WO2023215640A1 - Procédé et appareil pour manipuler une paroi latérale d'une lumière corporelle - Google Patents

Procédé et appareil pour manipuler une paroi latérale d'une lumière corporelle Download PDF

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Publication number
WO2023215640A1
WO2023215640A1 PCT/US2023/021387 US2023021387W WO2023215640A1 WO 2023215640 A1 WO2023215640 A1 WO 2023215640A1 US 2023021387 W US2023021387 W US 2023021387W WO 2023215640 A1 WO2023215640 A1 WO 2023215640A1
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WO
WIPO (PCT)
Prior art keywords
endoscope
hollow shaft
sleeve
lumen
distal end
Prior art date
Application number
PCT/US2023/021387
Other languages
English (en)
Inventor
Yukio Nakajima
Amos Cruz
Danielle BRUCATO
David GADDY
Original Assignee
Lumendi LLC
Priority date (The priority date is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the date listed.)
Filing date
Publication date
Application filed by Lumendi LLC filed Critical Lumendi LLC
Priority to CN202380052123.7A priority Critical patent/CN119604223A/zh
Publication of WO2023215640A1 publication Critical patent/WO2023215640A1/fr

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    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B1/00—Instruments for performing medical examinations of the interior of cavities or tubes of the body by visual or photographical inspection, e.g. endoscopes; Illuminating arrangements therefor
    • A61B1/00147—Holding or positioning arrangements
    • A61B1/00154—Holding or positioning arrangements using guiding arrangements for insertion
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
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    • A61B1/00064—Constructional details of the endoscope body
    • A61B1/00071—Insertion part of the endoscope body
    • A61B1/0008—Insertion part of the endoscope body characterised by distal tip features
    • A61B1/00082—Balloons
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    • A61B1/00064—Constructional details of the endoscope body
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    • A61B1/00098—Deflecting means for inserted tools
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    • A61B17/3421—Cannulas
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Definitions

  • This invention relates to surgical methods and apparatus in general, and more particularly to surgical methods and apparatus for manipulating the side wall of a body lumen and/or body cavity so as to provide increased visualization of the same and/or increased access to the same, and/or for stabilizing instruments relative to the same.
  • the human body comprises many different body lumens and body cavities.
  • the human body comprises body lumens such as the gastrointestinal (GI) tract, blood vessels, lymphatic vessels, the urinary tract, fallopian tubes, bronchi, bile ducts, etc.
  • the human body comprises body cavities such as the head, chest, abdomen, nasal sinuses, bladder, cavities within organs, etc.
  • GI gastrointestinal
  • the human body comprises body cavities such as the head, chest, abdomen, nasal sinuses, bladder, cavities within organs, etc.
  • the endoscopic examination and/or treatment of the side wall of a body lumen and/or body cavity can be complicated by the anatomic configuration (both regional and local) of the side wall of the body lumen and/or body cavity, and/or by the consistency of the tissue making up the side wall of the body lumen and/or body cavity, and/or by the tethering of the side wall of the body lumen and/or body cavity to other anatomical structures.
  • the intestine is an elongated tubular organ having an inner lumen and is characterized by frequent turns (i.e., the regional anatomic configuration of the intestine) and a side wall characterized by numerous folds (i.e., the local anatomic configuration of the intestine), with the side wall tissue having a relatively soft, pliable consistency, and with the colon in particular being tethered to the abdomen and/or other abdominal structures via soft tissue.
  • This spasming and/or contraction can cause the body lumen and/or body cavity to constrict and/or otherwise move and/or change its configuration, which can further complicate and/or compromise endoscopic visualization of the anatomy, and/or further complicate and/or compromise access to the anatomy using instruments introduced through conventional, flexible endoscopes.
  • the endoscope may grip and/or otherwise gather the colon during insertion and withdrawal and then suddenly slip and release the colon. This results in the endoscope moving quickly past significant lengths of the colon, thereby making accurate examination of the colon challenging.
  • the present invention comprises the provision and use of novel apparatus for manipulating the side wall of a body lumen and/or body cavity so as to better present the side wall tissue (including visualization of areas initially hidden or outside the field of view) for examination and/or treatment during an endoscopic procedure.
  • the present invention also comprises the provision and use of novel apparatus capable of steadying and/or stabilizing the distal tips and/or working ends of instruments (e.g., endoscopes, articulating and/or non-articulating devices such as graspers, cutters or dissectors, cauterizing tools, ultrasound probes, etc.) inserted into a body lumen and/or body cavity with respect to the side wall of the body lumen and/or body cavity, whereby to facilitate the precision use of those instruments.
  • instruments e.g., endoscopes, articulating and/or non-articulating devices such as graspers, cutters or dissectors, cauterizing tools, ultrasound probes, etc.
  • the present invention comprises the provision and use of novel apparatus capable of steadying and/or stabilizing the distal tips and/or working ends of endoscopes (and hence also steadying and/or stabilizing the distal tips and/or working ends of other instruments inserted through the working channels of those endoscopes, such as graspers, cutters or dissectors, cauterizing tools, ultrasound probes, etc.).
  • the present invention comprises the provision and use of novel apparatus capable of steadying and/or stabilizing the distal tips and/or working ends of instruments (such as graspers, cutters or dissectors, cauterizing tools, ultrasound probes, etc.) advanced to the surgical site by means other than through the working channels of endoscopes.
  • instruments such as graspers, cutters or dissectors, cauterizing tools, ultrasound probes, etc.
  • the present invention comprises the provision and use of novel apparatus capable of straightening bends, “ironing out” folds and creating a substantially static or stable side wall of the body lumen and/or body cavity which enables more precise visual examination (including visualization of areas initially hidden or outside the field of view) and/or therapeutic intervention.
  • apparatus comprising: a sleeve adapted to be slid over the exterior of an endoscope; a proximal balloon secured to said sleeve; an inflation/deflation tube carried by said sleeve and in fluid communication with the interior of said proximal balloon; a push tube slidably mounted to said sleeve; and a distal balloon secured to the distal end of said push tube, the interior of said distal balloon being in fluid communication with said push tube, wherein said distal balloon is capable of assuming a deflated condition and an inflated condition, and further wherein when said distal balloon is in its deflated condition, an axial opening extends therethrough, said axial opening being sized to receive the endoscope therein, and when said distal balloon is in its inflated condition, said axial opening is closed down.
  • a method for performing a procedure in a body lumen and/or body cavity comprising: providing apparatus comprising: a sleeve adapted to be slid over the exterior of an endoscope; a proximal balloon secured to said sleeve; an inflation/deflation tube carried by said sleeve and in fluid communication with the interior of said proximal balloon; a push tube slidably mounted to said sleeve; and a distal balloon secured to the distal end of said push tube, the interior of said distal balloon being in fluid communication with said push tube, wherein said distal balloon is capable of assuming a deflated condition and an inflated condition, and further wherein when said distal balloon is in its deflated condition, an axial opening extends therethrough, said axial opening being sized to receive the endoscope therein, and when said distal balloon is in its inflated condition, said axial opening is closed down; positioning said apparatus in the body
  • apparatus comprising: a sleeve adapted to be slid over the exterior of an endoscope, said sleeve comprising a passageway formed integral with said sleeve and a lumen formed integral with said sleeve for receiving an instrument; a proximal balloon secured to said sleeve; an inflation/deflation tube carried by said sleeve and in fluid communication with the interior of said proximal balloon; a push tube slidably mounted in said passageway of said sleeve; and a distal balloon secured to the distal end of said push tube, the interior of said distal balloon being in fluid communication with said push tube.
  • a method for performing a procedure in a body lumen and/or body cavity comprising: providing apparatus comprising: a sleeve adapted to be slid over the exterior of an endoscope, said sleeve comprising a passageway formed integral with said sleeve and a lumen formed integral with said sleeve for receiving an instrument; a proximal balloon secured to said sleeve; an inflation/deflation tube carried by said sleeve and in fluid communication with the interior of said proximal balloon; a push tube slidably mounted in said passageway of said sleeve; and a distal balloon secured to the distal end of said push tube, the interior of said distal balloon being in fluid communication with said push tube; positioning said apparatus in the body lumen and/or body cavity; inflating said proximal balloon; advancing said push tube distally; inflating said distal balloon; and performing the procedure.
  • apparatus comprising: a sleeve adapted to be slid over the exterior of an endoscope so as to substantially cover the endoscope from a point adjacent to the distal end of the endoscope to a point adjacent to the handle of the endoscope; a proximal balloon secured to said sleeve; an inflation/deflation tube carried by said sleeve and in fluid communication with the interior of said proximal balloon; a push tube slidably mounted to said sleeve; and a distal balloon secured to the distal end of said push tube, the interior of said distal balloon being in fluid communication with said push tube.
