the wound cable  10 , pushes the tag  12  out of the channel  9  and into the chamber  20  where it rotates out of alignment with aperture  18  to become captured in the chamber. 
     The wire  11  is then withdrawn proximally, followed by proximal withdrawal of the cable  10 , to withdraw the needle  8  from the tissue portion  19   a . The suction is then discontinued allowing the U-shaped tissue portion  19   a  to be released from the cavity  7 . As shown in  FIG. 30 , the released tissue is left with a suture thread  14  passing through the two layers of tissue that form the U-shaped fold  19   a . One end of the suture is joined to the tag  12  that remains captured in the chamber  20  and the other end of the suture extends through the patient&#39;s esophagus and out of the mouth. Finally, the endoscope and dewing device are withdrawn from the patient. In so doing, the thread  14  is pulled partially through the tissue portion  19   a , as the captured tag  12  is withdrawn proximally and brought outside the patient. 
     With both ends of the thread  14  outside of the patient, the thread can be knotted and the knot endoscopically pushed down to the suture site and severed by an endoscopic knot pusher such as that disclosed in U.S. Pat. No. 6,010,515 (Swain et al). As an alternative to tying a knot, a suture lock or clip may be guided over the suture thread, down the esophagus and secured via an endoscope or suitable delivery catheter to hold the suture thread tight against the tissue. Examples of suitable suture locks and delivery systems are disclosed in PCT Application PCT/US01/filed Mar. 5, 2001, the contents of which are incorporated herein by reference. In using the endoscopic suturing device to treat G.E.R.D. it is believed that capture of multiple tissue portions and suturing and gathering them together provide an effective treatment. To accomplish this using the prior art device, multiple intubations of the endoscope down the patient&#39;s esophagus are required. Once, multiple (tissue portions, have been captured and sutured with thread, they are gathered together and secured by tying of surgical knots in the thread or application of suture lock devices. Each step in the process requires separate intubations which prompts the need for an overtube, which is known to cause significant patient discomfort. It is an object of the present invention to enable the capturing, suturing and securing of multiple tissue portions into multiple plications with one intubation and without the need for an overtube. 
     Referring to  FIGS. 1 ,  19  and  20 , a multi-functional sewing device designated generally as  100  is shown separate from an endoscope. The sewing device comprises a generally cylindrical capsule  102  made illustratively from a machined biocompatible metal such as stainless steel or from an injected molded engineering grade of plastic or polymer. Capsule  102  has a modular or integral distal tip  104  that is preferably hemispherical in configuration to enhance ease of advancement through luminal channels or cavities of a mammalian body and to minimize trauma and irritation to the contacted tissue surfaces. Distal tip  104  has portions defining a distal chamber (not shown) that is used to receive a needle or suture tag as described below. Proximal to the distal tip is a suction port  106  adapted to receive tissue suctioned into the port with vacuum pressure. Suction port  106  is preferably formed as an oval or circle to eliminate edges that could irritate suctioned tissue. Suction port  106  opens into a vacuum chamber  108  formed in the body of capsule  102  that is adapted to receive suctioned tissue in preparation for suturing. 
     A locking sleeve  110  (shown in suction port  106 ) extends through a channel (not shown) in the proximal end of capsule  102 . A rigid attachment tube  112  integral to capsule  102  extends proximally from a proximal end of capsule  102  and is dimensioned to fit snugly within the working channel of an endoscope. Tube  112  provides leverage for securing capsule  102  to the distal end of an endoscope along with an attachment ramp  114  that uses a wedge (not shown) to frictionally engage and lock to the endoscope. A lumen of tube  112  is contiguous with the capsule channel through which locking sleeve  110  extends. Formed on a top surface of locking sleeve  110  is a flat surface  116  adapted to receive a suture  118 . Surface  116  provides an essentially low friction abrasion-free passage for suture  118  proximal to its insertion into a needle  126  shown in  FIG. 2 . Surface  116  extends proximal to but not into a distal end of locking sleeve  110  to maintain concentricity and radial strength of the distal end. 
