Abstract:
A method includes advancing an apparatus having an elongated member transorally into the stomach. The apparatus includes a distal end effector having first and second members configured to engage tissue. The first and second members are movable relatively toward one another generally in a first plane. The method includes moving the distal end effector relative to the elongated member in the first plane such that the distal end effector is retroflexed out of alignment with the elongated member to position the first and second members for engagement with the tissue. At least one of the first and second members carries a fixation device for fixing engaged portions of tissue together.

Description:
This application claims the priority of U.S. provisional application Ser. No. 60/306,652, filed Jul. 18, 2001, which is hereby incorporated by reference in its entirety. 
     This application is a continuation-in-part of copending application U.S. Ser. No. 09/859,579, filed May 18, 2001 now U.S. Pat. No. 6,821,285, entitled TISSUE RECONFIGURATION, which is a continuation-in-part of application U.S. Ser. No. 09/574,424, filed May 19, 2000 now U.S. Pat. No. 6,494,888, entitled TISSUE RECONFIGURATION, which is a continuation-in-part of application U.S. Ser. No. 09/520,273, filed Mar. 7, 2000 now U.S. Pat. No. 6,663,639, entitled METHODS AND DEVICES FOR TISSUE RECONFIGURATION, and application U.S. Ser. No. 09/519,945, filed Mar. 7, 2000 U.S. Pat. No. 6,506,196, entitled DEVICE AND METHOD FOR CORRECTION OF A PAINFUL BODY DEFECT, which claim priority from provisional application. U.S. Ser. No. 60/140,492, filed Jun. 22, 1999, entitled STOMACH ELEVATOR METHOD AND DEVICE, all hereby incorporated by reference in their entirety. 
    
    
     BACKGROUND OF THE INVENTION 
     Brief Description of the Related Art 
     This invention relates to devices and methods for treating gastroesophageal reflux disease, and more particularly, the invention relates to a minimally invasive device and method for creating and fixating a fold of tissue at or near the junction of the esophagus and the stomach. 
     Gastroesophageal reflux disease (GERD) is a common upper-intestinal disorder in which contents of the stomach flow inappropriately from the stomach into the esophagus. Backflow of gastric contents into the esophagus results when gastric pressure is sufficient to overcome the resistance to flow that normally exists at the gastroesophageal junction (GEJ), or when gravity acting on the contents is sufficient to cause flow through the GEJ. Medication, open surgical procedures, laparoscopic surgical procedures, and endoscopic techniques are known for treating GERD. 
     SUMMARY OF THE INVENTION 
     According to one aspect of the invention, a medical instrument includes moveable arms configured for fixating the wall of the stomach to the wall of the esophagus for the treatment of GERD. In one embodiment, the instrument includes a proximal end, a shaft, a retroflexing portion, movable arms, a retractor, and an implant. The movable arms are oriented with respect to the retroflexing portion in a position that allows the stomach wall to be folded against the esophagus wall. In one such embodiment of this instrument the movable arms open and close in the same plane within which the retroflexing portion moves. This configuration is in contrast to certain embodiments of the medical instrument described in the U.S. patent application Ser. No. 09/859,579, entitled “TISSUE RECONFIGURATION,” filed 18 May 2001, in which the moveable arms are oriented in a plane rotated 90 degrees from the plane in which the retroflexing portion moves. The mechanism of operation of the medical instrument of the current invention is as is disclosed in the patent applications incorporated by reference and listed above. 
     According to another aspect of the invention, a method of treatment includes fixating the wall of the stomach to the wall of the esophagus for the treatment of GERD. 
     According to another aspect of the invention, a method includes advancing an apparatus having an elongated member transorally into the stomach. The apparatus includes a distal end effector having first and second members configured to engage tissue. The first and second members are movable relatively toward one another generally in a first plane. The method includes moving the distal end effector relative to the elongated member in the first plane such that the distal end effector is retroflexed out of alignment with the elongated member to position the first and second members for engagement with the tissue. At least one of the first and second members carries a fixation device for fixing engaged portions of tissue together. 