  • a method for performing a procedure in a body lumen and/or body cavity comprising: providing apparatus comprising: a sleeve adapted to be slid over the exterior of an endoscope so as to substantially cover the endoscope from a point adjacent to the distal end of the endoscope to a point adj acent to the handle of the endoscope; a proximal balloon secured to said sleeve; an inflation/deflation tube carried by said sleeve and in fluid communication with the interior of said proximal balloon; a push tube slidably mounted to said sleeve; and a distal balloon secured to the distal end of said push tube, the interior of said distal balloon being in fluid communication with said push tube; positioning said apparatus in the body lumen and/or body cavity; inflating said proximal balloon; advancing said push tube distally; inflating said distal balloon; and performing the procedure.
  • apparatus comprising: a sleeve adapted to be slid over the exterior of an endoscope; a proximal balloon secured to said sleeve; an inflation/deflation tube carried by said sleeve and in fluid communication with the interior of said proximal balloon; a pair of push tubes slidably mounted to said sleeve; and a distal balloon secured to the distal ends of said pair of push tubes, the interior of said distal balloon being in fluid communication with said pair of push tubes.
  • a method for performing a procedure in a body lumen and/or body cavity comprising: providing apparatus comprising: a sleeve adapted to be slid over the exterior of an endoscope; a proximal balloon secured to said sleeve; an inflation/deflation tube carried by said sleeve and in fluid communication with the interior of said proximal balloon; a pair of push tubes slidably mounted to said sleeve; and a distal balloon secured to the distal ends of said pair of push tubes, the interior of said distal balloon being in fluid communication with said pair of push tubes; positioning said apparatus in the body lumen and/or body cavity; inflating said proximal balloon; advancing said pair of push tubes distally; inflating said distal balloon; and performing the procedure.
  • apparatus for accessing a body lumen or a body cavity comprising: a hollow shaft having a proximal end, a distal end and a lumen extending from the proximal end to the distal end, wherein the lumen of the hollow shaft is configured to receive an endoscope, and further wherein the distal end of the hollow shaft comprises an adjustable portion which is configured to be articulated between (i) a straight configuration in which the adjustable portion is parallel to a longitudinal axis of the hollow shaft, and (ii) an angled configuration in which the adjustable portion is disposed at an angle relative to the longitudinal axis of the hollow shaft, whereby to bend the endoscope disposed within the lumen of the hollow shaft; a sleeve having a proximal end, a distal end and a lumen extending from the proximal end to the distal end, wherein the lumen of the sleeve is configured to receive the hollow shaft and the endoscope disposed
  • a method for accessing a body lumen and/or body cavity of a patient comprising: providing apparatus comprising: a hollow shaft having a proximal end, a distal end and a lumen extending from the proximal end to the distal end, wherein the lumen of the hollow shaft is configured to receive an endoscope, and further wherein the distal end of the hollow shaft comprises an adjustable portion which is configured to be articulated between (i) a straight configuration in which the adjustable portion is parallel to a longitudinal axis of the hollow shaft, and (ii) an angled configuration in which the adjustable portion is disposed at an angle relative to the longitudinal axis of the hollow shaft, whereby to bend the endoscope disposed within the lumen of the hollow shaft; a sleeve having a proximal end, a distal end and a lumen extending from the proximal end to the distal end, wherein the lumen of the sleeve is configured to receive
  • a method for visualizing and/or accessing a bile duct of a patient comprising: providing apparatus comprising: a hollow shaft having a proximal end, a distal end and a lumen extending from the proximal end to the distal end, wherein the lumen of the hollow shaft is configured to receive an endoscope, and further wherein the distal end of the hollow shaft comprises an adjustable portion which is configured to be articulated between (i) a straight configuration in which the adjustable portion is parallel to a longitudinal axis of the hollow shaft, and (ii) an angled configuration in which the adjustable portion is disposed at an angle relative to the longitudinal axis of the hollow shaft, whereby to bend the endoscope disposed within the lumen of the hollow shaft; a sleeve having a proximal end, a distal end and a lumen extending from the proximal end to the distal end, wherein the lumen of the sleeve is configured
  • apparatus for accessing a body lumen or a body cavity comprising: a hollow shaft having a proximal end, a distal end and a lumen extending from the proximal end to the distal end, wherein the lumen of the hollow shaft is configured to receive an endoscope, and further wherein the distal end of the hollow shaft comprises an adjustable portion which is configured to be articulated between (i) a straight configuration in which the adjustable portion is parallel to a longitudinal axis of the hollow shaft, and (ii) an angled configuration in which the adjustable portion is disposed at an angle relative to the longitudinal axis of the hollow shaft, whereby to bend the endoscope disposed within the lumen of the hollow shaft; a sleeve having a proximal end, a distal end and a lumen extending from the proximal end to the distal end, wherein the lumen of the sleeve is configured to receive the hollow shaft and the endoscope disposed there
  • a method for accessing a body lumen and/or body cavity of a patient comprising: providing apparatus comprising: a hollow shaft having a proximal end, a distal end and a lumen extending from the proximal end to the distal end, wherein the lumen of the hollow shaft is configured to receive an endoscope, and further wherein the distal end of the hollow shaft comprises an adjustable portion which is configured to be articulated between (i) a straight configuration in which the adjustable portion is parallel to a longitudinal axis of the hollow shaft, and (ii) an angled configuration in which the adjustable portion is disposed at an angle relative to the longitudinal axis of the hollow shaft, whereby to bend the endoscope disposed within the lumen of the hollow shaft; a sleeve having a proximal end, a distal end and a lumen extending from the proximal end to the distal end, wherein the lumen of the sleeve is configured to receive
  • a method for visualizing and/or accessing a bile duct of a patient comprising: providing apparatus comprising: a hollow shaft having a proximal end, a distal end and a lumen extending from the proximal end to the distal end, wherein the lumen of the hollow shaft is configured to receive an endoscope, and further wherein the distal end of the hollow shaft comprises an adjustable portion which is configured to be articulated between (i) a straight configuration in which the adjustable portion is parallel to a longitudinal axis of the hollow shaft, and (ii) an angled configuration in which the adjustable portion is disposed at an angle relative to the longitudinal axis of the hollow shaft, whereby to bend the endoscope disposed within the lumen of the hollow shaft; a sleeve having a proximal end, a distal end and a lumen extending from the proximal end to the distal end, wherein the lumen of the sleeve is configured
  • apparatus for accessing a body lumen or a body cavity comprising: a hollow shaft formed from a single piece of flexible material, the hollow shaft comprising a proximal end, a distal end and a lumen extending from the proximal end to the distal end, wherein the lumen of the hollow shaft is configured to receive an endoscope, and further wherein the distal end of the hollow shaft comprises an adjustable portion which is configured to be articulated between (i) a straight configuration in which the adjustable portion is parallel to a longitudinal axis of the hollow shaft, and (ii) an angled configuration in which the adjustable portion is disposed at an angle relative to the longitudinal axis of the hollow shaft, whereby to bend the endoscope disposed within the lumen of the hollow shaft; a sleeve having a proximal end, a distal end and a lumen extending from the proximal end to the distal end, wherein the lumen of the sleeve is
  • a method for accessing a body lumen and/or body cavity of a patient comprising: providing apparatus comprising: a hollow shaft formed from a single piece of flexible material, the hollow shaft comprising a proximal end, a distal end and a lumen extending from the proximal end to the distal end, wherein the lumen of the hollow shaft is configured to receive an endoscope, and further wherein the distal end of the hollow shaft comprises an adjustable portion which is configured to be articulated between (i) a straight configuration in which the adjustable portion is parallel to a longitudinal axis of the hollow shaft, and (ii) an angled configuration in which the adjustable portion is disposed at an angle relative to the longitudinal axis of the hollow shaft, whereby to bend the endoscope disposed within the lumen of the hollow shaft; a sleeve having a proximal end, a distal end and a lumen extending from the proximal end to the distal end, wherein
  • a method for visualizing and/or accessing a bile duct of a patient comprising: providing apparatus comprising: a hollow shaft formed from a single piece of flexible material, the hollow shaft comprising a proximal end, a distal end and a lumen extending from the proximal end to the distal end, wherein the lumen of the hollow shaft is configured to receive an endoscope, and further wherein the distal end of the hollow shaft comprises an adjustable portion which is configured to be articulated between (i) a straight configuration in which the adjustable portion is parallel to a longitudinal axis of the hollow shaft, and (ii) an angled configuration in which the adjustable portion is disposed at an angle relative to the longitudinal axis of the hollow shaft, whereby to bend the endoscope disposed within the lumen of the hollow shaft; a sleeve having a proximal end, a distal end and a lumen extending from the proximal end to the distal end,
  • Fig. l is a schematic view showing novel apparatus formed in accordance with the present invention, wherein the novel apparatus comprises, among other things, a sleeve for disposition over the end of an endoscope, an aft balloon mounted to the sleeve, a pair of push tubes slidably mounted to the sleeve, a fore balloon mounted to the distal end of the push tubes, and a push tube handle mounted to the proximal ends of the push tubes;
  • Figs. 2-4 are schematic views showing various dispositions of the fore balloon relative to the aft balloon
  • Fig. 5 is a schematic view showing further details of the distal end of the apparatus shown in Fig. 1;
  • Fig. 6 is a section view taken along line 6-6 of Fig. 5;
  • Figs. 7 and 8 are schematic views showing further details of the fore balloon
  • Fig. 8A is a schematic view showing the push tube handle
  • Figs. 9 and 10 are schematic views showing construction details of the fore balloon
  • Fig. 11 is a schematic view showing one form of inflation mechanism provided in accordance with the present invention.
