Abstract:
Systems and methods are disclosed for the inversion of gastro intestinal diverticula and repair of associated intestinal wall tissue by means of endoscopy through a natural orifice such as the mouth or anus without making incisions in the abdominal wall or opening the peritoneal cavity.

Description:
I. FIELD OF THE INVENTION 
       [0001]    The present invention relates generally to systems and methods for transanal and transoral endoscopic inversion of diverticula and repair of intestinal wall defects that cause the diverticula. 
       II. BACKGROUND OF THE INVENTION 
       [0002]    Diverticulosis is an unfortunately common condition in which an area of the intestine bulges out into the peritoneal cavity to form a sac referred to as a “diverticulum”. Diverticula are also formed when a point of weakness in the intestinal wall, e.g., where blood vessels take their entry, causes the muscular structure to divide and allows part of the inner mucosal membrane to be pushed out of the hole into the peritoneal cavity and become filled with fecal matter. Diverticula may also be present in other parts of the gastrointestinal tract such as the esophagus or the duodenum. 
         [0003]    Symptoms may be mild and intermittent or acute and severe. In the latter case, the disease is usually caused by inflammation of the colonic wall and/or the pericolic fat. In this sense, diverticulitis requires both the presence of diverticula and inflammation by definition. Inflammation is often caused by impacted fecal matter or faecoliths. In other words, diverticular disease frequently arises due to the intestinal outpouchings (the diverticula) becoming blocked with feces, allowing bacteria to build up, causing infection. 
         [0004]    On a first admission with acute diverticulitis, the majority of patients respond to medical treatment (i.e., antibiotics), with the remainder requiring surgery. Those requiring surgery have a non-inconsequential mortality rate exceeding ten percent, and in the event that a diverticulum is itself perforated the mortality rate rises. Of the patients who respond to antibiotics, many experience at least one recurrence of diverticulitis with decreasing response to medical therapy and increasing requirement for surgical resolution. 
         [0005]    Accordingly, regardless of its cause, it happens that many patients suffering from diverticulitis require surgical intervention with its attendant risks. To this end, open or laparoscopic colonic segmental resection is the current method of choice, not an easy chore not least because it can be difficult to locate diverticulanested in the pericolic fat. 
         [0006]    Thus, since locating all of the diverticula in the pericolic fat is problematic and because much of the disease typically is associated with the sigmoid colon, the surgical strategy especially when preventing recurrent disease is to remove the diseased colonic segment. As understood herein, however, the colorectal junction area is sometimes alluded to as a high pressure zone, meaning that this area should be resected as well because when it is left behind recurrence is increased by many times. Thus, the current general perception is that the anastomosis should always be to the rectum below the peritoneal fold. 
         [0007]    As understood herein, removing so much of a patient&#39;s intestine is less than optimal, since the intestinal length is designed by nature to be as long as it is. Moreover, the 30-day complication rate from the above-described surgery may exceed twenty percent, with a measurable 30-day mortality rate and reoperation rate. 
         [0008]    U.S. Pat. No. 5,100,419, incorporated herein by reference, discloses a method for advancing an endoscope into the colon and resolving diverticula from the inside by using vacuum to invert them back into the scope apparatus, where they are closed using rubber bands. As understood by the present invention, while the &#39;419 patent offers an alternative method for treating diverticulitis that does not require anastomosis, it leaves the banded-off diverticula in the colon, depending on the diverticula to eventually slough off and pass through the colon. The present invention understands that it is desirable to maintain more positive control over both the removal of diverticula from the body, and ensuring that the colonic wall remains structurally sound, to prevent recurrences. The invention is also directed to addressing diverticula in other parts of the gastrointestinal tract that can be accessed through natural orifices. 
       SUMMARY OF THE INVENTION 
       [0009]    Using an endoscope referred to as a colonoscope that is advanced through a natural orifice such as the anus or esophagus, diverticulitis is treated by first inverting the diverticular tissue (called a “diverticulum”) into the intestinal passage, repairing the inverted tissue with trans-muscular sutures, then in some embodiments either cutting it off with a cautery wire or other cutting element such as a blade and retracting it through the instrument. Alternatively, the diverticulum can be left in place to slough off after wall repair. In any case, a suture can be placed through the muscular layer (to attach serosa to serosa on the outside) to thereby close the muscular leak that caused the defect in the first place. This suture is also placed using the instrument. Other means for resolving the deep tissue defect are also disclosed. 
