Abstract:
Apparatus for reconfiguring tissue, the apparatus comprising a shaft having a distal end and a proximal end; at least one effector mechanism movably mounted to the distal end of the shaft, each effector mechanism comprising at least one gripping element for gripping tissue to that effector mechanism, the at least one effector mechanism being configured to capture the gripped tissue against said shaft, at least one actuating mechanism mounted to the proximal end of the shaft, and at least one connection mechanism connecting the at least one actuating mechanism to the at least one effector mechanism, whereby a user may utilize the at least one actuating mechanism to actuate the at least one effector mechanism so as to reconfigure tissue.

Description:
REFERENCE TO PENDING PRIOR PATENT APPLICATIONS  
       [0001]    This patent application claims benefit of:  
         [0002]    (1) pending prior U.S. Provisional Patent Application Serial No. 60/429,568, filed Nov. 11, 2002 by John R. Liddicoat et al. for TISSUE MANIPULATING METHODS AND DEVICES (Attorney&#39;s Docket No. LIDDICOHN-1 PROV);  
         [0003]    (2) pending prior U.S. Provisional Patent Application Serial No. 60/453,294, filed Mar. 11, 2003 by John R. Liddicoat et al. for TISSUE MANIPULATING METHODS AND DEVICES (Attorney&#39;s Docket No. LIDDICOHN-2 PROV); and  
         [0004]    (3) pending prior U.S. Provisional Patent Application Serial No. 60/458,128, filed Mar. 27, 2003 by John R. Liddicoat et al. for TISSUE MANIPULATING METHODS AND DEVICES (Attorney&#39;s Docket No. LIDDICOHN-3 PROV).  
         [0005]    The three above-identified patent applications are hereby incorporated herein by reference.  
     
    
     
       FIELD OF THE INVENTION  
         [0006]    This invention relates to medical apparatus and methods in general, and more particularly to medical apparatus and methods for manipulating tissue.  
         BACKGROUND OF THE INVENTION  
         [0007]    Gastroesophageal reflux disease (GERD) is the most common gastrointestinal problem in humans. GERD occurs when the esophageal exposure to acid from the stomach is greater than that of the normal population. GERD may be a result from a defect in the stomach, the esophageal sphincter, or the esophagus. Heartburn is the most common symptom. GERD can result in complications such as esophagitis, esophageal ulceration, esophageal stricture, esophageal metaplasia (i.e., Barrett&#39;s esophagus) and short esophagus syndrome. Currently, patients with GERD are treated with both medicine and/or surgery. The goal of the treatment options is to decrease the esophageal exposure to the stomach acid.  
           [0008]    One possible way to treat GERD may be to alter the configuration of the esophagus and/or stomach. Thus, it would be beneficial to provide a novel apparatus and method for manipulating the esophagus and/or stomach so as to alter the configuration of the esophagus and/or stomach and thereby treat GERD.  
           [0009]    Severe obesity is associated with a large number of health-related problems. Several of these problems are underlying causes of earlier mortality for obesity. Obesity may be treated with mechanical interventions including surgical procedures.  
           [0010]    One possible way to treat obesity may be to manipulate the tissues of the gastrointestinal tract to alter the size and/or shape of the stomach. Thus, it would be advantageous to provide a novel apparatus and method for manipulating the tissues of the gastrointestinal tract so as to alter the size and/or shape of the stomach and thereby treat obesity.  
           [0011]    Still other medical disorders may be treated by manipulating tissue in selected ways, e.g., such as by bringing opposite walls of a tube of tissue into proximity with one another, or for creating a cylinder or tube of tissue wrapped partially or entirely by an outer layer of tissue, etc. Thus, it would be advantageous to provide a novel apparatus and method for manipulating tissue so as to achieve a desired shape.  
         SUMMARY OF THE INVENTION  
         [0012]    The present invention provides a novel apparatus and method for manipulating tissue so as to provide a therapeutic benefit.  