     Embodiments of this aspect of the invention may include one or more of the following features. The method includes engaging tissue by moving the first and second members relatively toward one another generally in the first plane. Moving the first and second members engages a first tissue section with a first securing part of the fixation device and a second tissue section with a second securing part of the fixation device. The method includes piercing the tissue with a third member of the distal end effector prior to engaging the tissue with the first and second members. 
     According to another aspect of the invention, a method of treatment includes advancing a flexible shaft to a treatment site, piercing tissue with a member located at a distal portion of the shaft, and stabilizing tissue being pierced by contacting a surface of the tissue with a tissue stabilizer biased in a distal direction such that as the tissue piercing member enters tissue, the tissue stabilizer is urged against the surface of the tissue. 
     According to another aspect of the invention, a medical instrument for reconfiguring tissue includes a flexible shaft defining a lumen housing actuating controls, and a distal actuating assembly. The distal actuating assembly includes a sealing portion configured to substantially seal the shaft lumen from contact with bodily fluids, and a tissue manipulator located distal of the sealing portion. The actuating member is coupled to the tissue manipulator such that the tissue manipulator is actuatable to deploy an implant located distal of the sealing portion. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       The invention will now be described in greater detail with reference to the preferred embodiment illustrated in the accompanying drawings, in which like elements bear like reference numerals, and wherein: 
         FIG. 1  is a side cross sectional view of a portion of an esophagus and a portion of a stomach, and a side view of an instrument in place in the esophagus and stomach; 
         FIG. 2  is a side cross sectional view of a portion of the esophagus and a portion of the stomach, and a side view of the instrument in place in the esophagus and stomach, showing the instrument in a retroflexed position; 
         FIG. 3  is a side cross sectional view of a portion of the esophagus and a portion of the stomach, and a side view of the instrument in place in the esophagus and stomach, showing the movable arms open; 
         FIG. 4  is a side cross sectional view of a portion of the esophagus and a portion of the stomach, and a side view of the instrument in place in the esophagus and stomach, showing a retractor engaging tissue; 
         FIG. 5  is a side cross sectional view of a portion of the esophagus and a portion of the stomach, and a side view of the instrument in place in the esophagus and stomach, showing the retractor retracting the tissue; 
         FIG. 6  is a side cross sectional view of a portion of the esophagus and a portion of the stomach, and a side view of the instrument in place in the esophagus and stomach, showing the movable arms closed, forming a tissue fold; 
         FIG. 7  is a side cross sectional view of a portion of the esophagus and a portion of the stomach, and a side view of the instrument in place in the esophagus and stomach, showing the movable arms open and an implant fixating the tissue fold; 
         FIG. 8  is a side cross sectional view of a portion of the esophagus and a portion of the stomach, and a side view of the instrument in place in the esophagus and stomach, showing the tissue fold, with the instrument in a straight configuration for removal from the patient. 
     
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT 
     In one aspect, the present invention provides endoscopic methods for reconfiguring tissue within a hollow body organ. The method of the invention may be applied to any hollow organ, as defined below. In a broad sense, the methods include at least the steps of engaging a portion of the inner surface of the hollow organ to be reconfigured, manipulating the engaged portion of tissue to create the reconfiguration, and fixing the manipulated tissue to retain the reconfiguration achieved in the manipulation. The methods may also include the step of endoscopic visualization during all or part of the procedure. Details of the shapes that can be assumed by the reconfigured tissue are discussed below. 
     As used herein, “endoscopic method” refers to a technique for performing a medical procedure on a subject in which access to the tissue to be treated is gained via an endoluminal approach. In a preferred embodiment an endoscopic method is performed without a contemporaneous invasive approach involving a surgical incision to gain access to the area of treatment. This preferred embodiment embraces use of at least one intravenous catheter for the administration of crystalloid or colloid fluids or medication to the subject, but does not require placement through the abdominal wall of an intraabdominal set of trocars, laparoscope, or the like. 