         [0010]    Accordingly, a method is disclosed for treating a diverticulum formed in an intestinal wall of a patient. The method includes advancing a tubular assembly through a natural orifice into the intestine to the site of the diverticulum, and drawing the diverticulum into the assembly. The method also includes resolving a defect area associated with the diverticulum at least in part using the assembly by attaching one portion of the entire muscular wall of the intestine to another portion of the entire muscular wall. An “entire wall” is composed of a mucosal-submucosal-muscular-serosal layer, from inside to out. 
         [0011]    In some implementations the defect area is resolved by drawing the diverticulum into the assembly, removing the diverticulum, and holding together intestinal wall tissue serosa to serosa, it being understood that holding tissue serosa to serosa optimized healing. For example, the intestinal wall tissue can be sutured or stapled to hold it together serosa to serosa. Or, the intestinal wall tissue can be held together using a barbed anchoring device. Yet again, the intestinal wall tissue may be held together serosa to serosa by clamping the wall between opposed arms of a tissue heating device and heating the arms to fuse clamped wall portions together. In other aspects, the defect area can be resolved by disposing a cover over the defect area and adhering the cover to the intestinal wall. In still other aspects, a plug is used to plug the defect area. 
         [0012]    In another aspect, an overtube assembly includes an overtube configured for advancement through a natural orifice such as the anus into the colon of a patient. Means are engageable with the overtube for inverting a diverticulum into the overtube. Also, means are engageable with the overtube for resolving a defect area associated with the diverticulum by closing a defect in a muscular wall of the colon. 
         [0013]    In yet another aspect, an assembly for removing diverticula and resolving associated defect areas includes an overtube advanceable into the colon of a patient, and an inversion component engageable with the overtube and juxtaposable with a diverticulum to invert the diverticulum into the colon. A ligator is engageable with the overtube and is operable to ligate the diverticulum. A defect&#39;resolution mechanism engages the overtube for resolving an intestinal wall defect associated with the diverticulum. 
         [0014]    The details of the present invention, both as to its structure and operation, can best be understood in reference to the accompanying drawings, in which like reference numerals refer to like, parts, and in which: 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0015]      FIG. 1  is a schematic view showing the tube assembly including overtube, colonoscope, and optional steering catheter being advanced through the anus into the colon; 
           [0016]      FIG. 2  is a schematic view showing the tube assembly advanced to a diverticulum, with the open end of the overtube positioned around the diverticulum; 
           [0017]      FIG. 3  is a schematic view showing an evacuation catheter advanced into the diverticulum, and also showing the proximal and distal vacuum seals, the colonoscope omitted for clarity; 
           [0018]      FIG. 4  is a schematic view showing the diverticulum inverted into the overtube and a prettied ligature loop advanced around the diverticulum, prior to tightening the ligating device; 
           [0019]      FIG. 5  is a schematic view showing the diverticulum inverted into the overtube and showing an alternate embodiment in which a suture needle is shown poised to be passed through the tissue; 
           [0020]      FIG. 6  is a schematic view showing the diverticulum inverted into the overtube and the needle passed through the tissue and impacted into the receiving plug; 
           [0021]      FIG. 7  is a schematic view showing the diverticulum inverted into the overtube and the plug with needle being retrieved to pass a suture through the diverticulum; 
           [0022]      FIG. 8  is a schematic view showing the diverticulum inverted into the overtube and tied shut using a knot pushing device to advance half hitch knots to the suture site; 
           [0023]      FIG. 9  is a schematic view showing the inverted and ligated diverticulum with an electrocautery polypectomy snare advanced around the suture site to transect the diverticulum; 
           [0024]      FIG. 10  is a schematic view showing a mechanical grasper for inverting a diverticulum; 
           [0025]      FIGS. 10A and 10B  are schematic views showing a bristle brush for inverting a diverticulum; 
           [0026]      FIGS. 11-15  are schematic side views showing a first embodiment of resolving the intestinal wall defect after the diverticulum has been transected, using a cover patch; 
           [0027]      FIGS. 16-21  are schematic side views showing a second embodiment of resolving the intestinal wall defect after the diverticulum has been transected, using staples; 
           [0028]      FIGS. 22-27  are schematic side views showing a third embodiment of resolving the intestinal wall defect after the diverticulum has been transected, using a barbed T-shaped anchor; 
           [0029]      FIGS. 28-31  are schematic side views showing a fourth embodiment of resolving the intestinal wall defect after the diverticulum has been transected, using heat sealing jaws; 
           [0030]      FIGS. 32-36  are schematic side views showing a fifth embodiment of resolving the intestinal wall defect after the diverticulum has been transected by pulling one part of the wall over another and fastening the two parts together using a T-shaped anchor; 
           [0031]      FIGS. 37-42  are schematic side views showing yet another alternate embodiment in which a hollow plug is first advanced into the diverticulum, with the diverticulum being inverted through the plug, removed, and the plug remaining in place to resolve the colonic wall defect; 
           [0032]      FIGS. 43-48  are side views of an alternate plug; and 
           [0033]      FIGS. 49 and 50  are side views of still another alternate plug. 