           [0013]    In one form of the invention, there is provided an apparatus for reconfiguring tissue, said apparatus comprising:  
           [0014]    a shaft having a distal end and a proximal end;  
           [0015]    at least one effector mechanism movably mounted to said distal end of said shaft, each said effector mechanism comprising at least one gripping element for gripping tissue to that effector mechanism, said at least one effector mechanism being configured to capture the gripped tissue against said shaft;  
           [0016]    at least one actuating mechanism mounted to said proximal end of said shaft; and  
           [0017]    at least one connection mechanism connecting said at least one actuating mechanism to said at least one effector mechanism, whereby a user may utilize said at least one actuating mechanism to actuate said at least one effector mechanism so as to reconfigure tissue.  
           [0018]    In another form of the invention, there is provided an apparatus for reconfiguring tissue, said apparatus comprising:  
           [0019]    a shaft having a distal end and a proximal end, wherein said distal end of said shaft comprises at least one gripping element for drawing tissue against said shaft and for selectively maintaining the tissue in such engagement;  
           [0020]    two effector mechanisms movably mounted to said distal end of said shaft, each said effector mechanism comprising at least one gripping element for gripping tissue to that effector mechanism, said two effector mechanisms being configured to capture the gripped tissue against said shaft, wherein said distal end of said shaft comprises a longitudinal axis, wherein said two effector mechanisms are pivotally mounted to said shaft along a pivot axis extending parallel to said longitudinal axis of said distal end of said shaft, wherein said two effector mechanisms are configured to move between (i) a closed position wherein said two effector mechanisms fold concentrically about said distal end of said shaft, and (ii) an open position wherein said two effector mechanisms rise like wings over said shaft, and wherein said at least one gripping element comprises a suction pod for drawing tissue against the effector mechanism and for maintaining the tissue in such engagement while suction is maintained;  
           [0021]    at least one actuating mechanism mounted to said proximal end of said shaft; and  
           [0022]    at least one connection mechanism connecting said at least one actuating mechanism to said two effector mechanisms, whereby a user may utilize said at least one actuating mechanism to actuate said two effector mechanisms so as to reconfigure tissue.  
           [0023]    In another form of the invention, there is-provided an apparatus for reconfiguring tissue, said apparatus comprising:  
           [0024]    a shaft having a distal end and a proximal end, wherein said distal end of said shaft comprises at least one gripping element for drawing tissue against said shaft and for maintaining the tissue in such engagement while suction is maintained;  
           [0025]    an effector mechanism movably mounted to said distal end of said shaft, said effector mechanism comprising at least one gripping element for gripping tissue to that effector mechanism, said effector mechanism being configured to capture the gripped tissue against said shaft, wherein said distal end of said shaft comprises a longitudinal axis, wherein said effector mechanism is pivotally mounted to said shaft along a pivot axis extending transverse to said longitudinal axis of said distal end of said shaft, wherein said effector mechanism is configured to move between (i) a closed position wherein said effector mechanism folds concentrically about said distal end of said shaft, and (ii) an open position wherein said effector mechanism rises over said shaft, and wherein said at least one griping element comprises a suction pod for drawing tissue against the effector mechanism and for maintaining tissue in such engagement while suction is maintained;  
           [0026]    at least one actuating mechanism mounted to said proximal end of said shaft; and  
           [0027]    at least one connection mechanism connecting said at least one actuating mechanism to said effector mechanism, whereby a user may utilize said at least one actuating mechanism to actuate said effector mechanism so as to reconfigure tissue.  
           [0028]    In another form of the invention, there is provided an apparatus for reconfiguring tissue, said apparatus comprising:  
           [0029]    a shaft having a distal end and a proximal end;  
           [0030]    a plurality of effector mechanisms mounted to said distal end of said shaft, each said effector mechanism comprising at least one gripping element for gripping tissue to that effector mechanism, said plurality of effector mechanisms being configured to capture the gripped tissue against said shaft, wherein said distal end of said shaft comprises a longitudinal axis, wherein said plurality of effector mechanisms extend parallel to said longitudinal axis of said distal end of said shaft, wherein said plurality of effector mechanisms are configured to move between (i) a first position wherein said plurality of effector mechanisms collectively form a tubular configuration, and (ii) a second position wherein said plurality of effector mechanisms collectively form a non-tubular configuration, and wherein said at least one gripping element comprises a suction pod for drawing tissue against the effector mechanism and for maintaining the tissue in such engagement while suction is maintained;  
           [0031]    at least one actuating mechanism mounted to said proximal end of said shaft; and  
           [0032]    at least one connection mechanism connecting said at least one actuating mechanism to said plurality of effector mechanisms, whereby a user may utilize said at least one actuating mechanism to actuate said plurality of effector mechanisms so as to reconfigure tissue.  