  • Fig. 11 A is a schematic view showing another form of inflation mechanism provided in accordance with the present invention.
  • Figs. 12 and 13 are schematic views showing another form of inflation mechanism provided in accordance with the present invention
  • Fig. 14 is a schematic view showing relief valves which may be used to ensure that the pressure within the fore balloon and/or aft balloon does not exceed a predetermined level
  • Fig. 15 is a schematic view showing a retraction system which may be used to take up slack in a flexible tube of the apparatus shown in Fig. 1;
  • Figs. 16-22, 22A-22D and 23-30 are schematic views showing preferred ways of using the apparatus of Fig. 1;
  • Fig. 30A is a schematic view showing an alternative construction for the push tubes and push tube handle of the present invention.
  • Fig. 31 is a schematic view showing another form of the sleeve, wherein the sleeve comprises additional lumens for receiving instruments;
  • Figs. 32-35 are schematic views showing how instruments may be advanced through the additional lumens of the sleeve
  • Fig. 36 is a schematic view showing instrument guide tubes which may be disposed in the additional lumens of the sleeve, wherein instruments may be advanced through the instrument guide tubes;
  • Figs. 37-47, 47A and 48 are schematic views showing a novel system for visualizing the bile duct
  • Figs. 49-53 are schematic views showing a novel method for visualizing the bile duct
  • Figs. 54-58 are schematic views showing another novel method for visualizing the bile duct
  • Figs. 59-105 are schematic views showing another novel system for visualizing the bile duct.
  • Figs. 106-111 are schematic views showing another novel method for visualizing the bile duct.
  • the present invention comprises the provision and use of novel apparatus for manipulating the side wall of a body lumen and/or body cavity so as to better present the side wall tissue (including visualization of areas initially hidden or outside the field of view) for examination and/or treatment during an endoscopic procedure.
  • endoscopic procedure is intended to mean substantially any minimally-invasive or limited access procedure, diagnostic and/or therapeutic and/or surgical, for accessing, endoluminally or transluminally or otherwise, the interior of a body lumen and/or body cavity for the purposes of viewing, biopsying and/or treating tissue, including removing a lesion and/or resecting tissue, etc.
  • the present invention also comprises the provision and use of novel apparatus capable of steadying and/or stabilizing the distal tips and/or working ends of instruments (e.g., endoscopes, articulating and/or non-articulating devices such as graspers, cutters or dissectors, cauterizing tools, ultrasound probes, etc.) inserted into a body lumen and/or body cavity with respect to the side wall of the body lumen and/or body cavity, whereby to facilitate the precision use of those instruments.
  • instruments e.g., endoscopes, articulating and/or non-articulating devices such as graspers, cutters or dissectors, cauterizing tools, ultrasound probes, etc.
  • the present invention comprises the provision and use of novel apparatus capable of steadying and/or stabilizing the distal tips and/or working ends of endoscopes (and hence also steadying and/or stabilizing the distal tips and/or working ends of other instruments inserted through the working channels of those endoscopes, such as graspers, cutters or dissectors, cauterizing tools, ultrasound probes, etc.).
  • the present invention comprises the provision and use of novel apparatus capable of steadying and/or stabilizing the distal tips and/or working ends of instruments (such as graspers, cutters or dissectors, cauterizing tools, ultrasound probes, etc.) advanced to the surgical site by means other than through the working channels of endoscopes.
  • instruments such as graspers, cutters or dissectors, cauterizing tools, ultrasound probes, etc.
  • the present invention comprises the provision and use of novel apparatus capable of straightening bends, “ironing out” folds and creating a substantially static or stable side wall of the body lumen and/or body cavity which enables more precise visual examination (including visualization of areas initially hidden or outside the field of view) and/or therapeutic intervention.
  • novel apparatus 5 which is capable of manipulating (e.g., stabilizing, straightening, expanding and/or flattening, etc.) the side wall of a body lumen and/or body cavity so as to better present the side wall tissue (including visualization of areas initially hidden or outside the field of view) for examination and/or treatment during an endoscopic procedure using an endoscope 10 (e.g., an articulating endoscope), and/or for stabilizing the distal end of endoscope 10 and/or the distal tips and/or working ends of other instruments (e.g., graspers, cutters or dissectors, cauterizing tools, ultrasound probes, etc., not shown in Fig. 1).
  • endoscope 10 e.g., an articulating endoscope
  • other instruments e.g., graspers, cutters or dissectors, cauterizing tools, ultrasound probes, etc., not shown in Fig.
  • apparatus 5 generally comprises a sleeve 15 adapted to be slid over the exterior of the shaft of endoscope 10, a proximal (or “aft”) balloon 20 (the terms “proximal” and “aft” will hereinafter be used interchangeably) secured to sleeve 15 near the distal end of the sleeve, and a base 25 secured to sleeve 15 at the proximal end of the sleeve.
  • a proximal balloon 20 the terms “proximal” and “aft” will hereinafter be used interchangeably
  • Apparatus 5 also comprises a pair of push tubes 30 slidably mounted to sleeve 15 as will hereinafter be discussed, and a distal (or “fore”) balloon 35 (the terms “distal” and “fore” will hereinafter be used interchangeably) secured to the distal ends of push tubes 30, such that the spacing between aft balloon 20 and fore balloon 35 can be adjusted by the physician (or other operator or user) by moving push tubes 30 relative to sleeve 15 (e.g., by advancing the two push tubes simultaneously at push tube handle 37, see below). See Figs. 1 and 2-4.
  • Apparatus 5 also comprises an associated inflation mechanism 40 (Fig. 1) for enabling selective inflation/deflation of one or both of aft balloon 20 and fore balloon 35 by the physician or (or other operator or user).
  • sleeve 15 generally comprises an elongated, thin-walled tube configured to be slid over the exterior of the shaft of endoscope 10 (e.g., retrograde from the distal tip of the endoscope) so as to make a close fit therewith, with the sleeve being sized and constructed so that it will slide easily back over the endoscope during mounting thereon (preferably with the scope “dry”) but will have sufficient residual friction (when gripped by the hand of the physician or other operator or user) with the outer surface of the endoscope such that the sleeve will remain in place to allow torqueing (i.e., rotational turning) and pushing/pulling of the endoscope during use (e.g., within the colon of a patient).
  • torqueing i.e., rotational turning
  • pushing/pulling of the endoscope during use e.g., within the colon of a patient.
  • sleeve 15 can move circumferentially to some extent about endoscope 10 (and when gripped securely by the hand of the physician or other operator or user, can rotate in conjunction with the shaft of the endoscope); but sleeve 15 can only move nominally in an axial direction relative to endoscope 10.
  • Sleeve 15 is sized so that when its distal end is substantially aligned with the distal end of endoscope 10, sleeve 15 (in conjunction with base 25) will substantially cover the shaft of the endoscope.
  • sleeve 15 is sized so that when it is mounted to endoscope 10 and endoscope 10 is inserted into a patient, sleeve 15 extends out of the body of the patient.
  • apparatus 5 is provided according to the particular endoscope with which it is intended to be used, with apparatus 5 being sized so that when base 25 is in engagement with the handle of the endoscope, the distal end of sleeve 15 will be appropriately positioned at the distal end of the endoscope, i.e., substantially aligned with the distal end of the endoscope or slightly proximal to the distal end of the endoscope.
  • the distal end of sleeve 15 may be provided with a radially- inwardly-extending stop (not shown) to positively engage the distal end surface of endoscope 10, whereby to prevent the distal end of sleeve 15 from moving proximally beyond the distal end surface of endoscope 10.
  • a radially- inwardly-extending stop can also assist in preventing “torque slip” of sleeve 15 relative to endoscope 10 during torqueing (i.e., rotational turning) of the endoscope while within the colon, and/or “thrust slip” of sleeve 15 relative to endoscope 10 during forward pushing of the endoscope while within the colon.