       
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT 
       [0034]    Referring initially to  FIG. 1 , a catheter assembly is shown, generally designated  10 , that includes a flexible hollow overtube  12  fixedly or slidably holding one or more components such as but not limited to a colonoscope  14  and a steering catheter  16 . The colonoscope  14  may extend from the open distal end  18  of the overtube  12  as shown to a colonoscope control hub  20  that is external to the patient. In this way, for example, images of the colon  22  from the colonoscope  14  can be presented on a monitor to a surgeon. Other components in the overtube  12  may extend to other hubs, e.g., the steering catheter  16  may extend to manipulable control hub  24  for turning and directing the steering catheter  16  (and, hence, the overtube  12 ) under visualization provided by the colonoscope  14 . The overtube  12  itself may have steering capability my means of, e.g., anchoring a steering wire in the overtube  12  near the distal end  18 , with the steering wire being manipulable to bend the overtube  12 . 
         [0035]    The components  14 ,  16  may extend through respective working lumens of the overtube  12 . Additional components may extend through additional working lumens and/or may be swapped according to the stage of the procedure for the components  14 ,  16 . As described further below, the additional components may include catheters for inverting diverticula into the intestinal lumen, transmural suturing/clipping devices, detachable ligating devices, and polypectomy snares. Thus, in non-limiting implementations the overtube  12  may include additional lumens with respective proximal and distal openings. 
         [0036]    As intended herein, the overtube  12  can be flexible and can be sized as appropriate for the patient, e.g., shorter overtubes can be provided for pediatric patients. Although not shown in  FIG. 1 , the open distal end  18  of the overtube  12  may be tapered into a frusto-conical shape to reduce the risk that parts of the colon wall may become trapped between the overtube  12  and the colonoscope  14  during advancement of the overtube  12 . Also, the inner surface of the overtube  12  can be coated with a lubricious material to ensure smooth advancement of the overtube  12  over the colonoscope  14 . 
         [0037]    Prior to discussing details of various structures for resolving defect areas associated with diverticula,  FIGS. 2-9  first will be described to give both an overview of one example procedure in accordance with present principles, as well as non-limiting structure that can be used to undertake the procedure. As shown in  FIG. 2 , the catheter assembly  10  is advanced through the anus  26  into the colon  22  to an area of diverticular disease, i.e., to a diverticulum  28 . Due to the nature and location of the diverticulum  28 , the assembly  10  may be guided by colonoscopy. Alternatively, the catheter can be advanced into the small intestine through the esophagus, in which case upper GI imaging and enteroscopy may be used to guide the catheter. 
         [0038]    The overtube  12  is typically advanced together with the colonoscope  14 . When the distal end  18  of the overtube  12  is kept behind the tip of the colonoscope  14 , the colonoscope  14  has full maneuverability. During colonoscopy, air or some other gas may be used if desired to insufflate the otherwise collapsed colon. A flexible seal  30  can be provided in the proximal part of the overtube  12  to prevent insufflation air from leaking between the colonoscope  14  and overtube  12 . When the air or the gas is removed by suction through a channel such as an instrument channel of the colonoscope  14 , this seal  30  also ensures the maintenance of vacuum in the overtube  12  for inversion of the diverticulum  28  as will be shortly discussed. 
         [0039]    To enhance locating diverticula, a barium study can first be employed to ascertain the number and location of diverticula prior to diverticuloectomy. Alternatively, contrast media can be flushed into the colonic lumen during colonoscopy. 
         [0040]    Turning to  FIG. 3 , once the overtube  12  has been positioned adjacent to a diverticulum  28 , the steering catheter  16  if not already positioned may be advanced through a working channel of the overtube  12  to the diverticulum  28  as shown. The catheter  16  may include its own working lumens such that saline can be infused into the diverticulum  28  to flush out fecal matter for later removal through, e.g., the instrument channel of the colonoscope  14 . At this point of the procedure, acute diverticulitis can be diagnosed by the appearance of purulent material at the diverticular orifice. 