     The methods of the invention also contemplate gaining access to the interior of a subject&#39;s stomach via a gastrotomy or gastrostomy. Such methods, which retain the feature of involving minimally invasive access to tissue to be reconfigured, may be of particular value in situations where access via the esophagus is not possible due to distortion or disruption of normal oropharyngeal or proximal esophageal anatomy. Such methods may also be of particular value when a gastrotomy or gastrostomy is present for other medical reasons, such as for enteral feeding, for example. 
     As used herein, “hollow organ” refers to an organ of a subject&#39;s body which depends for its principal function upon its ability to receive and/or act as a conduit for liquid contents. A hollow organ typically is in fluid communication with another hollow organ and/or with the outside of the body. Many organs of the gastrointestinal and genitourinary tracts are classified as hollow viscus organs. These include stomach, gall bladder, uterus, and bladder. Other hollow organs which act more as fluid passageways include esophagus, small and large intestines, hepatic ducts, cystic duct, common bile duct, pancreatic duct, heart, veins, arteries, vagina, uterine (i.e., Fallopian) tubes, ureters, and urethra. 
     Endoscopic visualization can be used for all, at least a part, or none of the procedure. In certain preferred embodiments of the invention, the method is performed in conjunction with endoscopic visualization of at least the engaged portion of tissue. Typically, a first step in the method of the invention includes advancing an endoscope into the interior or lumen of a first hollow organ. Preferably, but not necessarily, endoscope is advanced into the interior of first hollow organ by way of a lumen of a second hollow organ in fluid communication with the first hollow organ. 
     Endoscopes are well known in the art. Viewing endoscopic instruments typically are equipped with a lighting element and a viewing element enabling an operator to view the interior of the accessed body cavity. Viewing endoscopic instruments often also include at least one fluid channel suitable for introducing and/or withdrawing a fluid, gas, or medicament, and a working channel suitable to accommodate a remotely operated surgical tool such as a needle, a grasper, a biopsy device, a brush, an electrocautery electrode, and the like. Acceptable viewing elements include fiberoptic-assisted direct visualization, television array, and video array endoscopes. Endoscope can be introduced into lumen of the first hollow organ for at least one aspect of the procedure and removed for at least one other aspect of the procedure. Accordingly, a viewing endoscope can be introduced, removed, and reintroduced for any one or for any combination of steps of the method of the invention. 
     For the purposes of the invention, a viewing endoscope can be an instrument separate from any other instrument employed in the practice of the method of the invention. Alternatively, a viewing endoscope can work cooperatively with at least one other instrument used in the practice of the invention by, for example, the at least one other instrument&#39;s cooperatively positioning the endoscope. In other embodiments, a viewing endoscope can be incorporated into a tissue engaging device, at least a portion of a tissue fixing device, or part of a combined tissue engaging and tissue securing device. 
     In other embodiments of the invention, the method is performed at least in part with non-endoscopic visualization of the tissue engaged. Non-endoscopic methods of visualization include techniques well known in the art, such as, without limitation, fluoroscopy, either with or without the use of a suitable radiographic contrast agent, and ultrasound. In some embodiments the procedure can be performed without any endoscopic visualization. 
     As used herein, the term “engaging” refers to an act of reversibly penetrating, gripping, tweezing, holding, pressing, clamping, sucking, or otherwise contacting a tissue in a mechanical fashion so as to establish a physical connection with the tissue. In certain preferred embodiments of the invention the engagement of tissue occurs reversibly and essentially atraumatically. 
     For example, in a most preferred embodiment the tissue engagement device includes a novel corkscrew-type element, described below. Even though the sharpened end of the spiral corkscrew-type element pierces in order to engage tissue, when the spiral is removed by unscrewing it from tissue, it leaves a single discrete point of penetration which self-seals in the extremely pliable tissue lining of the stomach, much as does a hole made in the same tissue with a hypodermic needle. 