  • Sleeve 15 preferably has a smooth outer surface so as to be non-traumatic to tissue, and is preferably made of a highly flexible material such that the sleeve will not inhibit bending of the endoscope during use.
  • sleeve 15 comprises polyurethane, polyethylene, poly(vinyl chloride) (PVC), polytetrafluoroethylene (PTFE), etc., and is preferably transparent (or at least translucent) so as to allow distance markings on endoscope 10 to be visualized through sleeve 15.
  • sleeve 15 preferably has nominal hoop strength, so that the physician (or other operator or user) can grip endoscope 10 through sleeve 15, e.g., so as to torque the scope.
  • sleeve 15 can include a lubricious coating (e.g., a liquid such as perfluoropolyether synthetic oil, a powder, etc.) on some or all of its interior and/or exterior surfaces, so as to facilitate disposition of the sleeve over the endoscope and/or movement of apparatus 5 through a body lumen and/or body cavity.
  • a lubricious coating e.g., a liquid such as perfluoropolyether synthetic oil, a powder, etc.
  • sleeve 15 may be formed of a material which is itself lubricious, e.g., polytetrafluoroethylene (PTFE), etc. It should be appreciated that the inside surface of sleeve 15 may include features (e.g., ribs) to prevent the sleeve from rotating relative to the endoscope during use. If desired, a vacuum may be “pulled” between sleeve 15 and endoscope 10, whereby to secure sleeve 15 to endoscope 10 and minimize the profile of sleeve 15.
  • PTFE polytetrafluoroethylene
  • a vacuum may be introduced at the proximal end of sleeve 15 (i.e., at base 25) or a vacuum may be introduced at a point intermediate sleeve 15.
  • removal of sleeve 15 from endoscope 10 may be facilitated by introducing a fluid (e.g., air or a liquid lubricant) into the space between sleeve 15 and endoscope 10, e.g., at the proximal end of sleeve 15 (i.e., at base 25) or intermediate sleeve 15.
  • a fluid e.g., air or a liquid lubricant
  • aft balloon 20 is secured to sleeve 15 just proximal to the articulating joint of the endoscope near to, but spaced from, the distal end of the sleeve.
  • Aft balloon 20 is disposed concentrically about sleeve 15, and hence concentrically about an endoscope 10 disposed within sleeve 15.
  • aft balloon 20 has a generally toroidal shape.
  • Aft balloon 20 may be selectively inflated/deflated by means of a proximal inflation/ deflation tube 45 which has its distal end in fluid communication with the interior of aft balloon 20, and which has its proximal end in fluid communication with a fitting 46 mounted to base 25.
  • Fitting 46 is configured for connection to the aforementioned associated inflation mechanism 40.
  • Fitting 46 is preferably a luer-activated valve, allowing inflation mechanism 40 to be disconnected from fitting 46 without losing pressure in aft balloon 20.
  • Infl tion/deflation tube 45 may be secured to the exterior surface of sleeve 15 or, more preferably, inflation/deflation tube 45 may be contained within a lumen 47 formed within sleeve 15.
  • aft balloon 20 is disposed a short distance back from the distal end of sleeve 15, i.e., by a distance which is approximately the same as the length of the articulating portion of a steerable endoscope 10, such that the articulating portion of the steerable endoscope will be disposed distal to aft balloon 20 when the steerable endoscope is disposed in sleeve 15.
  • This construction allows the flexible portion of the steerable endoscope to be articulated even when aft balloon 20 has been inflated in the anatomy so as to stabilize the adjacent non-articulating portion of the endoscope relative to the anatomy, as will hereinafter be discussed in further detail.
  • aft balloon 20 when inflated, provides a secure platform for maintaining endoscope 10 in a stable position within a body lumen or body cavity, with endoscope 10 centered within the body lumen or body cavity.
  • endoscope 10 can provide improved visualization of the anatomy.
  • instruments advanced through the internal lumens (sometimes referred to as the “working channel” or “working channels”) of endoscope 10 will also be provided with a secure platform for supporting those instruments within the body lumen or body cavity.
  • aft balloon 20 When aft balloon 20 is appropriately inflated, the aft balloon can atraumatically engage and form a sealing relationship with the side wall of a body lumen within which apparatus 5 is disposed.
  • aft balloon 20 is formed out of polyurethane.
  • Base 25 is secured to the proximal end of sleeve 15.
  • Base 25 engages endoscope 10 and helps secure the entire assembly (i.e., apparatus 5) to endoscope 10.
  • Base 25 preferably comprises a substantially rigid or semi-rigid structure which may be gripped by the physician (or other operator or user) and pulled proximally, whereby to allow the physician (or other operator or user) to pull sleeve 15 over the distal end of endoscope 10 and then proximally back along the length of endoscope 10, whereby to mount sleeve 15 to the outer surface of the shaft of the endoscope.
  • base 25 is pulled proximally along the endoscope until base 25 seats against the handle of the endoscope, thereby prohibiting further proximal movement of base 25 (and hence thereby prohibiting further proximal movement of sleeve 15).
  • base 25 makes a sealing engagement with endoscope 10.
  • Push tubes 30 are slidably mounted to sleeve 15, whereby the distal ends of the push tubes can be extended and/or retracted relative to sleeve 15 (e.g., by advancing or withdrawing the push tubes via push tube handle 37, see below), and hence extended and/or retracted relative to the distal end of endoscope 10 which is disposed in sleeve 15.
  • push tubes 30 are slidably disposed in support tubes 50 which are secured to the outer surface of sleeve 15 or, more preferably, are contained within lumens 52 formed within sleeve 15.
  • Support tubes 50 are preferably formed out of a low friction material (e.g., polytetrafluoroethylene, also known as “PTFE”) so as to minimize resistance to movement of push tubes 30 relative to support tubes 50 (and hence minimize resistance to movement of push tubes 30 relative to sleeve 15).
  • PTFE polytetrafluoroethylene
  • support tubes 50 are flexible (so as to permit endoscope 10, and particularly the articulating portion of steerable endoscope 10, to flex as needed during the procedure); however, support tubes 50 also provide some column strength.
  • sleeve 15 when support tubes 50 are mounted within lumens 52 formed in sleeve 15, the assembly of sleeve 15 and support tubes 50 is flexible yet has a degree of column strength (whereas sleeve 15 alone is flexible but has substantially no column strength).
  • lumens 52 are preferably lubricated so as to minimize friction between push tubes 30 and lumens 52.
  • the proximal ends of push tubes 30 are connected to push tube handle 37.
  • pushing distally on push tube handle 37 causes the distal ends of push tubes 30 to move distally (at the same rate) relative to sleeve 15 (whereby to move fore balloon 35 distally relative to aft balloon 20) and pulling proximally on push tube handle 37 causes the distal ends of push tubes 30 to retract proximally (at the same rate) relative to sleeve 15 (whereby to move fore balloon 35 proximally relative to aft balloon 20).
  • a clamp 53 (Figs. 12 and 15) is provided at base 25 for holding push tubes 30 in a selected disposition relative to base 25 (and hence in a selected disposition relative to sleeve 15).
  • Push tubes 30 are preferably formed out of a relatively flexible material which provides good column strength, e.g., a thermoplastic polyethylene resin such as IsoplastTM (available from The Lubrizol Corporation of Wickliffe, Ohio), polyethylene, polypropylene, nylon, etc. It should be appreciated that push tubes 30 can comprise a single material or a plurality of materials, and that the stiffness of push tubes 30 can vary along their length. By way of example but not limitation, the distal -most portion of push tubes 30 can be formed of the same material as the remainder of the push tubes but have a lower modulus so as to be more flexible than the remainder of the push tubes, or the distal-most portion of push tubes 30 can comprise a different, more resilient flexible material.
  • a relatively flexible material which provides good column strength
  • a thermoplastic polyethylene resin such as IsoplastTM (available from The Lubrizol Corporation of Wickliffe, Ohio)
  • the stiffness of push tubes 30 can vary along their length.
  • the distal -most portion of push tubes 30 can
  • the distal-most portion of push tubes 30 can comprise Nitinol.
  • the distal-most portion of push tubes 30 can comprise a stainless steel coil covered with an outer jacket of polytetrafluoroethylene (PTFE), with the distal-most jacket/more- proximal tubing together providing a sealed lumen for inflating/deflating fore balloon 35.
  • PTFE polytetrafluoroethylene
  • push tubes 30 are configured to maintain a parallel disposition when they are in an unbiased state, i.e., when no force is being applied to push tubes 30. This is true regardless of the state of inflation or deflation of fore balloon 35.
  • the distal-most portion of push tubes 30 can be configured to bend inwardly or outwardly if desired. With such a configuration, when the distal tips of push tubes 30 are maintained stationary (e.g., by an inflated fore balloon, as will hereinafter be discussed) and a sufficient distally-directed force is applied to push tubes 30, the middle portions of push tubes 30 (i.e., the portions between the inflated fore balloon 35 and sleeve 15) can bend or bow outwardly, whereby to push outwardly on the side wall of the body lumen which apparatus 5 is disposed in, thereby providing a “tenting” effect on the side wall of the body lumen and/or body cavity in the space between aft balloon 20 and fore balloon 35.