         [0041]    If desired, contrast media can be infused through the catheter  16  to facilitate obtaining radiographs from the diverticulum  28 . In this way, the size and location of the diverticulum  28  can better be seen using fluoroscopy, to check the diverticulum  28  for signs of fistulization or perforation. If the diverticular orifice shows a stricture or does not have an adequate diameter for inversion, it may be dilated using an inflatable balloon or similar structure that can be engaged with the catheter  16 . 
         [0042]    Next and cross-referencing  FIGS. 3 and 4 , the open distal end  18  of the overtube  12  preferably is provided with a distal seal  32  for sealing against the intestinal wall ( FIG. 3 ), and then a vacuum is drawn through the overtube  12  to invert the diverticulum  28  ( FIG. 4 ). In lieu of using the entire overtube  12  the catheter  16  or another catheter such as the colonoscope  14  may be used for evacuation purposes. Regardless of which catheter is used, the diverticulum  28  is pulled into the overtube  12  in the intestinal lumen. 
         [0043]    The distal seal  32  of the overtube  12  may be established by spikes, rings, wires, balloons, forceps, flaps, high friction surfaces, glue, or any combination thereof. In non-limiting implementations the distal seal  32  can be moved into position after the overtube  12  has been navigated into position with the colonoscope  14 . For example, a tether can be pulled to draw the seal  32  into place to provide a vacuum seal. 
         [0044]    It may now be appreciated that the overtube  12  produces counterforce around the orifice of the diverticulum  28  as the diverticulum is inverted. This causes the diverticulum  28  to partially or completely invert into the intestinal lumen. Vacuum is built up in the space of inversion and is sealed from leaking to the intestinal lumen by the distal seal  32  of the overtube  12 . As stated above, not only may the vacuum be established and/or maintained by applying suction through the catheter  16 , it may also be established/maintained by applying suction through the colonoscope  14  or through a separate suction lumen of the overtube  12 . 
         [0045]    Once the diverticulum  28  is inverted,  FIG. 4  illustrates that it may be ligated. In one non-limiting implementation, a preloaded string or detachable loop  34  such as a prettied ligature loop is disposed on the overtube  12  at the distal end  18  thereof such that the diverticulum  28  is inverted through the loop. The string  34  extends through the overtube  12  as shown so that it may cinched tight around the diverticulum  28 . 
         [0046]    Alternatively, a transmural suture or clipping device can be placed at the distal end  18  of the overtube  12 . The transmural device has the ability to close the opening in the muscular layer of the bowel wall and to prevent recurrence of a diverticular pouch. 
         [0047]      FIGS. 5-9  show remaining steps of the procedure with alternate ligating structure. For completeness of disclosure  FIGS. 5-9  show an alternate overtube  12   a  that has a side opening  36  in lieu of or in addition to an open distal end (which otherwise can be sealed off if desired with, e.g., a balloon), it being understood that the overtube  12  shown in  FIGS. 1-4  equally may employ the following principles. 
         [0048]    As shown best in  FIGS. 5 and 6 , a needle catheter  38  holding one or more preloaded suture needles  40  may be disposed in the overtube  12   a  as shown. Equivalently, a lumen of the overtube  12  can be used to deliver the needles  40 . The needles  40  can be pushed distally using an external pusher handle  42  ( FIG. 6 ) or other structure. For example, the needles  40  can simply be nested into the end of a pushrod since all the required pushing force is in one direction. Each needle  40  is attached to opposite ends of a single length of suture string  43 . 
         [0049]    A plug  44  of material such as urethane foam, rubber, etc. is disposed on the opposite side of the side opening  36  from the needles  40  as shown. With this structure, the needles  40  can be pushed through the diverticulum  28  into the plug  44 , which captures the needles  40  after penetrating the tissue, as shown in  FIG. 6 . If desired, the needles  40  may be barbed to enhance their pullout strength. 