     The tissue engaging device in some embodiments can be a separate instrument unto itself. In other embodiments the tissue engaging device can be used in combination with another endoscopic instrument. In yet other embodiments the tissue engaging device can be an element of a combination endoscopic instrument. In a preferred embodiment the tissue engaging device is an element of an endoscopic instrument which also incorporates a tissue securing device (see below). 
     In certain preferred embodiments the engaged portion involves just the inner lining of the first hollow organ. For example the engaged portion can involve only the mucosa in a stomach. In other embodiments the engaged portion can involve the inner lining and at least one additional tissue layer of first hollow organ. Again with reference to the stomach, the reconfigured portion can involve the mucosa and at least one layer of muscular wall, up to and including the full thickness of the stomach wall. 
     In certain preferred embodiments the tissue engaging device can engage tissue in a reversible and essentially atraumatic manner. Engagement of tissue in such embodiments is effective for performing subsequent steps of the method but also allows release of engaged tissue in a manner which causes little or no disruption of tissue integrity. 
     For example, in a most preferred embodiment the tissue engagement device includes a novel corkscrew-type element, described below. Even though the sharpened end of the spiral corkscrew-type element pierces in order to engage tissue, when the spiral is removed by unscrewing it from tissue, it leaves a single discrete point of penetration which self-seals in the extremely pliable tissue lining of the stomach, much as does a hole made in the same tissue with a hypodermic needle. 
     In yet other embodiments the tissue engaging device can be a known clamping device. Examples of suitable endoscopic clamping devices are well known in the art, including, without limitation, endoscopic alligator grasping forceps, forked jaw grasping forceps, rat tooth grasping forceps, three-prong grasping forceps, tripod grasping forceps, fenestrated cup forceps, and ellipsoid fenestrated forceps. As used herein, each such endoscopic clamping device is considered to engage a single portion of tissue, i.e., all tissue contacted by the various jaws of a single clamping device is considered as a single point of tissue engagement. 
     In other preferred embodiments the tissue engaging device can be a novel suction device, as described below. Tissue is engaged when contacted with suction and released atraumatically when the suction is broken at a point other than the point of tissue engagement. 
     According to the above embodiments, the tissue engaging device can engage tissue for the purposes of side-to-side manipulation, twisting, pushing, or retracting tissue. In yet another embodiment a tissue engaging device may be the sharpened end of, for example, at least one leg of a surgical staple. According to this embodiment, the tissue engaging device can engage tissue for the purposes of side-to-side manipulation, twisting, or pushing, but not for retracting tissue. 
     In a preferred embodiment a tissue engaging device may be incorporated into a tissue manipulating device. In this embodiment, the elongate portion of the tissue engaging device is further structured to permit manipulation of tissue engaged by atraumatic grasping, suction, or piercing as above. In a most preferred embodiment, as discussed below, a novel single instrument incorporating both a tissue engaging and tissue manipulation device is structured to permit independent engagement of tissue at two or more points, and to permit manipulation of at least two points of tissue with respect to each other in any direction in three-dimensional space. The two or more independent points of tissue engagement typically are separated by at least 1 cm prior to tissue engagement. 
     In a preferred embodiment, an endoscopic tissue engaging device is advanced into lumen of first hollow organ, preferably via a lumen of second hollow organ. The first hollow organ is shown as a stomach and second hollow organ is shown as an esophagus in fluid communication with organ. The related portion of inner surface of first hollow organ is engaged with endoscopic tissue engaging device, which is described below. 
     In one preferred embodiment engaging is accomplished by gripping tissue with a known jawed forceps device. The device includes opposed jaws and/or having teeth or the like. The engaging force must be sufficient to maintain physical connection with the engaged portion of tissue when a tissue-deforming torque, push, or retraction is applied to the engaged tissue via the tissue engaging device, while at the same time the force distribution is sufficient to avoid piercing, tearing, or cutting the surface of the engaged portion. 