  • This “tenting” effect can significantly enhance visibility and/or tissue stability in the area distal to endoscope 10, by pushing outwardly on the side wall of the body lumen and/or body cavity in which apparatus 5 is disposed.
  • push tubes 30 by forming push tubes 30 out of a flexible material, it is possible to manually adjust their position during use (e.g., by using a separate tool, by torqueing the apparatus, etc.) so as to prevent the push tubes from interfering with visualization of the patient’s anatomy and/or interfering with diagnostic or therapeutic tools introduced into the space between the fore and aft balloons.
  • apparatus 5 is disposed in the anatomy in such a way that a push tube 30 blocks visual or physical access to a target region of the anatomy
  • the flexible push tube 30 may be moved out of the way by using a separate tool or instrument, or by rotating the apparatus with a torqueing motion so as to move the flexible push tube 30 out of the way, etc.
  • push tubes 30 By way of further example but not limitation, by constructing push tubes 30 so that they are circular and flexible and of a diameter significantly smaller than the round circumference of endoscope 10, the movement of the round endoscope, when articulated, can simply push the push tubes out of the way and provides a unobstructed visual path to the tissue of interest.
  • push tubes 30 can be marked with an indicator including distance markers (not shown in the figures), e.g., colored indicators or radiopaque indicators, so that a physician (or other operator or user) observing the surgical site via endoscope 10 or by radiological guidance (e.g., X-ray fluoroscopy) can ascertain the relative disposition of push tubes 30 at the surgical site both longitudinally and/or circumferentially with respect to the side wall of the body lumen and/or other body cavity.
  • distance markers e.g., colored indicators or radiopaque indicators
  • push tubes 30 are hollow, and have their distal ends in fluid communication with the interior of fore balloon 35 (Figs. 1-5, 7 and 8) and their internal lumens in fluid communication with a fitting 56 mounted to base 25.
  • Fitting 56 is configured for connection to the aforementioned associated inflation mechanism 40, in order that fore balloon 35 may be selectively inflated/deflated with air or other fluids (including liquids).
  • Fitting 56 is preferably a luer-activated valve, allowing inflation mechanism 40 to be disconnected from fitting 56 without losing pressure in fore balloon 35.
  • push tube handle 37 comprises a hollow interior 57.
  • Push tubes 30 are mounted to push tube handle 37 so that push tubes 30 will move in conjunction with push tube handle 37, and so that the hollow interiors of push tubes 30 are in fluid communication with the hollow interior 57 of push tube handle 37.
  • Push tube handle 37 also comprises a fitting 58 which is in fluid communication with hollow interior 57 of push tube handle 37.
  • a flexible tube 59 connects fitting 58 with an internal chamber (not shown) in base 25, with this internal chamber in base 25 being in fluid communication with the aforementioned fitting 56.
  • dual push tubes provides numerous advantages.
  • the provision of dual push tubes provides a symmetric force to fore balloon 35 when the fore balloon is advanced distally into a body lumen, as will hereinafter be discussed.
  • the provision of dual push tubes 30 provides equal outward forces against the adjacent anatomy when the push tubes are employed to straighten out the anatomy in the area proximate the distal end of endoscope 10, thereby enhancing visualization of, and/or access to, the anatomy, as will hereinafter be discussed.
  • dual push tubes ensures that fore balloon 35 remains centered on endoscope 10, thereby facilitating un-docking of fore balloon 35 from endoscope 10 and re-docking of fore balloon 35 over endoscope 10, as will hereinafter be discussed.
  • the provision of dual push tubes 30 helps ensure that fore balloon 35 is stable relative to the tip of the endoscope, minimizing rotational movement of the fore balloon when inflated.
  • the provision of dual hollow push tubes provides a redundant air transfer system for inflating or deflating fore balloon 35.
  • Fore balloon 35 is secured to the distal ends of push tubes 30, whereby the spacing between aft balloon 20 and fore balloon 35 can be adjusted by moving push tubes 30 relative to sleeve 15, i.e., by moving push tube handle 37 relative to sleeve 15.
  • hollow push tubes 30 provide a conduit between the interior of fore balloon 35 and fitting 56, whereby to permit selective inflation/deflation of fore balloon 35 via fitting 56.
  • fore balloon 35 is configured so that (i) when it is deflated (or partially deflated) and it is in its “retracted” position relative to sleeve 15 (Fig. 2), fore balloon 35 provides an axial opening 63 (Figs. 7, 8 and 10) sufficient to accommodate sleeve 15 and the shaft of endoscope 10 therein, whereby fore balloon 35 can be “docked” over sleeve 15 and endoscope 10, and (ii) when fore balloon 35 is in its “extended” position relative to sleeve 15 and is appropriately inflated (Fig. 4), axial opening 63 is closed down (and preferably completely closed off).
  • the fore balloon when appropriately inflated, can atraumatically engage and form a sealing relationship with the side wall of a body lumen and/or body cavity within which apparatus 5 is disposed.
  • the fore balloon when fore balloon 35 is appropriately inflated, can effectively seal the body lumen and/or body cavity distal to fore balloon 35, by closing down axial opening 63 and forming a sealing relationship with the side wall of the body lumen and/or body cavity within which apparatus 5 is disposed.
  • the two balloons will create a sealed zone therebetween (sometimes hereinafter referred to as “the therapeutic zone”).
  • fore balloon 35 has a “torus” shape when deflated (to allow it to seat over the distal end of the endoscope) and a substantially “solid” shape when inflated (to allow it to close off a body lumen or body cavity).
  • fore balloon 35 is preferably manufactured as a single construct comprising a body 67 having a proximal opening 69 and a distal opening 71, a proximal extension 73 having a “key-shaped” cross-section comprising lobes 74, and a distal extension 76 having a circular cross-section.
  • lobes 74 are disposed on proximal extension 73 with a configuration which matches the configuration of push tubes 30 (i .e., where apparatus 5 comprises two push tubes 30 diametrically opposed to one another, proximal extension 73 will comprise two lobes 74 diametrically opposed to one another; where apparatus 5 comprises three push tubes 30 equally- circumferentially-spaced about the perimeter of sleeve 15, proximal extension 73 will comprise three lobes 74 equally-circumferentially-spaced about the perimeter of proximal extension 73; where apparatus 5 comprises one push tube 30, proximal extension 73 will comprise one lobe 74, etc.
  • proximal extension 73 and lobe(s) 74 may be collectively referred to as having a “key-shaped” cross-section).
  • push tubes 30 are seated in lobes 74 of proximal extension 73, proximal extension 73 is everted into the interior of body 67 (with the interiors of hollow push tubes 30 being in fluid communication with the interior of body 67), and then distal extension 76 is everted into the interior of proximal extension 73, whereby to provide a fore balloon 35 having axial opening 63 extending therethrough, with push tubes 30 being secured to fore balloon 35 and communicating with the interior of fore balloon 35.
  • axial opening 63 is sized to receive the distal end of endoscope 10 therein.
  • formation of fore balloon 35 by the aforementioned process of everting proximal extension 73 into the interior of body 67, and then everting distal extension 76 into the interior of proximal extension 73, provides multiple layers of balloon material around push tubes 30, thereby providing a more robust balloon construction.
  • providing multiple layers of balloon material around push tubes 30 adds cushioning to the distal ends of push tubes 30, thereby providing an even more atraumatic distal tip to push tubes 30 and further ensuring that the distal tips of push tubes 30 do not damage the adjacent tissue.
  • fore balloon 35 is formed out of polyurethane.
  • fore balloon 35 when fore balloon 35 is in its deflated condition, the material of fore balloon 35 substantially encompasses the distal ends of push tubes 30 (while still allowing push tubes 30 to be in fluid communication with the interior of fore balloon 35), thereby providing an atraumatic tip for advancing fore balloon 35 distally through a body lumen.
  • push tubes 30 and the deflated fore balloon 35 can, together, essentially function as a soft-tipped lead for apparatus 5 and endoscope 10, as discussed further below (Fig. 20).
  • one or both of aft balloon 20 and fore balloon 35 can be marked with an indicator (e.g., a color indicator or a radiopaque indicator) so that a physician (or other operator or user) observing the surgical site via endoscope 10 or radiological guidance (e g., X-ray fluoroscopy) can ascertain the disposition of one or both of the balloons at the surgical site.
  • an indicator e.g., a color indicator or a radiopaque indicator
  • Inflation mechanism 40 provides a means to selectively inflate aft balloon 20 and/or fore balloon 35.