         [0050]    The plug  44  is attached to a retrieval string  46  that extends through a lumen of the overtube  12  as shown in  FIG. 6 . The plug  44  with embedded needles  40  is then retrieved by tensioning the retrieval string  46  ( FIG. 7 ) to thereby pull the suture string  43  through the diverticulum  28  and back out to the operator. The operator can then use a knot pushing device to advance half hitch knots  50  to the suture site in accordance with suture principles known in the art ( FIG. 8 ). Alternatively, a crimpable sleeve or compression sleeve can be advanced over the suture tails to secure the closure. If desired, in addition to the distal seal  32 , when the overtube  12   a  has an open distal end in addition to the side opening  36 , a closure or seal  52  can be provided on the open distal end as shown. If desired, the diverticulum  28  with associated bowel wall can be twisted prior to suturing to improve closure. In this embodiment the intestinal wall is resolved by a serosa to serosa closure. 
         [0051]    Next, as shown in  FIG. 9  an electrocautery polypectomy snare  54  can be advanced under visualization provided by the colonoscope  14  through a working channel of the colonoscope. The snare  54  is positioned around the ligated diverticulum  28  as shown and actuated to transect the diverticulum  28  using electrocut and/or electrocoagulation. The colonoscope  14  may then be used to retrieve the diverticulum  28  by pulling it through the overtube  12   a  using, e.g., forceps that are advanced through the colonoscope  14  or overtube  12   a . The overtube can be kept in place and used for fast reinsertion of the colonoscope  14  for the purpose of a second look at the site of colonoscopic diverticuloectomy. Several diverticula can be removed within a single endoscopic procedure. In some embodiments, the diverticula may be simply ligated and left in place to slough off later through the colon. 
         [0052]    As shown in the above figures and as discussed more fully below, serosa to serosa closure preferably is effected, in which the entire muscular wall of the colon is inverted and sutured. This closes the muscular leak that caused the primary defect for the diverticulum  28  to be formed in the first place, minimizing recurrences of diverticular disease at the same site. 
         [0053]      FIG. 10  shows that in lieu of inversion using vacuum, a mechanical grasper or hooking device  56  can be advanced through the overtube  12  or  12   a  and into the diverticulum  28  to grasp the tissue of the diverticulum  28 . The grasper  56  is then retracted into the overtube to invert the diverticulum  28 , which can then be ligated and transected in accordance with above principles. Alternatively, as shown in  FIG. 10A  a bristle brush  56   a  may be advanced through the overtube  12  or  12   a  and into the diverticulum  28 . A vacuum may be applied through the overtube to suck the tissue against the bristles of the brush, which then is rotated as shown in  FIG. 10B  to further grasp the tissue of the diverticulum  28 , after which the brush  56   a  may be retracted into the overtube to invert the diverticulum. 
         [0054]    The above approach of evacuating the entire overtube to effect inversion may also be used in natural orifice appendectomy procedures or other natural orifice procedures in the gastrointestinal tract. 
         [0055]      FIGS. 11-50  show the details of various mechanisms for effecting deep tissue closure of the diverticular area after removal of the diverticulum, it being understood that the various mechanisms shown and discussed below can be advanced to the affected site using the catheter assembly  10 . 
         [0056]      FIGS. 11-15  show that the diverticulum  28  ( FIG. 11 ) can be inverted, ligated with the loop  34  ( FIG. 12 ), tied off using the knots  50  and removed ( FIG. 13 ), with the remaining muscular tissue area of the colon being tied serosa to serosa. In other words, as best shown in  FIG. 12  the colonic wall is pursed serosa to serosa, with what had been the outer surface portion  60  of the wall on one side of the diverticulum  28  being flush against the outer surface portion  62  of the wall on the opposing side of the diverticulum  28  to form the pursed serosa-to-serosa structure shown in  FIG. 13 . Element  64  in  FIG. 12  is the inner mucosal membrane or lining of the colon. Once the diverticulum  28  has been removed, a patch  66  is positioned over the stump  68  of the colonic wall and if desired adhered to the colonic wall using a cyanoacrylate as shown in  FIGS. 14 and 15 . 
         [0057]      FIGS. 16-18  show that the diverticulum  28  can be inverted into the overtube  12   a  between a staple cartridge  70  and an opposed staple anvil  72 . The staples can be ejected from the cartridge  70  in accordance with staple ejection principles known in the art to close off the diverticulum  28  as showman  FIG. 19 , preferably with the muscular wall of the colon pursed as shown in  FIG. 20  to form a stump  74 . A cutter  76  optionally may be used to cut off the diverticulum, which is removed as described previously, to leave the pursed stump  74  shown in  FIG. 21 . 