           [0033]    In another form of the invention, there is provided a method for reconfiguring tissue, said method comprising:  
           [0034]    providing apparatus comprising:  
           [0035]    a shaft having a distal end and a proximal end, wherein said distal end of said shaft comprises at least one gripping element for drawing tissue against said shaft and for selectively maintaining the tissue in such engagement;  
           [0036]    two effector mechanisms movably mounted to said distal end of said shaft, each said effector mechanism comprising at least one gripping element for gripping tissue to that effector mechanism, said two effector mechanisms being configured to capture the gripped tissue against said shaft, wherein said distal end of said shaft comprises a longitudinal axis, wherein said two effector mechanisms are pivotally mounted to said shaft along a pivot axis extending parallel to said longitudinal axis of said distal end of said shaft, wherein said two effector mechanisms are configured to move between (i) a closed position wherein said two effector mechanisms fold concentrically about said distal end of said shaft, and (ii) an open position wherein said two effector mechanisms rise like wings over said shaft, and wherein said at least one gripping element comprises a suction pod for drawing tissue against the effector mechanism and for maintaining the tissue in such engagement while suction is maintained;  
           [0037]    at least one actuating mechanism mounted to said proximal end of said shaft; and  
           [0038]    at least one connection mechanism connecting said at least one actuating mechanism to said two effector mechanisms, whereby a user may utilize said at least one actuating mechanism to actuate said two effector mechanisms so as to reconfigure tissue;  
           [0039]    positioning said two effector mechanisms in said closed position;  
           [0040]    advancing said apparatus so that said distal end of said shaft is positioned adjacent tissue to be reconfigured;  
           [0041]    positioning said two effector mechanisms in said open position;  
           [0042]    gripping tissue against said distal end of said shaft and against said two effector mechanisms; and  
           [0043]    positioning said two effector mechanisms in said closed position so as to reconfigure the gripped tissue and capture that tissue against said shaft.  
           [0044]    In another form of the invention, there is provided a method for reconfiguring tissue, said method comprising:  
           [0045]    providing apparatus comprising:  
           [0046]    a shaft having a distal end and a proximal end, wherein said distal end of said shaft comprises at least one gripping element for drawing tissue against said shaft and for maintaining the tissue in such engagement while suction is maintained;  
           [0047]    an effector mechanism movably mounted to said distal end of said shaft, said effector mechanism comprising at least one gripping element for gripping tissue to that effector mechanism, said effector mechanism being configured to capture the gripped tissue against said shaft, wherein said distal end of said shaft comprises a longitudinal axis, wherein said effector mechanism is pivotally mounted to said shaft along a pivot axis extending transverse to said longitudinal axis of said distal end of said shaft, wherein said effector mechanism is configured to move between (i) a closed position wherein said effector mechanism folds concentrically about said distal end of said shaft, and (ii) an open position wherein said effector mechanism rises over said shaft, and wherein said at least one griping element comprises a suction pod for drawing tissue against the effector mechanism and for maintaining tissue in such engagement while suction is maintained;  
           [0048]    at least one actuating mechanism mounted to said proximal end of said shaft; and  
           [0049]    at least one connection mechanism connecting said at least one actuating mechanism to said effector mechanism, whereby a user may utilize said at least one actuating mechanism to actuate said effector mechanism so as to reconfigure tissue;  
           [0050]    positioning said effector mechanism in said closed position;  
           [0051]    advancing said apparatus so that said distal end of said shaft is positioned adjacent tissue to be reconfigured;  
           [0052]    positioning said effector mechanism in said open position;  
           [0053]    gripping tissue against said distal end of said shaft and against said effector mechanism; and  
           [0054]    positioning said effector mechanism in said closed position so as to reconfigure the gripped tissue and capture that tissue against said shaft.  