     In certain preferred embodiments of the invention the engagement involves simultaneous engagement of at least two distinct sites. This effect can be achieved by simultaneously applying at least two tissue engagement devices, e.g., two separate endoscopic forceps clamps, or applying a single tissue engagement device designed to engage tissue simultaneously at distinct sites. 
     Release of the engaged portion is necessary in order to remove the engaging device from the hollow organ of the subject after having engaged the tissue. The engaged portion typically will participate in the reconfigured portion; i.e., the reconfigured tissue will typically comprise in some aspect, be it at a basal, apical, or intermediate position relative to the reconfigured portion as a whole, the tissue actually engaged by the engaging device in the course of reconfiguring. 
     In a subsequent step of the invention, the engaged portion of inner surface of first hollow organ is manipulated to reconfigure at least a portion of first hollow organ. The inner surface of first organ is manipulated by device to create a reconfigured portion. In the manipulating step a physical force is applied by device to the engaged portion of tissue of inner surface effective for pushing, pulling, twisting, rolling, folding, gathering, or otherwise displacing tissue from its original position and/or configuration prior to application of such force. In preferred embodiments, tissue in adjacent continuity with the portion actually engaged will undergo at least some degree of physical deformation from its original conformation in proportion to the magnitude and direction of force applied to the engaged portion. Manipulation of engaged tissue may be used to create an invagination, an evagination, or a combination of invagination and evagination of at least inner layer of first hollow organ. 
     In one embodiment of this aspect of the invention, manipulation of the engaged portion of inner surface of first hollow organ is achieved by applying traction force or torquing force to create reconfigured portion, which is an invagination. Traction force can be linear, such as achieved by pulling. Alternatively, traction force can be nonlinear, such as can be achieved by winding engaging tissue onto a spool. 
     As used herein, “invaginated portion” or “invagination” refers to a region of tissue displaced toward the interior cavity of the hollow organ as a combined result of engaging and manipulating. The particular shape assumed by the invaginated portion will depend on factors including the geometry of the engaged portion, the anatomy of the engaged organ, the plasticity of the segment of the organ engaged, and the direction and magnitude of the force applied. 
     According to an embodiment of this aspect of the invention, manipulation can entail bringing into apposition at least two points of tissue which are independently engaged by at least one tissue engaging device. 
     According to yet another embodiment of this aspect of the invention, combinations of tissue invaginations are created. Thus for example a flap and a bulge can be created in combination. Other embodiments include, without limitation, at least two flaps; at least two bulges; at least two rolls; a roll and a bulge; etc. Combinations of tissue invaginations can be created essentially contemporaneously or consecutively. 
     According to yet another embodiment of this aspect of the invention, manipulation of the engaged portion of the inner surface of the first hollow organ can be achieved by applying a leading or pushing force so as to create, from within, an outward protrusion of the first hollow organ (not shown). According to this method reconfigured portion is an evagination rather than an invagination. An evaginated portion can assume any of a number of shapes as viewed from the exterior of the hollow organ, including, without limitation, a bulge, a lump, a ridge, a flap, a fold, a tube, a horn, and a cone. As also viewed from the exterior of the hollow organ, a tissue evagination can be smooth, dimpled, or furrowed. The circumference at its base can be irregular or it can be substantially regular, e.g., substantially elliptical, substantially circular, substantially triangular, or substantially rectangular. The method also contemplates the formation of a plurality of evaginations, which may be created either simultaneously or sequentially. At least one evagination can be combined with at least one invagination. 