  • inflation mechanism 40 comprises a single-line syringe inserter 140 comprising a body 145 and a plunger 150.
  • a spring 153 is provided in body 145 to automatically return plunger 150 at the end of its stroke.
  • Syringe inserter 140 is connected to one or the other of fittings 46, 56 via a line 155.
  • syringe inserter 140 when single-line syringe inserter 140 is to be used to inflate aft balloon 20, syringe inserter 140 is connected to fitting 46 via line 155 so that the output of single-line syringe inserter 140 is directed to aft balloon 20 (i.e., via proximal inflation/deflation tube 45).
  • syringe inserter 140 when single-line syringe inserter 140 is to be used to inflate fore balloon 35, syringe inserter 140 is connected to fitting 56 via line 155 so that the output of single-line syringe inserter 140 is directed to fore balloon 35 (i.e., via flexible tube 59 and the hollow interiors of push tubes 30).
  • inflation mechanism 40 comprises an elastic bulb 156 having a first port 157 and a second port 158.
  • a one-way valve 159 e.g., a check valve
  • Another one-way valve 159 is disposed in second port 158 so that air can only pass through second port 158 when traveling in an inward direction.
  • elastic bulb 156 is compressed (e.g., by hand), air within the interior of elastic bulb 156 is forced out first port 157; and when elastic bulb 156 is thereafter released, air is drawn back into the interior of elastic bulb 156 through second port 158.
  • first port 157 is connected to fitting 46 via line 155 so that the positive pressure output of elastic bulb 156 is directed to aft balloon 20.
  • Elastic bulb 156 may thereafter be used to deflate aft balloon 20, i.e., by connecting second port 158 to fitting 46 via line 155 so that the suction of elastic bulb 156 is directed to aft balloon 20.
  • first port 157 is connected to fitting 56 via line 155 so that the positive pressure output of elastic bulb 156 is directed to fore balloon 35.
  • Elastic bulb 156 may thereafter be used to deflate fore balloon 35, i.e., by connecting second port 158 to fitting 56 via line 155 so that the suction of elastic bulb 156 is directed to fore balloon 35.
  • a syringe 160 may be used to inflate aft balloon 20 and/or fore balloon 35.
  • Inflation mechanism 160 comprises a body 161 and a plunger 162.
  • a spring (not shown) is provided in body 161 to automatically return plunger 162 at the end of its power stroke.
  • Syringe 160 is connected to fittings 46, 56 via a line 163.
  • syringe 160 comprises a valve 165 for connecting syringe 160 to fore balloon 35 or aft balloon 20, and a valve 170 for selecting inflation or deflation of the connected-to balloon.
  • valve 165 (a two-position valve that connects valve 170 to either the fore balloon or the aft balloon) is set so that the syringe 160 is connected through fitting 46 to aft balloon 20, and valve 170 (a 2-way crossover valve which allows the one-way valves to be arranged to inflate in one configuration and deflate in the other configuration) is set so that syringe 160 is providing inflation pressure. Thereafter, when aft balloon 20 is to be deflated, valve 170 is set to its deflate position.
  • valve 165 is set so that syringe 160 is connected through fitting 56 to fore balloon 35
  • valve 170 is set so that syringe 160 is providing inflation pressure.
  • valve 170 is set to its deflate position.
  • inflation mechanism 40 may comprise an automated source of fluid pressure (either positive or negative), e.g., an electric pump.
  • a relief valve 175 can be connected to the inflation/deflation line which connects to fore balloon 35 so as to ensure that the pressure within fore balloon 35 does not exceed a predetermined level.
  • a relief valve 180 can be connected to the inflation/deflation line which connects to aft balloon 20 so as to ensure that the pressure within aft balloon 20 does not exceed a predetermined level.
  • one or more pressure gauges 182 (Fig. 1 or Fig.
  • 13 may be incorporated into the fluid line connected to aft balloon 20, and/or the fluid line connected to fore balloon 35, whereby to provide the physician (or other operator or user) with information relating to the pressure inside aft balloon 20 and/or fore balloon 35 so as to avoid over inflation and/or to help the physician (or other operator or user) ascertain the inflation state of a balloon during a procedure.
  • a flexible tube retraction system 185 may be provided (e.g., within base 25) to take up slack in flexible tube 59 when fore balloon 35 is extended.
  • Apparatus 5 may be used to manipulate, (e.g., stabilize, straighten, expand and/or flatten, etc.) the side wall of a body lumen and/or body cavity so as to better present the side wall tissue (including visualization of areas initially hidden or outside the field of view) for examination and/or treatment during an endoscopic procedure using endoscope 10, and/or to stabilize the distal tips and/or working ends of instruments (e.g., graspers, cutters or dissectors, cauterizing tools, ultrasound probes, etc.), e.g., advanced into the therapeutic zone.
  • instruments e.g., graspers, cutters or dissectors, cauterizing tools, ultrasound probes, etc.
  • sleeve 15 is first mounted to endoscope 10 (Fig. 1). This may be accomplished by pulling base 25 proximally over the distal end of endoscope 10 and then pulling proximally along the length of endoscope 10 until the distal end of sleeve 15 is substantially aligned with the distal tip of endoscope 10. At this point, aft balloon 20 is deflated, fore balloon 35 is deflated, and fore balloon 35 is docked over the distal end of endoscope 10. Endoscope 10 and apparatus 5 are ready to be inserted as a unit into the patient.
  • endoscope 10 and apparatus 5 are inserted as a unit into a body lumen and/or body cavity of the patient.
  • endoscope 10 and apparatus 5 are inserted as a unit into the gastrointestinal (GI) tract of the patient.
  • Endoscope 10 and apparatus 5 are advanced along the body lumen and/or body cavity to a desired location within the patient (Figs. 17 and 18).
  • aft balloon 20 is inflated so as to stabilize apparatus 5 (and hence endoscope 10) within the body lumen and/or body cavity. See Fig. 19. This may be done using the aforementioned associated inflation mechanism 40.
  • the endoscope inasmuch as the articulating portion of the endoscope resides distal to aft balloon 20, the endoscope will be able to articulate distal to aft balloon 20 so as to facilitate visualization of the anatomy even after aft balloon 20 is inflated.
  • aft balloon 20 stabilizes endoscope 10 within the gastrointestinal tract and distends the colon and increases the colon to a fixed diameter directly adjacent to aft balloon 20.
  • push tubes 30 are advanced distally in the body lumen and/or body cavity (i.e., so as to move fore balloon 35 further ahead of aft balloon 20) by pushing distally on push tube handle 37.
  • push tubes 30, and hence fore balloon 35 move distally relative to endoscope 10 (which is stabilized in position within the gastrointestinal tract by the inflated aft balloon 20).
  • the deflated fore balloon 35 covers the distal ends of push tubes 30 during such distal advancement of fore balloon 35, thereby ensuring atraumatic advancement of fore balloon 35.
  • atraumatic advancement of fore balloon 35 may be further enhanced by forming the distal ends of push tubes 30 out of a more resilient material.
  • fore balloon 35 is inflated (Fig. 20) so as to secure fore balloon 35 to the anatomy. Again, this may be done using the aforementioned associated inflation mechanism 40.
  • the inflated fore balloon 35, the inflated aft balloon 20, and push tubes 30 will all complement one another so as to stabilize, straighten, expand and/or flatten the side wall of the body lumen and/or body cavity so as to better present the side wall tissue (including visualization of areas initially hidden or outside the field of view) for examination and/or treatment during an endoscopic procedure using endoscope 10.
  • the inflated fore balloon 35 and the inflated aft balloon 20 will together expand and tension the side wall of the body lumen and/or body cavity, and push tubes 30 will tend to straighten the anatomy between the two inflated balloons when the fore balloon is extended distally from the aft balloon.
  • the inflated fore balloon 35 and the inflated aft balloon 20 will together define a substantially closed region along the body lumen and/or body cavity (i.e., an isolated therapeutic zone which prevents the passage of fluid and/or other liquids by virtue of the air-tight seals established by the inflated fore balloon 35 and aft balloon 20).
  • the side wall of the body lumen and/or body cavity will be tensioned by inflation of fore balloon 35 and aft balloon 20, whereby to better present the side wall of the body lumen and/or body cavity for viewing through endoscope 10.
  • the expansion and tensioning of the side wall of the body lumen and/or body cavity effected by the inflated fore balloon 35, the inflated aft balloon 20, and push tubes 30, can be further enhanced by advancing the fore balloon when it is inflated and gripping the side wall of the body lumen and/or body cavity, whereby to tension the side wall of the body lumen and/or body cavity.
  • this region can then be inflated (Fig. 21) with a fluid (e.g., air, CO2, etc.) so as to further tension the side wall of the body lumen and/or body cavity, whereby to better present the side wall of the body lumen and/or body cavity for viewing through endoscope 10 and stabilize the side wall so as to facilitate more precise therapeutic interventions.