           [0055]    In another form of the invention, there is provided a method for reconfiguring tissue, said method comprising:  
           [0056]    providing apparatus comprising:  
           [0057]    a shaft having a distal end and a proximal end;  
           [0058]    a plurality of effector mechanisms mounted to said distal end of said shaft, each said effector mechanism comprising at least one gripping element for gripping tissue to that effector mechanism, said plurality of effector mechanisms being configured to capture the gripped tissue against said shaft, wherein said distal end of said shaft comprises a longitudinal axis, wherein said plurality of effector mechanisms extend parallel to said longitudinal axis of said distal end of said shaft, wherein said plurality of effector mechanisms are configured to move between (i) a first position wherein said plurality of effector mechanisms collectively form a tubular configuration, and (ii) a second position wherein said plurality of effector mechanisms collectively form a non- tubular configuration, and wherein said at least one gripping element comprises a suction pod for drawing tissue against the effector mechanism and for maintaining the tissue in such engagement while suction is maintained;  
           [0059]    at least one actuating mechanism mounted to said proximal end of said shaft; and  
           [0060]    at least one connection mechanism connecting said at least one actuating mechanism to said plurality of effector mechanisms, whereby a user may utilize said at least one actuating mechanism to actuate said plurality of effector mechanisms so as to reconfigure tissue;  
           [0061]    positioning said effector mechanisms in said first position;  
           [0062]    advancing said apparatus so that said distal end of said shaft is positioned adjacent tissue to be reconfigured;  
           [0063]    gripping tissue against said distal end of said shaft and against said effector mechanisms; and  
           [0064]    positioning said effector mechanisms in said second position so as to reconfigure the gripped tissue and capture that tissue against said shaft.  
           [0065]    In another form of the invention, there is provided a method for treating GERD, comprising:  
           [0066]    creating a neoesophagus that extends into the abdomen. 
       
    
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       [0067]    These and other objects and features of the present inventions will be more fully disclosed or rendered obvious by the following detailed description of the preferred embodiments of the invention, which is to be considered together with the accompanying drawings wherein like numbers refer to like parts and further wherein:  
         [0068]    [0068]FIGS. 1-4 are a series of schematic views showing a first preferred embodiment of the present invention;  
         [0069]    [0069]FIGS. 5-10 are a series of schematic views showing the apparatus of FIGS. 1-4 being used in a procedure to treat GERD;  
         [0070]    [0070]FIGS. 11 and 12 are schematic views showing an alternative form of the procedure shown in FIGS. 5-10;  
         [0071]    [0071]FIGS. 13-18 are a series of schematic views showing a second preferred embodiment of the present invention;  
         [0072]    [0072]FIGS. 19-22 are a series of schematic views showing the apparatus of FIGS. 13-18 being used in a medical procedure;  
         [0073]    [0073]FIGS. 23 and 24 are schematic views showing alternative forms of the procedure shown in FIGS. 19-22; and  
         [0074]    [0074]FIGS. 25-31 are a series of schematic views showing a third preferred form of the present invention. 
     
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT  
     General Description  
       [0075]    The present invention relates to apparatus and methods for manipulating tissue. This invention can be used to manipulate tissue so as to create many different shapes and configurations. For example, in one form of the invention, apparatus is provided which can be used to bring opposite walls of a hollow organ or viscus into close apposition such that they form a tube of tissue, and/or apparatus is provided which can be used to create a cylinder or tube of tissue wrapped partially or entirely by an out-pouching of the same hollow viscus. More particularly, in one form of the present invention, apparatus is provided that can be used to create an inner tube of stomach or esophagus wrapped by a pouch of stomach, and/or apparatus is provided which can be used to create a tube of stomach in continuity with the esophagus, whereby to essentially create a neoesophagus which may be wrapped partially or entirely by an outer pouch of the stomach, the lumen of which is in continuity with the main lumen of the stomach, esophagus, and neoesophagus.  