     A pusher  120  is provided to advance and retract needle  126 . Pusher  120  is concentric to locking sleeve  110  and is dimensioned to extend through and slide freely within locking sleeve  110  as well as through and out the proximal end of the endoscope working channel to which capsule  102  is attached. Attached to a proximal end of pusher  120  is pusher handle  122  configured to provide a surface to apply hand pressure with the palm of a hand to advance needle  126  and a finger gripping surface on a distal side to retract needle  126 . 
     Shown in  FIGS. 2 ,  8  and  9  is a needle assembly designated generally as  124  that is comprised of the locking sleeve  110  and a slotted hypodermic needle  126  with a preferred beveled distal tip  128 . Needle  126  can be made from any suitable biocompatible metal such as stainless steel or polymeric compound such as PEEK (polyetheretherketone), commercially available from Victrex. The compound is a linear aromatic semi-crystalline polymer. A needle suture slot  130  is formed preferably in a central portion of needle  126  to receive in locking engagement suture  118 . Any number of methods can be used to secure suture  118  to needle  126  including crimping, staking, thermo bonding or melting (for needles made from polymeric materials), and knotting.  FIGS. 3-8  show a suture locking plug  144  securing suture  118  to needle  126 . 
     Shown in  FIGS. 3-7  is needle  126  releasably locked to pusher  120  through the interaction of mating surfaces formed on the two components. Needle  126  has an inwardly directed annular ring  132  projecting from an inner wall of needle  126 . Pusher  120  has an annular channel  134  dimensioned to conform to the shape of annular ring  132 . Pusher  120  has a cross-sectional diameter that is dimensioned to fit within the inner diameter of needle  126 . A distal tip of pusher  120  is preferably hemispherical in configuration to facilitate registration of pusher  120  in the proximal end of needle  126 . Forward advancement of pusher  120  causes annular channel  134  to engage annular ring  132 . Subsequent forward advancement of locking sleeve  110  secures the engagement of channel  134  to ring  132 . In an alternative embodiment, the proximal portion of ring  132  is removed (not shown) so that the proximal end of needle  126  has a reduced neck configuration. This configuration eases the release of pusher  120  when retracted out of distal tip  104  subsequent to the retraction of locking sleeve  110 . 
     Slots  127  formed in the annular wall of needle  120  extend from the proximal end toward the distal end, a fraction of the longitudinal length of needle  126 . The slots are preferably diametrically opposed 180° and allow for the proximal end of needle  126  to flex radially outwardly. One or more slots can be used; two are preferred. The relative flexibility of the proximal end of needle  126  allows the portion of pusher  120  distal to channel  134  to traverse ring  132  during distal advancement. A sleeve channel  136  formed in the distal end of capsule  102 , and concentric with the channel receiving needle  126 , is dimensioned to receive in sliding engagement, locking sleeve  110 . A distal end  138  of sleeve channel  136  is preferably beveled to the same degree as the distal end  139  of locking sleeve  110 . Distal end  138  acts as a stop to prevent needle  126  from being advanced into the inner surface of distal tip  104 . A shoulder  140  is formed on the inner surface of locking sleeve  110  for contacting a proximal edge  123  of needle  126  to maintain the concentricity of needle  126  when being urged distally in capsule  102 . 
     Provided in distal tip  102  are detent springs  142 , the distal edges of which contact the proximal edge  121  of needle  120 . Springs  142  are preferably substantially parallel and oriented perpendicular to the capsule longitudinal axis. The ends of the springs  142  are secured to the inner wall of distal tip  102  by either sitting in annular depressions formed on the inner wall or by mechanical fasteners. Springs  142  are adapted to provide a mechanical stop that prevents needle  126  from being retracted out of distal tip  104  when pusher  120  is retracted. To perform this retention function, any spring can be used that can apply a radial force to needle. Among the possible variants are flat, round and helical springs. The importance of this function is explained below. 