         [0058]      FIGS. 22-27  show another structure for resolving the deep muscle defect associated with the diverticulum  28  after optional removal of the diverticulum leaves a pursed stump  80 . A hollow elongated needle tube  82  extends through the overtube  12   a  and may be supported by an elongated support rod  84  near its distal end as shown. The distal end  86  of the needle tube  82  is curved as shown, and a curved cinch tube  88  slidably surrounds the distal end  86  and is movable my means of reciprocating the support rod  84 . A hollow curved needle  90  protrudes out of the distal end  86  of the needle tube  82 . 
         [0059]    The needle  90  contains one or more barbed “T”-shaped anchors  92  ( FIG. 23 ). As set forth further below, the anchors  92  are delivered through the needle  90  into the stump  80 . As shown in  FIG. 23 ; each anchor  92  may include a shank  94  having barbs  96  formed thereon. A cross-bar  98  is formed on one end of the shank  94 , and the anchor  92  is made of material that is sufficiently resilient that the bar  98  can be bent parallel to the shank  94  when housed in the needle  90 , owing to material bias assuming the shape shown in  FIG. 23  once released from the needle  90 . 
         [0060]    With the above description in mind, as shown in  FIG. 24  the needle  90  is passed through the stump  80 .  FIG. 25  shows that an anchor  92  is ejected through the needle  90  cross-bar  98  first. Then, as shown in  FIG. 26  the cinch tube  88  is slid against the stump  80  to capture the stump  80  between the cross-bar of the anchor  92  and the cinch tube  88  while the needle tube  82  is retracted. The barbs  96  of the anchor  92  engage the stump  80  once the cinch tube  88  is retracted as shown in  FIG. 27  to trap the stump  80  between the cross-bar  98  and the barbs  96 . Proximal barbs  96  may be snipped off or otherwise trimmed away once the anchor  92  is in place. As stated above, the serosa-to-serosa closure may be effected after removing the diverticulum or without removing the diverticulum. 
         [0061]      FIGS. 28-31  show that the mechanical grasper  56  shown in  FIG. 10  may be advanced out of a lumen in a catheter such as the colonoscope  14  through the side opening  36  of the overtube  12   a  to grasp the diverticulum  28  and invert it into the overtube as described previously to effect serosa-to-serosa closure, it being understood that as described above vacuum can be used to invert the diverticulum and that the overtube  12  with the open distal end can also be used. As also described above and as shown in  FIG. 29 , the diverticulum  28  can be inverted through a ligating loop  34  formed by control wires that draw the jaws over the tissue and that are slidably surrounded by a cinch tube  100 , which causes the jaws to close as the control wires are drawn into the cinch tube. 
         [0062]    In accordance with the embodiment shown in  FIGS. 28-31 , a tissue heating device  102  can be provided in the overtube  12   a .  FIGS. 28 and 29  show that the tissue heating device includes opposed arms  104 ,  106  that pivot, relative to each other at a pivot joint  108 . The device  102  may be attached to a closed distal end of the overtube  12   a  by a return spring  110 . 
         [0063]    It may be appreciated in reference to  FIGS. 28 and 29  that the inner surfaces  112  of the arms  104 ,  106  may be flat, and electrical leads can extend from the arms  104 ,  106  through the overtube  12   a  to a source of electricity that is external to the patient to heat the inner surfaces  112 . The arms  104 ,  106  may be hollow so that they may be evacuated to further draw tissue into them.  FIG. 30  shows that the cinch tube  100  can be advanced using, e.g., a push tube within the overtube  12   a  to ligate the diverticulum  28 , and the heating device  102  likewise can be advanced to position the arms  104 ,  106  on opposite sides of the diverticulum  28 . The heating device  102  may be advanced by any suitable means, e.g., using a push tube over an affixed wire or other means. 
         [0064]    As the heating device  102  is advanced over the diverticulum  28 , owing to the tensioning of the spring  110  the arms  104 ,  106  pivot toward each other, clamping the pursed colonic wall between them. The inner surfaces  112  are then heated to fuse clamped colonic wall portions together while cutting off the diverticulum  28 . Instead of rigid arms  104 ,  106 , a flexible conductive loop of, e.g., wire can be used and positioned around the stump, tightened, and energized to fuse clamped colonic wall portions together while cutting off the diverticulum  28 . By “fuse” is meant tissue welding using principles of bipolar electrocautery, ultrasonic tissue welding, laser tissue welding, etc. in addition to heat fusion, in which case the arms  104 ,  106  are configured as electrocautery arms, ultrasonic transducers, laser emitters, etc. 