  • a fluid e.g., air, CO2, etc.
  • fore balloon 35 can be retracted toward aft balloon 20 (i .e., by pulling push tube handle 37 proximally), while remaining inflated (and hence maintaining a grip on the side wall of the body lumen and/or body cavity), so as to move the visible mucosa and further improve visualization and access (see Fig. 22), e.g., so as to position a particular target area on the side wall of the body lumen and/or body cavity at a convenient angle relative to the endoscope and endoscopic tools.
  • push tubes 30 may be advanced distally a portion - but only a portion - of their full distal stroke, then fore balloon 35 may be inflated so as to grip the side wall of the body lumen and/or body cavity, and then push tubes 30 may be further advanced distally.
  • This action will cause flexible push tubes 30 to bow outwardly (see Figs. 22A-22D), contacting the side wall of the body lumen and/or body cavity and pushing the side wall of the body lumen and/or body cavity outwardly, e.g., in a “tenting” fashion, whereby to further enhance visualization of the side wall of the body lumen and/or body cavity by endoscope 10.
  • instruments 190 may be advanced through working channels of endoscope 10 so as to biopsy and/or treat pathologic conditions (e.g., excise pathological anatomy). It will be appreciated that such instruments will extend through the distal end of the endoscope, which is effectively stabilized relative to the anatomy via aft balloon 20, so that the working ends of instruments 190 will also be highly stabilized relative to the anatomy. This is a significant advantage over the prior art practice of advancing instruments out of the nonstabilized end of an endoscope.
  • instruments 190 include articulating instruments having a full range of motion, whereby to better access target anatomy.
  • the isolated therapeutic zone permits rapid flushing of the anatomic segment in which the therapeutic zone lies (e.g., with a liquid such as saline) with rapid subsequent removal of the flushing liquid (see Figs. 24-26).
  • fore balloon 35 can be directed with high precision to a bleeding site, whereupon fore balloon 35 may be used (e.g., inflated) to apply local pressure to the bleeding site in order to enhance bleeding control (see Fig. 27). This can be done under the visualization provided by endoscope 10.
  • endoscope 10 is repositioned within the anatomy with minimal interference from apparatus 5
  • fore balloon 35 is returned to its torus configuration (i.e., partially deflated)
  • the fore balloon is retracted proximally and “re-docked” on the distal end of endoscope 10
  • aft balloon 20 is deflated, and then endoscope 10 (with apparatus 5 carried thereon) is repositioned within the anatomy.
  • fore balloon 35 is to be re-docked on the distal end of endoscope 10
  • fore balloon 35 is preferably only partially deflated until fore balloon 35 is re-docked on the distal end of the endoscope, since partial inflation of fore balloon 35 can leave fore balloon 35 with enough “body” to facilitate the re-docking process. Thereafter, fore balloon 35 may be fully deflated if desired, e.g., so as to positively grip the distal end of endoscope 10.
  • fore balloon 35 may be used as a drag brake to control retrograde motion of the endoscope. More particularly, in this form of the invention, endoscope 10 and apparatus 5 are first advanced as a unit into the body lumen and/or body cavity until the tip of the endoscope is at the proper location. Next, aft balloon 20 is inflated, push tubes 30 are advanced distally, and then fore balloon 35 is inflated (Fig. 28). Visualization and, optionally, therapeutic treatment may then be effected at that location.
  • aft balloon 20 When the apparatus is to be moved retrograde, aft balloon 20 is deflated, fore balloon 35 is partially deflated, and then the endoscope is withdrawn proximally, dragging the semi-inflated fore balloon 35 along the body lumen and/or body cavity (Fig. 29), with fore balloon 35 acting as something of a brake as the endoscope is pulled proximally, thereby enabling more controlled retrograde movement of the endoscope and hence better visualization of the anatomy.
  • aft balloon 20 and fore balloon 35 can be re-inflated, as shown in Fig. 30, with or without introduction of a fluid into the “isolated therapeutic zone” established between the two balloons, so as to stabilize, straighten, expand and/or flatten the anatomy.
  • aft balloon 20 as a brake when withdrawing the endoscope (and hence apparatus 5) from the anatomy, either alone or in combination with the aforementioned braking action from fore balloon 35.
  • endoscope 10 and apparatus 5 are withdrawn from the anatomy.
  • this is done by deflating (or partially deflating) fore balloon 35, retracting push tubes 30 so that fore balloon 35 is “re- docked” onto the distal end of endoscope 10, fully deflating fore balloon 35 so that it grips the distal end of the endoscope, deflating aft balloon 20 (if it is not yet deflated), and then withdrawing endoscope 10 and apparatus 5 as a unit from the anatomy.
  • apparatus 5 may also be used advantageously in various ways other than those disclosed above.
  • endoscope 10 and apparatus 5
  • the fore balloon and flexible push tubes 30 may act as an atraumatic lead (guiding structure) for the endoscope as the endoscope advances through the colon.
  • the flexible push tubes 30 can deflect so that the fore balloon tracks the path of the colon, thereby aiding atraumatic advancement of the endoscope along the colon.
  • apparatus 5 may also be used advantageously in other ways to facilitate further examinations of the luminal surface otherwise difficult to be performed currently. Such an example is endoscopic ultrasound examination of the lumen which would be facilitated by the fluid-filled inflated fore balloon and ultrasound probe examination.
  • apparatus 5 may be constructed so that push tubes 30 may be advanced or retracted independently of one another, as well as in conjunction with one another - such independent advancement or retraction of push tubes 30 can aid in steering the partially- or fully-deflated fore balloon 35 through the body lumen and/or body cavity, whereby to facilitate advancement or retraction of endoscope 10 through the body lumen and/or body cavity, and/or such independent advancement or retraction of push tubes 30 can facilitate applying a “turning force” to the anatomy with an inflated fore balloon 35, whereby to better present the anatomy for visualization and/or treatment.
  • push tubes 30 are each independently slidably mounted to push tube handle 37 so that push tubes 30 can move independently of push tube handle 37 and each other. Stops 191 limit distal movement of push tubes 30 relative to push tube handle 37 so that a push tube cannot be moved completely out of push tube handle 37.
  • push tubes 30 are moved distally, either together or independently of one another.
  • push tubes 30 are moved proximally, either together or independently of one another.
  • push tubes 30 can be moved independently of one another so as to “turn” the fore balloon, e.g., such as when fore balloon 35 is inflated and engaging the anatomy, whereby to apply a “turning force” to the anatomy, or where fore balloon 35 is partially inflated and is being used as an atraumatic tip for the advancing assembly, whereby to help “steer” the assembly through the anatomy.
  • push tubes 30 may be held in a particular disposition by mounting push tubes 30 in the aforementioned clamp 53 (Figs. 12 and 15).
  • sleeve 15 so as to support instruments (or hollow instrument guide tubes) external to endoscope 10. More particularly, looking again at Figs. 5 and 6, it will be seen that in the construction shown in Figs. 5 and 6, sleeve 15 comprises a lumen 47 for receiving inflation/deflation tube 45 for inflating/deflating aft balloon 20, and a pair of lumens 52 for receiving support tubes 50 which receive push tubes 30 for manipulating and inflating/deflating fore balloon 35. However, if desired, sleeve 15 may include additional lumens for supporting instruments (or hollow instrument guide tubes) external to endoscope 10.
  • sleeve 15 which includes a plurality of lumens 195 for slidably receiving instruments 190 therein.
  • aft balloon 20 when inflated, aft balloon 20 provides a secure platform for maintaining endoscope 10 and sleeve 15 within a body lumen or body cavity, with endoscope 10 and sleeve 15 centered within the body lumen or body cavity.
  • the distal ends of lumens 195 of sleeve 15 will also be securely maintained within the body lumen or body cavity so as to provide a secure support for instruments advanced through lumens 195 of sleeve 15.
  • the proximal ends of lumens 195 may extend to, and through, base 25, in which case instruments may be inserted into lumens 195 at base 25, or the proximal ends of lumens 195 may terminate proximal to base 25 (but still outside the body of the patient), in which case instruments may be inserted into lumens 195 intermediate sleeve 15.
  • endoscope 10 is 180 cm in length and instruments 190 are 60 cm in length, it can be advantageous to insert instruments 190 into lumens 195 at a point closer to balloons 20, 35 (rather than at base 25). Note that in Fig.
  • Figs. 32-35 show various instruments 190 extending out of lumens 195.
  • instruments 190 preferably comprise articulating instruments, e.g., graspers 190A in Figs 32-35, a cauterizing device 190B in Figs. 32-33, scissors 190C in Figs. 34 and 35, and a suction device 190D in Figs. 32-35.