     To operate this embodiment of the invention, sewing device  100  is back-loaded into the working channel of an endoscope  90  and secured to its distal end as shown in  FIGS. 12 ,  18 N and  18 O. A suture  118  is secured to needle  124  after being threaded through the working channel of the endoscope and over flat surface  116  of locking sleeve  110 . The endoscope/sewing device assembly is advanced through a body lumen to a selected site, preferably within the stomach below the lower esophageal or cardiac sphincter. Once in place, vacuum pressure is commenced in vacuum chamber  108  from a source external to the endoscope to suction tissue from the body lumen into suction port  106 . Needle  126  with attached suture  118  is advanced distally through the tissue and into distal tip  104  of capsule  102 . Distal advancement of needle  126  is accomplished by providing a distally directed force to pusher handle  122  that causes distal translation of pusher  120  and needle  126 . Preferably, a locking sleeve handle (not shown), attached to the proximal end of locking sleeve  110  and located distal to pusher handle  122 , projects proximally from the proximal end of the endoscope, and is advanced simultaneously with pusher handle  122  to ensure a positive lock between needle  126  and pusher  120 . Locking sleeve  110  can be maintained in a distally extended position by maintaining manual pressure on the locking sleeve handle or via springs as described in PCT Application No. PCT/US01/07349. 
     Distal advancement of the pusher/locking sleeve/needle assembly is continued until distal end  139  of locking sleeve  110  contacts distal end  138  of locking channel  136 . The distal travel of needle  126  into distal tip  104  results in the proximal end of needle  126  advancing distally past a distal edge  143  of springs  142  as illustrated in  FIG. 6 . With suture  118  advanced completely through the captured tissue, locking sleeve  110  is proximally retracted to allow for the disengagement of pusher  120  from needle  126  ( FIG. 4 ). Preferably, locking sleeve  110  is retracted until distal end  139  is proximal to vacuum chamber  108 . 
     Proximal retraction of pusher  120  while still engaged to needle  126  causes proximal edge  121  to register with distal edge  143  of spring  142  thereby restraining needle  126  in distal tip  104 . Further retraction of pusher  120  coupled with the restraining force provided by spring  142  causes the proximal end of needle  126  to flex radially outwardly thereby disengaging the mating surfaces of ring  132  and channel  134 . Needle  126  is cradled in distal tip  104  by the cylindrical opening formed in distal tip  104 . To allow for the release of the captured tissue, pusher  120  is retracted proximal to vacuum chamber  108 . Following retraction of locking sleeve  110  and pusher  120 , the vacuum pressure is terminated which releases the captured tissue. 
     To prepare sewing device  100  to capture and suture another fold of tissue, pusher  120  is re-advanced through vacuum chamber  108 , through springs  142  which expand radially outwardly and into the proximal end of needle  126 . Locking sleeve  110  is advanced either simultaneously or slightly behind pusher  120  to lock the engagement of ring  132  and channel  134 . With locking sleeve  110  maintained over pusher  120  and needle  126 , pusher handle  122  and handle for locking sleeve  110  are proximally retracted as a unit to retract needle  126  out of distal tip  104 . Needle assembly  124  is retracted until substantially proximal to vacuum chamber  108 . The cycle is then repeated for a new portion of stomach wall tissue using the same needle and the same suture without the need for multiple intubations. Once the desired number of tissue mounds has been sutured, needle  126  is retracted out the proximal end of locking sleeve  110  to allow removal of needle  126  from the suture. The suture is then threaded into a suture securing device as described below. It is to be noted that the use of the same suture to secure multiple tissue folds allows for the determination of the distance between adjacent tissue folds. Suture  118  is typically provided on a reel having graduations. By monitoring the length of suture being advanced off the reel from one tissue fold to the next, the operator can approximate the distance of the tissue folds. 
     In an alternative embodiment, a suture tag  150  is used in conjunction with needle  126  to effectuate the suturing of multiple tissue mounds with one intubation. Depicted in  FIG. 17 , tag  150  is a generally cylindrical in overall shape with a through bore formed preferably along a central longitudinal axis. Formed in a sidewall of tag  150  are notches  152  that are preferably diametrically opposed to engage springs  142 . Tags  150  are dimensioned to fit within a channel  129  formed in a needle  126 ′ that is a modified version of needle  126  as shown in  FIGS. 15A ,  15 B and  16 . The dimensions of tag  152  are adjusted so that a sidewall of tag  150  frictionally engages an inner wall of needle  126 ′ when locking sleeve  110  is advanced distally over needle  120 . The frictional engagement is sufficient to allow for the transfer of tag  150  through capsule  102  with an attached suture  118  but weak enough to be overcome by the radial engagement of springs  142  with detents  152  when locking sleeve  110  is retracted. Needle  126 ′ has a slot  127 ′ that preferably extends the entire length of needle  126 ′ to allow for the needle sidewall to expand radially outwardly to release tag  150 . The features of needle  126 ′ that allow engagement with pusher  120  are not shown for purposes of clarity but are the same as those for needle  126 . In this embodiment, however, locking sleeve  110  is retracted only from the distal end of needle  126 ′ to allow for the release of tag  152  but not the release of needle  126 ′ from pusher  120 . 