         [0065]      FIGS. 32-36  show that one of the anchors  92  described above may be used in an alternate embodiment to resolve the diverticular area of the colonic wall after removal of the diverticulum  28  in which a non-pursed stump structure remains. More specifically, as figuratively shown in  FIG. 32 , the diverticulum  28  exists and as shown in  FIG. 33  is inverted into the colonic lumen using the assembly  10  described above. As indicated by the arrow  114  in  FIG. 34 , the diverticulum  28  is then pulled forcefully using, e.g., the grasper  56  described previously to draw a first portion  116  of the colonic wall into an overlapping relationship with a second portion  118  of the colonic wall. It may be appreciated in reference to  FIGS. 34 and 35  that the outer surface of the first portion  116  is flush against the inner surface of the second portion  118  in the overlapping relationship shown, i.e., that in this less preferred embodiment a serosa-to-mucosa mating is established. After the diverticulum  28  has been optionally removed as indicated by the arrow  120  in  FIG. 36  using one of the above-described methods, one or more of the anchors  92  can be driven into the portions  116 ,  118  to hold them together as shown. The anchors  92  may be delivered using the structure described above in reference to  FIGS. 22-27 . 
         [0066]      FIGS. 37-42  show that a plug  130  can be advanced through the colon wall  22  into the diverticulum  28  prior to inversion. In one non-limiting implementation the plug  130  can be positioned as shown in  FIG. 37  by pushing it through the lumen of a catheter such as the overtube  12  or the catheter  14  or  16  ( FIGS. 1-3 ) under, e.g., colonoscopic visualization. 
         [0067]    In cross-reference to  FIGS. 37 and 38 , the plug  130 , which is preferably made of biocompatible plastic, includes a half-dome-shaped stopper  132  that is radially larger than the remainder of the plug structure and also is radially larger than the opening of the diverticulum  28  as shown. Attached to the stopper  132  are plural elastic wings  134  that may be made of shape memory material, and passing centrally through the stopper  132  is a hollow cylindrical delivery tube  136 . As shown in  FIG. 37 , the ends of the wings  134  opposite the stopper  132  are temporarily bonded using, e.g., a weak adhesive to the delivery tube  136  to hold the wings  134  in the straight configuration shown. When the delivery tube  136  is retracted into the overtube  12  as shown by the arrows  138  in  FIG. 38 , the bond breaks, freeing the wings  134  to assume their materially biased configuration in which they bend back parallel to or even against the outer surface of the colonic wall as shown in  FIGS. 38 and 39 . In this way, the colonic wall is sandwiched between the stopper  132  and wings  134 . 
         [0068]    Because the delivery tube  136  is hollow, irrigating fluid can be directed through the tube  136  to clean the diverticulum  28  prior to inversion. After cleaning, inversion may be effected by advancing a grasper  140  ( FIG. 39 ) through the tube  136  to grasp the diverticulum  28  and retracting the grasper  140  to invert the diverticulum  28  back through the delivery tube into the colonic lumen as shown in  FIG. 40  (and, thus, into the overtube  12  or  12   a ). The diverticulum  28  can then be cut off using any of the above-described methods and removed from the patient through the overtube. 
         [0069]    Next, as shown by the arrows  142  in  FIG. 41 , the delivery tube  136  is retracted out of the stopper  132 , releasing an inward mechanical force of the plug  130  on the inverted tissue, thereby effecting ligation. With the wings  134  preventing inward migration of the plug  130  into the colon, the plug  130  remains in place as shown in  FIG. 42 , ensuring that no leakage of air or fluids occurs from the colon to the peritoneal cavity and thus resolving the defect in the diverticular tissue. The wings  134  may be covered in an atraumatic material or configured as an atraumatic structure to avoid perforation and promote ingrowth. In addition to the hollow plug now being blocked by tissue, if desired glue or other substance may be infused into the hollow portion with the tissue to further block the plug. 
         [0070]      FIGS. 43-48  illustrate another plug embodiment, generally designated  150 . The plug  150  is a silastic plug, i.e., a plug with rubber-like qualities of silicone which enable the parts to snap fit together. 