     In some embodiments reconfigured portion involves just the inner lining of the first hollow organ. For example reconfigured portion can involve only the mucosa in a stomach. In other embodiments reconfigured portion can involve the inner lining and at least one additional tissue layer of first hollow organ. Again with reference to the stomach, the reconfigured portion can involve the mucosa and at least one layer of muscular wall, up to and including the full thickness of the stomach wall. 
     After the manipulating step, a subsequent step involves permanently securing the reconfigured portion of the first hollow organ to effect a substantially permanent retention of the shape of the reconfigured portion. While the reconfigured portion of the organ is maintained under control of the operator through the manipulating force applied to the engaged portion of tissue via the tissue engaging device, the operator causes a distal effector end of a tissue securing device to come into contact with the reconfigured portion. The distal effector end of the tissue securing device includes at least one biocompatible tissue fixation device and is structured for application of at least one biocompatible tissue fixation device into the reconfigured portion. The tissue securing device is advanced into the lumen of the first hollow organ before, along with, or after the tissue engaging device; thereafter, the tissue securing device is actuated to apply at least one biocompatible tissue fixation device to permanently secure or fix the shape of reconfigured portion. 
     The tissue securing device in some embodiments can be a separate instrument unto itself. In other embodiments the tissue securing device can be used in combination with another endoscopic instrument. In yet other embodiments the tissue securing device can be an element of a combination endoscopic instrument. In a preferred embodiment, the tissue securing device is an element of an endoscopic tissue shaping instrument which also incorporates a tissue engaging device. 
     In certain embodiments, the tissue fixation device penetrates only an internal layer of first hollow organ. The internal layer can be, for example, the mucosa lining the interior of the stomach. Alternatively, the tissue fixation device penetrates both internal and at least one additional layer of first hollow organ. The at least one additional layer can be, for example, a muscle layer of the stomach wall. The combined inner layer and at least one additional layer constitute either a partial-thickness layer or a full-thickness layer. The securing step of this method includes, for example, fixation of an inner layer to a partial-thickness layer. This step also includes, for example, fixation of an inner layer to a full-thickness layer. In certain other methods, in the securing step, the tissue fixation device penetrates (1) a partial-thickness layer and (2) a full-thickness layer, or two full-thickness layers of the first hollow organ  10 . This latter securing step fixes, for example, a full-thickness invagination in which two or more distinct regions of the exterior surface of the first hollow organ are brought into apposition (not shown). 
     Bench testing was conducted using an excised pig stomach and attached esophagus to demonstrate the principle of creating a bulge to prevent gastroesophageal reflux. The duodenum was clamped, an incision was made in the greater curvature of the stomach, and the stomach was inverted and filled with water. Water was observed to flow under the force of gravity from the stomach to the esophagus in a steady stream. A bulge was made in the wall of the stomach within one inch of the opening of the esophagus into the stomach. The bulge was fixed in place with a staple. The stomach was then refilled with water. No water was observed to flow under the force of gravity from the stomach to the esophagus following this procedure. A one-half inch diameter cylinder was passed through the esophagus and opening of the esophagus into the stomach both before and after creation of the bulge, indicating that the bulge did not close the lumen of the opening of the esophagus into the stomach. 
     The device consists of an instrument  10  with a proximal end (not shown), a shaft  12 , a retroflexing portion  14 , and a distal end effector  15  including movable arms  16 , a retractor  20 , and an implant  22 . The function of the instrument is controlled by the user by controls at the proximal end, as is disclosed in the referenced patent applications. The device and method of the present invention will be illustrated using the accompanying drawings. 
       FIG. 1  shows the instrument  10  in place in the esophagus  30  and the stomach  32 . The instrument is in a straight configuration, which is the configuration in which it is inserted into the esophagus and stomach  FIG. 2  shows the instrument  10  in place in the esophagus  30  and the stomach  32 , with the instrument  10  in a retroflexed position. Retroflexion of retroflexing portion  14  is accomplished as disclosed in the referenced patent applications. In this position, the distal end of the movable arms  16  of distal end effector  15  is located near the junction  34  of the esophagus  30  and the stomach  32 . 