         [0076]    The present invention comprises multiple components which may be used alone, together, or in various combinations. The present invention may provide stabilizing means (such as suction, pins, barbs, hooks, adhesive, glue, magnets, etc.) to effect conformational changes in tissue configurations, and fixation means (such as staples, pins, barbs, hooks, adhesive, glue, magnets, etc.) to secure the tissue in such configuration after the stabilizing means are withdrawn.  
         [0077]    In one aspect of the invention, novel apparatus may be used to treat disease states. One of these disease states is GERD. Another of these disease states is obesity. Hereinafter, various embodiments of the invention will sometimes be discussed in the context of these two disease states, i.e., GERD and obesity. However, it is to be appreciated that this is intended to be by way of example and not limitation, and that the present invention may be applied to the treatment of other disease states as well.  
         [0078]    In one preferred embodiment of the present invention, the apparatus comprises a flexible tube with effector mechanisms on the distal end and actuating mechanisms on the proximal end. If desired, other devices (including but not limited to endoscopes, cables, pulleys, staplers, magnets, other tubes, devices for conveying a variety of energy sources, tubes for delivering adhesives and glues, etc.) may be passed through the lumen of the flexible tube. In addition to the foregoing, the walls of the tube may also have one or more additional lumens through which one or more devices may be passed.  
         [0079]    The effector mechanisms may be used to grasp tissue to assist in manipulating that tissue. The effector mechanisms may take any form that will grip the tissue, such as suction, one or more hooks, one or more staples, glue, magnets, etc. For purposes of illustration but not limitation, the preferred embodiments disclosed herein utilize suction to grasp the tissue.  
         [0080]    In one preferred form of effector mechanism, the suction is applied to the tissue through pods. These pods are mounted on the distal end of the flexible tube. The pods may comprise any shape or configuration consistent with the application intended. By way of example but not limitation, in the preferred embodiments disclosed herein, the pods comprise a low-profile curvilinear box with one or more holes formed therein. The side of the box with the one or more holes contacts the tissue. Another side of the box has one or more ports to which suction is applied. Suction can be applied to the port through one or more small conduits which run inside, outside, or in the sidewall of the flexible tube. Suction can be applied to the conduits by any means capable of generating satisfactory suction (e.g., a suction pump). By way of example but not limitation, in the preferred embodiments disclosed herein, the suction conduits run inside the sidewall of the flexible tube. The distal ends of the conduits are connected to the pods, and the proximal ends of the conduits are connected to the suction source.  
         [0081]    The actuating mechanisms are disposed at least in part on the proximal end of the flexible tube. The actuating mechanisms are used to effect movement of the effector mechanisms which engage and manipulate the tissue. The actuating mechanisms may move the effector mechanisms by any of the various means well known in the art including, but not limited to, cables, cogs, motor systems, remote wireless systems, etc. By way of example but not limitation, in the preferred embodiments disclosed herein, cables are used to move the effector mechanisms. More particularly, the effector mechanisms are connected to a series of cables that run within the flexible tube. These cables run the length of the tube, from the distal end to the proximal end. This allows a doctor to manipulate the effector mechanisms at distal end of the device by turning or pulling and releasing the cables on the proximal end of the device.  
         [0082]    The flexible tube itself can be directly maneuvered by the doctor, or the flexible tube can be mounted on another instrument (e.g., an endoscope) and passively steered by maneuvering of that other instrument.  
         [0083]    In one preferred form of the invention, the apparatus may comprise a visualization unit to assist in appropriately directing the apparatus. This visualization unit may be an integral component of the system, similar to a flexible endoscope or ultrasound probe or wireless video transmitter, etc. Alternatively, the visualization unit may be independent of the system, e.g., it may comprise a CT or MRI machine. Alternatively, the present invention could be employed without visual aid. By way of example but not limitation, in the preferred embodiments disclosed herein, an endoscope is used to assist in visualization, with the endoscope passing through the central lumen of the flexible tube.  
         [0084]    Once the effector mechanisms have manipulated the tissue into proper position, the tissue can be held in position by various types of fixation mechanisms including, but not limited to, staples, sutures, magnets, glue, etc. By way of example but not limitation, in several of the preferred embodiments disclosed herein, staples are located in the flexible tube, and the effector mechanisms can act as anvils for the staples. These staples may be actuated by actuating mechanisms (e.g., cables) similar to those used to manipulate the effector mechanisms.  