         [0071]    As shown, the plug  150  includes an outer part  152  having a flange  154  that engages the outer colonic wall when deployed and a hollow shank  156  depending from the flange  154 . The hollow shank  156  includes structure  158  such as a tapered ring that engages complementary structure  159  (such as a radial groove) on a hollow inner part  160  that is shaped substantially similarly to the stopper  132  discussed above and shown in  FIGS. 37-42 . The inner part  160  engages the inner surface of the colon. 
         [0072]    As shown in  FIG. 45 , the flange  154  ultimately is established by a foldable flange  162 ,  164  that can be pulled into a delivery tube  166  to be nearly parallel with the hollow shank  156 . The delivery tube is advanced into the diverticulum  28  as shown in  FIG. 45  and then retracted, freeing the flange  164 ,  166  to assume the flange-like configuration shown in  FIG. 46 , thereby establishing the flange  154  on the outer surface of the colonic wall  22  as shown. 
         [0073]    As also shown in  FIG. 46  and as indicated by the arrows  168 , the inner part  160  is advanced over the shank  154  until the interlocking structures  158 ,  159  of the outer part  150  and inner part  160 , respectively, engage each other as shown in  FIG. 47  to clamp the colonic wall between the flange  154  of the outer part  150  and the flat surface of the half dome-shaped inner part  160 . The portion  170  of the hollow shank  156  that extends inwardly beyond the inner part  160  can be cut off, and a delivery tube  172  for flushing and inverting the diverticulum  28  can be advanced through the plug  150  as described above in relation to the plug  130  shown in  FIGS. 37-42 . 
         [0074]      FIGS. 49 and 50  show an alternate plug  180  configured generally as a rivet. The plug  180  includes a stopper  182  with hollow central passageway  183 , and the stopper  182  shown in  FIGS. 49 and 50  is substantially identical in configuration and purpose to the stopper  132  shown in  FIGS. 37-42 . 
         [0075]    Plural rivet legs  184  extend from the stopper  182  and as indicated by the arrows  186  in  FIG. 49 , are biased to bend radially outward at respective, bend joints  188  to assume the flattened, radially enlarged configuration of  FIG. 50 . To facilitate advancing the legs  184  through the diverticular defect into the diverticulum (not shown in  FIG. 49 ), the ends of the legs  184  opposite the stopper  182  are connected to a rivet cap  190 , and a push rod  192  is advanced into the rivet cap  190  and is pushed into the diverticulum to move the legs  184  to the relatively straight configuration shown in  FIG. 49 . In this configuration the legs  182  are moved through the colonic wall into the diverticulum, at which point the push rod  192  is retracted, allowing the legs  184  to assume the configuration shown in  FIG. 50 , clamping the colonic wall  22  between the stopper  182  and the legs  184  as shown. A delivery tube  194  is then advanced through the passageway  183  of the stopper  182  for flushing and inverting the diverticulum  28  through the plug  180  as described above in relation to the plug  130  shown in  FIGS. 37-42 . 
         [0076]    With the above disclosure in mind, it may now be appreciated that the present invention affords the following advantages. A diagnostic procedure (imaging) and a therapeutic procedure (inversion and removal) are combined in one procedure. No incisions of the skin and muscular layers need be made, since the diverticulum is reached through a natural orifice. Likewise, general anesthesia is not required because the procedure can be done similar to polypectomy. Moreover, the patient suffers comparatively less pain after the procedure. Additionally, the risk of peri-interventional infection is reduced because the lumen of the bowel is not opened. Also, costs are reduced because a sterile operating room and hospitalization are not required to effect the procedure. Repair of the intestinal wall defect is done to prevent reoccurrence of the diverticulum. 
         [0077]    While the particular SYSTEMS AND METHODS FOR ENDOSCOPIC TREATMENT OF DIVERTICULA are herein shown and described in detail, it is to be understood that the subject matter which is encompassed by the present invention is limited only by the claims. For example, the diverticulum  28  may be ablated through the overtube  12 , and in lieu of being removed may be glued or bricked off. Or, the diverticulum may be covered and/or excised without inverting. The diverticulum may be desiccated by cautery, laser, chemical, cryogenics to make it slough off harmlessly. The defect may be plugged with a mesh or plug as discussed above. The process can involve anastomosing the defect closed, as well as the use of an implant overlay of the defect similar to a hernia treatment. The bowel layers may be folded over the defect to make multiple layer closure. Tissue growth factors can be infused through the overtube  12  to better heal the site, as can be antibiotics prior to removal. Moreover, radiopaque clips can be implanted through the overtube  12  and left in pace to facilitate monitoring the site for future recurrences of diverticular disease.