     Operation of this embodiment is graphically illustrated in  FIGS. 18A-18I . To begin operation this embodiment, suture  118  is secured to tag  150  via any number of conventional means as described above for the affixation of suture  118  to needle  126 . The combination of tag  150  and suture  18  is then mounted in needle  126 ′. The needle/tag/suture assembly is advanced through locking sleeve  110  via pusher  120  in the same manner as described for needle  126  and as shown in  FIG. 18B . Following the suction of a tissue fold into vacuum chamber  108 , shown in  FIG. 18A , the assembly is forced through tissue mound  95  and into distal tip  104  ( FIG. 18C ). Springs  142  engage detents  152  upon delivery of tag  152  into distal tip  104 . Locking sleeve  110  is partially retracted from the distal end of needle  126 ′ to allow for the release of tag  150 . Needle  126 ′ is retracted by proximally retracting pusher  120  in the manner described for needle  126  and as shown in  FIG. 18D . The engaging surfaces of detents  152  and springs  142  overcome the frictional engagement of tag  150  to needle  126 ′ and cause the sidewall of needle  126 ′ to flex radially outwardly to release tag  150  which is retained in distal tip  104 . 
     Upon retraction of needle  126 ′ substantially proximal to vacuum chamber  108 , suction is terminated to allow for the release of tissue mound  95  with suture  118  secured therein as shown in  FIG. 18E . Needle  126 ′ is then distally advanced into distal tip  104  to re-engage tag  150  as shown in  FIG. 18F . Sliding sleeve  110  is advanced to an extreme distal position to allow for the capture of tag  150  within needle  126 ′. The combination of locking sleeve  110 , needle  126 ′, tag  150  and pusher  120  are retracted, preferably in unison by simultaneously retracting the pusher handle  122  and the locking sleeve handle to preferably retract the combination proximal to vacuum chamber  108  as shown in  FIG. 18G . The process is then repeated with second tissue mound  95 ′ as shown in  FIGS. 18H and 18I . An alternate embodiment is shown in  FIGS. 10A-10D  in which the tag retaining features are eliminated in distal tip  104  and tags  150  are used as anchors, one per tissue mound. In this alternate embodiment, needle assembly is completely removed from the device to allow for additional tags  150  to be secured to the same suture. Once a desired number of tissue mounds have been sutured, the next step is to secure the suture and cinch the mounds together into a plication. 
     Referring to  FIGS. 21 ,  23  and  24 , the distal end of a suture clip delivery and locking catheter is shown generally as  200 . Catheter distal end  200  is comprised primarily of a collet cage  202  to which the other components of distal end  200  are attached. Collet cage  202  is essentially a cylinder with two or more collet fingers  208  extending distally from a distal end of collet cage  202 . When viewed from a distal end of collet cage  202 , collet fingers  208  preferably form a segmented 360° ring. Extending radially inwardly from a distal end of each collet finger  208  is a collet finger flange  210  that functions as a stop to arrest distal advancement of a suture clip assembly loaded into collet cage  202 . The combination of the distal end of collet cage  202 , collet fingers  208  and distal flanges  210  define a cage within which the components of a suture clip are releasably encapsulated for delivery to a sutured tissue site. The cage further functions to align the suture clip components for assembly. 