         [0085]    Furthermore, once the tube or fold of tissue has been formed and secured by one of the fixation mechanisms, it may be desirable to fold additional tissue around the tube. This additional tissue can be held around the underlying tube or fold of tissue by various mechanisms including, but not limited to, staples, magnets, sutures, glue, etc.  
         [0086]    As noted above, in some cases it may be desirable to create tubes or folds of tissue of varying sizes and shapes. One way to do this is by providing the aforementioned effector mechanisms at the distal end of the flexible tube. Another way to do this is to form at least the distal end of the tube out of a sufficiently flexible material that it can be reshaped into a desired configuration. By way of example but not limitation, the distal end of the tube could be formed out of a balloon-like material that can be inflated to a desired size and shape, whereby the tissue can be manipulated as needed.  
         [0087]    As noted above, GERD is the most common gastrointestinal problem in humans, and may be treated by altering the configuration of the esophagus and/or stomach. The present invention comprises a novel apparatus and method for manipulating the esophagus and/or stomach so as to alter the configuration of the esophagus and/or stomach and thereby treat GERD.  
         [0088]    Furthermore, severe obesity is associated with a large number of health related problems, and may be treated by manipulating the tissues of the gastrointestinal tract to alter the size and/or shape of the stomach. The present invention provides a novel apparatus and method for manipulating the tissues of the gastrointestinal tract so as to alter the size and/or shape of the stomach and thereby treat obesity.  
       First Preferred Embodiment  
       [0089]    Looking now at FIGS. 1-4, in a first preferred embodiment of the present invention, an apparatus  5  comprises a flexible tube  10  having an outer surface  15  and an inner lumen  20 . Various devices (e.g., working tools, scopes, etc.) can pass through inner lumen  20 . Pods  25  (shown in FIGS. 3 and 4 but omitted from the remaining drawings for purposes of clarity) are provided in the outer surface  15  of flexible tube  10 , whereby tissue may be drawn to the outer surface  15  of flexible tube  10 . Conduits  30  (shown in FIGS. 3 and 4 but omitted from the remaining drawings for purposes of clarity) are formed in the side wall of flexible tube  10  and supply suction to pods  25 .  
         [0090]    Effector mechanisms  35  are configured to concentrically close about flexible tube  10 . Preferably, effector mechanisms  35  are pivotally mounted to flexible tube  10  by a mount  40 , with actuating mechanism  45  (preferably including a flexible tube  50 ) being used to position flexible tube  10  and effector mechanisms  35  relative to the tissue, and to open and close effector mechanisms  35  relative to flexible tube  10 . Preferably pods  25  (shown in FIGS. 3 and 4 but omitted from the remaining drawings for purposes of clarity) are also provided on the interior walls of effector mechanisms  35 . Conduits  30  (shown in FIGS. 3 and 4 but omitted from the remaining drawings for purposes of clarity) may be provided in the interior walls of effector mechanisms  35  and extend out through flexible tube  50  for connection to a vacuum source.  
         [0091]    Fixation mechanisms in the form of staples  55  (FIGS. 2 and 4) are preferably provided in the sidewall of flexible tube  10 . Actuating mechanisms of the sort well known in the art (not shown) may be provided to drive staples  55  radially outward from flexible tube  10 ; when effector mechanisms  35  are closed down concentrically around flexible tube  10  (FIGS. 1 and 2), the effector mechanisms can serve as anvils to bend the staples closed.  