       FIG. 3  shows the instrument  10  in place in the esophagus  30  and the stomach  32 , with the instrument  10  in a retroflexed position and the movable arms  16  in an open position revealing a portion  18  of an implant  22  ( FIG. 7 ). It is important to note that the moveable arms  16  are oriented relative to the retroflexing portion  14  to grasp the tissue at the junction  34  of the esophagus  30  and the stomach  32 . The movable arms  16  open and close in the same plane within which the retroflexing portion  14  moves. The actuating mechanism used to open movable arms  16  is substantially the same as the mechanisms used to actuate the medical instruments described in the U.S. patent application Ser. No. 09/859,579, entitled “TISSUE RECONFIGURATION,” filed 18 May 2001, with the movable arms rotated 90.degree. with respect to the configuration of the published application such that the arms  16  open and close in the same plane within which the retroflexing portion  14  moves. 
       FIG. 4  shows the instrument  10  in place in the esophagus  30  and the stomach  32 , with the instrument  10  in a retroflexed position, the movable arms  16  in an open position, and the retractor  20  engaged with the tissue at or near the junction  34  of the esophagus  30  and the stomach  32 . Engagement of the retractor  20  with the tissue at or near the junction  34  is accomplished as is disclosed in the referenced patent applications. 
       FIG. 5  shows the instrument  10  in place in the esophagus  30  and the stomach  32 , with the instrument  10  in a retroflexed position, the movable arms  16  in an open position, and the retractor  20  retracting the tissue at or near the junction  34  of the esophagus  30  and the stomach  32  into the space between the movable arms  16 . 
       FIG. 6  shows the instrument  10  in place in the esophagus  30  and the stomach  32 , with the instrument  10  in a retroflexed position, and the movable arms  16  closed, to create a fold  36  of tissue at or near the junction  34  of the esophagus  30  and the stomach  32 . The mechanism to close movable arms is as is disclosed in the referenced patent applications. 
       FIG. 7  shows the instrument  10  in place in the esophagus  36  and the stomach  32 , with the instrument  10  in a retroflexed position, and the movable arms  16  opened. An implant  22  has been placed through the tissue to maintain fixation of the tissue fold  36 . Placement of the implant is accomplished as is disclosed in the referenced patent applications. 
       FIG. 8  shows the instrument  10  in place in the esophagus  30  and the stomach  32 , with the instrument  10  in a straight position, and the movable arms  16  closed. The tissue fold  36  is shown, fixated by implant  22 . The instrument  10  is in position for removal from the patient. 
     This invention provides a device and method which can be used to treat GERD by creating and fixating a fold of tissue at or near the junction of the esophagus and the stomach, thereby fixating the wall of the stomach to the wall of the esophagus. This invention allows this fold to be created and fixated via a completely endoluminal technique. 
     In another aspect of the invention, more than one fold is created in the tissue at or near the junction of the esophagus and the stomach. 
     In another aspect of the invention, the movable arms are attached to the retroflexing portion in a manner that allows the operator to rotate the position of the movable arms relative to the retroflexing portion about the center axis of the movable arms, thus allowing the operator to vary the orientation of the tissue fold. 
     While the invention has been described in detail with reference to the preferred embodiments thereof, it will be apparent to one skilled in the art that various changes and modifications can be made and equivalents employed, without departing from the present invention. For example, in the embodiment described above in conjunction with  FIGS. 1-8 , the moveable arms open and close in the same plane within which the retroflexing portion moves. However, it is appreciated that the plane in which the moveable arms open and close relative to the retroflexing portion can be at other orientations including angles between the same plane (i.e., 0.degree.) and a plane transverse (i.e., 90.degree.) to the plane within which the retroflexing portion moves. Indeed, in certain embodiments, the medical instrument can include a mechanism for allowing the user to adjust the angle of the moveable arms relative to the retroflexing portion.