     In a preferred embodiment, collet finger flanges  210  have radiused outer distal edges  212  to minimize trauma to a patient and radiused inner distal edges  214  to ease loading of suture clip components. In one embodiment (not shown), outer distal edges  212  extend radially outwardly beyond outer walls of collet finger  208  to function as a stop for an outer sliding sleeve  220  described below. Inner proximal faces of collet finger flanges  210  are oriented to a longitudinal axis of the collet fingers so that a plane occupied by flange proximal surfaces  216  forms an angle from about 90° to about 135° and preferably either 135° or 90° with 90° being the most preferred to maximize the stopping function. 
     Finger slots  218  are formed between and defined by collet fingers  208  and function as egress ports for sutures threaded through the components of a suture clip loaded into collet cage  202 . Preferably, collet fingers  208  are biased in an open position so that radial force need only be applied to move the fingers from an open, suture clip loading/releasing position to a closed, suture clip confining position. Alternatively, finger collets  208  can be biased in a closed position as described in PCT Application No. PCT/US01/07349, the contents of which are incorporated herein by reference. 
     Situated within a hollow chamber defined by the inner walls of collet cage  202  is clip pusher  230  that freely slides within collet cage  202 . Pusher  230  is adapted to be proximally advanced into registry with suture clip components to urge the components into engagement with suture  118 . Pusher  230  can be a solid rod or a hollow cylinder such as a hypotube. 
     Situated in coaxial relationship with and freely sliding about collet cage  202  is outer sliding sleeve  220  that performs at least two functions; providing a radially inwardly directed force against collet fingers  208  to maintain the fingers in a closed position during suture clip delivery to a tissue site to minimize potential trauma that could be caused by open collet fingers and providing a means to sever the tail ends of a suture that has been secured with a suture clip. When advanced distally, sliding sleeve  220  encompasses collet fingers  208  and restricts radial movement of the fingers regardless whether the fingers are biased in an open or closed position. In this position, sliding sleeve  220  prevents premature opening of the collet. 
     When proximally retracted, sliding sleeve  220  severs directly or cooperates with other components to sever suture material proximal to a cinched suture clip. In one embodiment shown in  FIGS. 21-24 , a suture slot  222  is formed in the sidewall of sliding sleeve  220  preferably in the area occupied by a proximal end of collet cage  202  when sliding sleeve  230  is in its distal most position. As shown in  FIGS. 23-25 , a collet cage cutting edge  203  is formed in a proximal end of sliding sleeve  220  at or near the distal end of collet cage  202  and extends radially outwardly toward sliding sleeve  220 . As shown, a distal end  223  of suture slot  222  engages suture  118  and carries it toward a distal end of the body of collet cage  202 . When the distal end  223  of suture slot  222  travels past cutting edge  203 , suture  118  is pinched between the surfaces of suture slot  223  and cutting edge  203  that causes the suture to be severed as shown in  FIG. 25 . 
     At least one suture slot  223  is formed toward the distal end of sliding sleeve  30  to provide egress for excess suture material that typically extends beyond the orifice through which the catheter is inserted. It is preferred that finger slots  218  and suture slots  223  are at least partially aligned to allow a path for excess suture material to exit the suture clip delivery device. To accomplish alignment, an option alignment slot (not shown) can be formed preferably near a proximal end of sliding sleeve  30 . An alignment pin (not shown) is optionally affixed to collet cage  202  and dimensioned to freely slide within the alignment slot. A version of this alignment feature is described and shown in PCT Application No. PCT/US01/07349. 
     The suture clips used in delivery device  200  are in the preferred form of a ring  260  and a plug  262 . As shown in  FIGS. 23-25 , ring  260  is dimensioned to fit within collet cage  202  such that the concentricity of ring  260  is maintained with respect to the longitudinal axis of collet cage  202 . Plug  262  is preferably of a headless design as shown and dimensioned to frictionally engage an inner wall of ring  260 . Plug  262  is preferably formed with tapered ends to facilitate reception of suture  118 , to ease insertion into ring  260  and to prevent abrasion of suture  118  between the ends of plug  262  and ring  260 . Further details of suture clip components that can be used with delivery device  200  are disclosed in PCT Application No. PCT/US01/07349. 