         [0092]    Apparatus  5  can be used to gather and fold tissue into a tube configuration, e.g., for treatment of GERD. More particularly, with effector mechanisms  35  in a closed position (e.g., FIGS. 1 and 2), apparatus  5  is advanced down the esophagus and into the stomach. Next, and looking now at FIG. 5, effector mechanisms  35  are brought to the open position in the main body of the stomach. Then apparatus  5  is brought up to the angle of the stomach near the gastroesophageal junction (FIGS. 6 and 7). Next, suction is applied to pods  25  (FIG. 8), thereby bringing tissue into proximity with outer surface of flexible tube  10  and the underside of effector wings  35 . It will be appreciated that, as this occurs, the tissue brought into proximity with the outer surface of flexible tube  10  will essentially form a neoesophagus. Then, effector wings  35  are brought to the closed position (FIG. 9). In so doing, the anterior and posterior pouches of stomach are folded around the outer wall of the neoesophagus. Staples  55  may then be activated so as to hold the walls of the tube of tissue TT together and secure the wrapped pouches in place, and the apparatus  5  removed (FIG. 10). In this way, a tube of tissue TT, having a lumen TL, can be created that is surrounded by pouches of stomach that are in luminal continuity with the main lumen of the stomach. In the context of the GERD therapy, it will be appreciated that this tube is effectively a wrapped neoesophagus which may minimize gastroesophageal reflux.  
         [0093]    Significantly, the novel apparatus and method may be used to create a tube of esophagus (e.g., neoesophagus) that may extend into the abdomen. This tube of esophagus may then be surrounded in part or completely by the stomach (i.e., the wrap). This neoesophagus may prevent reflux because the lengthening of the esophagus has caused it to be in the abdominal cavity and is thus under positive pressure. This positive pressure may cause the neoesophagus to collapse, thereby preventing reflux. This neoesophagus may also prevent reflux because it is wrapped by the stomach in such a way that the lumen of the wrap of stomach may exert a collapsible force on the esophagus and/or neoesophagus as it distends, thereby preventing reflux.  
         [0094]    It should be appreciated that the wrap effected by apparatus  5  may be of various circumferential degree. Thus, for example, FIG. 10 depicts a wrap of approximately  270  degrees, however, this wrap could be anywhere up to 360 degrees.  
         [0095]    Furthermore, it should also be appreciated that, for various applications, it may be important to provide a fluidtight tube of tissue TT. Thus, for example, where the apparatus  5  is to create a wrapped neoesophagus to treat GERD, it can be important to provide a fluidtight tube of tissue TT. To this end, and looking now at FIG. 11, it may be beneficial to provide a fluidtight material  65  on the underside of effector wings  35 , so that the fluidtight material  65  may be applied to outer wall of the tube of tissue TT created by apparatus  5 . Staples (fired outwardly from flexible tube  10 ) may serve to hold the fluidtight material  65  to the outside surface of the tube of tissue TT. Alternatively, stapling mechanisms of the sort well known in the art (not shown) may be provided on the underside of effector wings  35 , whereby the staples  70  (using the outside wall of flexible tube  10  as an anvil) may secure the fluidtight material  65  to the outer wall of the tube of tissue TT. See FIG. 12.  
         [0096]    It should also be appreciated that, if desired, flexible tube  10  and effector mechanisms  35  may omit suction pods or other tissue gripping mechanisms, and the stomach tissue may be wrapped around the neoesophagus by using appropriate apparatus geometry moving about the neoesophageal fixation line. This may be facilitated by vacuum evacuation of the stomach contents to bring the stomach walls into contact with the effector arms.  
       Second Preferred Embodiment  
       [0097]    Looking now at FIGS. 13-18, in a second preferred embodiment of the present invention, an apparatus  105  comprises a flexible shaft  110  with an actuator end  115  and an effector end  120 . The effector end  120  has one or more effector mechanisms  125 . The distal end of the device has a hollow tube  130  with a central lumen  135  (FIGS. 14 and 16). Objects such as a working instrument, endoscope, etc. can pass through the central lumen  135 .  
         [0098]    Effector mechanism  125  is adapted to open and close about an end pivot  140 . A septum  145  has one portion anchored to effector mechanism  125  and another portion anchored to hollow tube  130 . In one preferred construction, septum  145  enters the interior of effector mechanism  125  via a slot  150  (FIG. 16), and septum  145  enters the side wall of hollow cylinder  130  via a slot  155 . The top portion of hollow tube  130 , the underside of effector mechanism  125  and/or the septum  145  have suction pods  160  disposed therein, with suction being supplied to the suction pods  160  via flexible shaft  110 . In this way, effector mechanism  125  can be opened relative to hollow tube  130 , suction applied to draw tissue against effector mechanism  125 , hollow tube  130  and/or septum  145 , and then effector mechanisms  125  closed so as to reconfigure the tissue. Preferably the underside of effector mechanism  125  includes a plurality of staples  165  which can be fired out of the bottom of effector mechanism  125  by stapling mechanisms of the sort well known in the art (not shown).  
         [0099]    Apparatus  105  can be used in various ways to therapeutically reconfigure tissue. By way of example but not limitation, and looking now at FIGS. 19-22, apparatus  105  has its effector mechanism  125  placed into its closed position (FIGS. 13 and 14), the distal end of apparatus  105  is positioned between two opposing walls of tissue T, and effector mechanism  125  is opened (FIG. 19). Next, suction is applied so as to cause the tissue T to be drawn against effector mechanism  125 , hollow tube  130  and/or septum  145  (FIG. 20). Then effector mechanism  125  is closed and staples  165  set (using the outer surface of hollow tube  130  as an anvil). See FIG. 21. Thereafter effector mechanism  125  is opened so as to release the tissue, and the apparatus withdrawn, leaving the tissue in the reconfigured arrangement shown in FIG. 22.  
         [0100]    If desired, the staple  165  may be supported by one (FIG. 23) or two (FIG. 24) pieces of material  170 , with the material being carried into position by effector mechanism  125  (in the example shown in FIG. 23) or by effector mechanism  125  and hollow tube  130  (in the example shown in FIG. 24).  
       Third Preferred Embodiment  
       [0101]    Looking now at FIGS. 25-29, in a third preferred embodiment of the present invention, an apparatus  205  comprises a flexible tube  210  with an outer surface  215 , an inner surface  220  and a central lumen  225 . The sidewall  230  of flexible tube  210  may be solid, and/or the sidewall  230  of flexible tube  210  may be hollow through which other devices such as suction tubes, cables, wires, etc. may run.  
         [0102]    Apparatus  205  includes an effector end  235  and an actuator end  240 . The effector end  235  comprises a plurality of effector mechanisms  245 . The effector mechanisms  245  can be parallel to but otherwise independent of one another (e.g., as a series of independent elements collectively forming the distal end of hollow tube  210 ) or one or more of the effector mechanisms  245  can be connected to one another (e.g., so as to form a slotted tube configuration, such as that shown in FIGS. 25, 28 and  29 ). Each of the effector mechanisms  245  is provided with one or more suction pods  250  (only shown on some of the effector mechanisms  245  for clarity of illustration) for gripping tissue and one or more fastening elements  255 . The fastening elements  255  may be any elements that are adapted to secure themselves to one another; in one preferred form of the invention, fastening elements  255  are magnets. The actuating end  240  has suction ports  260  which connect to suction pods  250 , whereby suction may be applied to suction pods  250 , and cables  270  to individually manipulate the relative position of effector mechanisms  245  (e.g., to move them longitudinally relative to the long axis of hollow tube  210 , or to move them laterally relative to the longitudinal axis of hollow tube  210 , etc.).  
         [0103]    [0103]FIGS. 28 and 29 show how cables  270  may be used to manipulate the effector end  235  of hollow tube  210  from a normal round configuration (FIG. 28) to a folded configuration (FIG. 29).  
         [0104]    As a result of the foregoing construction, it will be appreciated that tissue may first be gripped by moving the effector end  235  of tube  210  adjacent to tissue and applying suction to suction ports  260 , whereby tissue will be drawn against suction pods  250 , and the tissue may thereafter be folded by actuating cables  270  whereby to bring the tissue together (FIG. 29). This action simultaneously brings fastening elements  255  into proximity with each other, whereby the fastening elements  255  can secure the tissue in such position.  
         [0105]    [0105]FIGS. 30 and 31 shown the same structure shown in FIGS. 29-29, except that an additional fastener element  255 A is provided on the device. This additional fastening element  255 A can be placed anywhere in, on or around the device so that additional folds of tissue may be created.  
       Additional Embodiments  
       [0106]    It should be understood that the specific embodiments shown herein are presented by way of illustration and not limitation, and that various changes and modifications may be made by one skilled in the art without departing from the spirit and scope of the present invention.