     As will be appreciated, the cross-sectional diameter of plug  262  is smaller than the cross-sectional diameter of the outer wall of ring  260 . Because of this necessary discrepancy in the dimensions of the suture clip components, accommodation is needed in collet cage  202  to ensure the concentricity of plug  262  when advanced distally into ring  260 . One approach is to establish a reduced diameter portion in the proximal end of collet cage  202  to receive and maintain plug  262  in alignment with ring  260 . In an alternate embodiment, shown in  FIGS. 23-25 , a generally cylindrical bushing  205  is provided in the proximal end of collet cage  202  to reduce the complexity of the geometry of the inner walls of collet cage  202 . Bushing  205  is adapted to allow for the free axial movement of plug  262  within collet cage  202 . 
     The overall configuration of the suture clip delivery device is shown in  FIGS. 26 and 27 . A control handle  270  is attached to a proximal end of a collet cage tube  271  that may be in the form of a hypotube. A distal end of tube  271  is attached to the proximal end of collet cage  202 . Tube  271  has an inner diameter that is adapted to receive clip pusher  230  that slides freely within tube  271 . To operate the working features of the delivery device, two control surfaces are provided for advancing and retracting the various sliding components. The first, clip pusher handle  232 , is attached to the proximal end of clip pusher  230 . The second is sliding sleeve handle  274  which is attached to a proximal end of a sliding sleeve tube  276 , the distal end of which comprises sliding sleeve  220 . Sliding sleeve tube  276  may be in the form of a hypotube with an inner diameter dimensioned to receive collet cage tube  271  that slides freely within sliding sleeve tube  276 . Clip pusher  230 , collet cage tube  271  and sliding sleeve tube  276  are all coaxially arranged to allow the system to be dimensioned to slide freely within the working channel of endoscope  90  and the needle assembly channel of capsule  102 . 
     To operate the suture clip delivery device, clip pusher handle  232  and sliding sleeve handle  274  are retracted to allow collet fingers  208  to spring radially outwardly to receive the suture clip components, plug  262  and ring  260 . Next, suture  118  previously placed into a plurality of tissue mounds is threaded through ring  260 , collet cage  202  and out suture slot  222 . The ends of the suture are maintained out of the delivery device and endoscope  90 . 
     With the suture threaded through the suture clip delivery device, the device is distally advanced through the working channel of endoscope  90 , into the proximal end of capsule  102  and into vacuum chamber  108  as shown in  FIGS. 18J ,  18 K and  22 . The device is now in a position to begin the suture cinching procedure. Because of inherent flexibility in the device, collet cage  202  may slightly rotate out of axial alignment with the longitudinal axis of capsule  102  toward the sutured tissue mounds via the tension created by suture  118 . This is a desired effect as it allows the distal end of collet cage  202  to come into closer proximity to the last tissue mound sutured. This maximizes the potential to provide a tight plication since suture slack can be minimized. In short, the tissue mounds can be cinched closer together the closer collet cage  202  can be situated to the tissue mounds. 
     The cinching process begins by providing a distally directed force onto clip pusher handle  232 . This causes the forward advancement of pusher  230  into registration with the proximal end of plug  262  that, in turn, is urged distally into ring  260  to thereby capture suture  118  via the frictional engagement of plug  262  to ring  260 . Once plug  262  has been preferably fully engaged to ring  260 , sliding sleeve handle  274  can be proximally retracted to sever the excess suture  118  and to allow collet fingers  208  to flex radially outwardly to allow for the release of the cinched suture clip as shown in  FIG. 18L . The plication formed according to the procedure described herein forms a  FIG. 8  suture pattern with an attached suture clip as shown in  FIG. 13 .  FIGS. 11 and 14  show a plication formed with the use of tag  150  as an anchor with twists in the tissue mounds and suture paths shown with directional arrows. The delivery device can then be retracted out of capsule  102  and endoscope  90  to end the procedure or to prepare for another cycle of suturing and suture cinching. At all times during the procedure or multiple cycles of the procedures described herein, endoscope  90  and capsule  102  can be maintained in the patient with a single intubation event. Endoscope is simply maneuvered to the desired tissue locations to perform the gastroplasty procedure. 
     It should be understood that the foregoing description of the invention is intended merely to be illustrative thereof and that other modifications, embodiments and equivalents may be apparent to those who are skilled in the art without departing from its spirit.