  • sleeve 15 comprises its central passageway for receiving endoscope 10, lumen 47 for receiving inflation/deflation tube 45, lumens 52 for receiving support tubes 50 which receive push tubes 30, and/or lumens 195 for slidably receiving instruments 190 therein, sleeve 15 is preferably formed by an extrusion process.
  • lumen 47 for receiving inflation/deflation tube 45, lumens 52 for receiving support tubes 50 which receive push tubes 30, and/or lumens 195 for slidably receiving instruments 190 may have a fixed configuration (i.e., a fixed diameter), so that sleeve 15 has a fixed outer profile.
  • lumen 47 for receiving inflation/deflation tube 45, lumens 52 for receiving support tubes 50 which receive push tubes 30, and/or lumens 195 for slidably receiving instruments 190 may have an expandable configuration (i.e., they may have a minimal profile when empty and expand diametrically as needed when filled), so that the overall profile of sleeve 15 is minimized.
  • sleeve 15 comprises a plurality of lumens 195 for slidably receiving instruments 190 therein
  • a support ring may be provided at the distal end of sleeve 15, wherein the support ring provides openings for the passage of push tubes 30 and openings for the passage of instruments 190.
  • the openings in such a support ring for the passage of instruments 190 preferably make a close fit with the instruments so as to provide excellent instrument support at the distal end of sleeve 15.
  • lumens 195 may accommodate hollow instrument guide tubes which themselves accommodate instruments therein.
  • Such hollow instrument guide tubes can provide greater structural integrity to the distal ends of lumens 195 so as to provide improved support for the instruments 190 received within lumens 195.
  • Such hollow instrument guide tubes may be of fixed geometry or of bendable or articulating geometry. See, for example, Fig. 36, which shows hollow instrument guide tubes 200 extending out of lumens 195 and receiving instruments 190 therein.
  • hollow instrument guide tubes 200 may be independently movable relative to one another (and independently movable relative to sleeve 15).
  • instruments 190 preferably make a close fit with hollow instrument guide tubes 200 so as to provide excellent instrument support at the distal end of sleeve 15.
  • the two push tubes 30 may be replaced by a single push tube 30 or by more than two push tubes 30, e g., by three push tubes 30. It will be appreciated that, where a plurality of push tubes 30 are provided, it will generally be desirable to equally -circumferentially-space the push tubes from one another, e.g., where two push tubes 30 are provided, it is generally desirable that the two push tubes 30 be spaced 180 degrees apart, where three push tubes 30 are provided, it is generally desirable that the push tubes be spaced 120 degrees apart, etc.
  • the present invention comprises the provision and use of novel apparatus for manipulating the side wall of a body lumen and/or body cavity so as to better present the side wall tissue (including visualization of areas initially hidden or outside the field of view) for examination and/or treatment during an endoscopic procedure, e.g., to straighten bends, “iron out” inner luminal surface folds and create a substantially static or stable side wall of the body lumen and/or body cavity which enables more precise visual examination (including visualization of areas initially hidden or outside the field of view) and/or therapeutic intervention.
  • the novel apparatus can be used to stabilize, straighten, expand and/or flatten bends and/or curves and/or folds in the side wall of the intestine so as to better present the side wall tissue (including visualization of areas initially hidden or outside the field of view) for examination and/or treatment during an endoscopic procedure.
  • the present invention also comprises the provision and use of novel apparatus capable of steadying and/or stabilizing the distal tips and/or working ends of instruments (e.g., endoscopes, articulating and/or non-articulating devices such as graspers, cutters or dissectors, cauterizing tools, ultrasound probes, etc.) inserted into a body lumen and/or body cavity during an endoscopic procedure with respect to the side wall of the body lumen and/or body cavity, whereby to facilitate the precision use of those instruments.
  • instruments e.g., endoscopes, articulating and/or non-articulating devices such as graspers, cutters or dissectors, cauterizing tools, ultrasound probes, etc.
  • the present apparatus can provide a stable platform (i.e., a stable endoscope, stable therapeutic tools and a stable colon wall, all stable with respect to one another) for the performance of numerous minimally-invasive procedures within a body lumen and/or body cavity, including the stabilization of an endoscope and/or other surgical instruments (e.g., graspers, cutters or dissectors, cauterizing tools, ultrasound probes, etc.) within the body lumen and/or body cavity, e.g., during a lesion biopsy and/or lesion removal procedure, an organ resection procedure, endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR), etc., while at the same time stabilizing the colon (including decreasing deformation of the colon wall) so as to enable more precise visualization, intervention and/or surgery
  • the present invention provides novel apparatus capable of steadying and/or stabilizing the distal tips and/or working ends of endoscopes (and hence also steadying and/or stabilization
  • the present invention provides novel apparatus capable of steadying and/or stabilizing the distal tips and/or working ends of instruments (such as graspers, cutters or dissectors, cauterizing tools, ultrasound probes, etc.) advanced to the surgical site by means other than through the working channels of endoscopes.
  • instruments such as graspers, cutters or dissectors, cauterizing tools, ultrasound probes, etc.
  • the novel apparatus of the present invention can be used in substantially any endoscopic procedure to facilitate the alignment and presentation of tissue during an endoscopic procedure and/or to stabilize the working end of an endoscope (and/or other instruments advanced through the endoscope) relative to tissue or to assist in the advancement of the endoscope during such a procedure.
  • the present invention is believed to have widest applications with respect to the gastrointestinal (GI) tract (e.g., large and small intestines, esophagus, stomach, etc.), which is generally characterized by frequent turns and which has a side wall characterized by numerous folds and disease processes located on and between these folds.
  • GI gastrointestinal
  • the methods and apparatus of the present invention may also be used inside other body lumens (e.g., blood vessels, lymphatic vessels, the urinary tract, fallopian tubes, bronchi, bile ducts, etc.) and/or inside other body cavities (e.g., the head, chest, abdomen, nasal sinuses, bladder, cavities within organs, etc.).
  • a novel system 500 for use in treating diseases and/or infections of the biliary system, and specifically for visualizing the bile duct.
  • the bile duct can become blocked and cause illness or death. It is often desirable to visualize the bile duct to determine whether there is a blockage in the bile duct. Visualization is typically done using fluoroscopy, however, the 2-D images from a fluoroscope provide limited views of the bile duct.
  • D-POCS Direct Per Oral Cholangioscopy
  • the distal endoscope is “turned” (i.e., angled away from the longitudinal axis of the endoscope) towards the bile duct to directly visualize the bile duct.
  • the turn from the duodenum to the bile duct is a sharp turn (i.e , approximately 140 degrees) which is difficult to accomplish with conventional endoscopes.
  • the present invention provides a novel system 500 for deflecting an endoscope positioned in the duodenum into the bile duct in order to visualize the bile duct.
  • System 500 generally comprises apparatus 5 (as previously discussed above) endoscope 10 (as previously discussed above) and an endoscope deflecting device 505 which will be discussed in further detail below.
  • apparatus 5 generally comprises a sleeve 15 having a proximal end 16, a distal end 17 and a lumen 18 extending between the proximal end and the distal end, an aft balloon 20 secured to sleeve 15 near the distal end of the sleeve, and a base 25 secured to sleeve 15 at the proximal end of the sleeve.
  • apparatus 5 also comprises a pair of hollow push tubes 30 slidably mounted to sleeve 1 , and a fore balloon 35 secured to the distal ends of hollow push tubes 30, such that the spacing between aft balloon 20 and fore balloon 35 can be adjusted by the user by moving hollow push tubes 30 relative to sleeve 15 (e.g., by advancing or retracting the two hollow push tubes simultaneously at push tube handle 37).
  • aft balloon 20 and fore balloon 35 can be inflated to create a sealed therapeutic zone between the inflated aft balloon and the inflated fore balloon.
  • hollow push tubes 30 and/or fore balloon 35 may be omitted from apparatus 5 if a procedure does not require the creation of a sealed therapeutic zone between an inflated aft balloon and an inflated fore balloon (e.g., if it is only necessary to seal one end of a body lumen or body cavity).
  • hollow push tubes 20 and/or fore balloon 35 are omitted from sleeve 15, the distal end of sleeve 15 will need to be formed with an atraumatic tip in order to ensure that the distal end of sleeve 15 does not damage tissue as it is being maneuvered through the anatomy of the patient.
  • At least one of aft balloon 20 and fore balloon 35 comprises at least one radiopaque marker (not shown) on at least one of the proximal end and the distal end of aft balloon 20 and fore balloon 35.
  • both the proximal ends and the distal ends of both aft balloon 20 and fore balloon 35 comprise radiopaque markers.
  • Apparatus 5 also comprises an associated inflation mechanism 40 for enabling selective inflation/deflation of aft balloon 20. Furthermore, apparatus 5 comprises associated inflation apparatus (not shown in Figs. 37-48) for inflation/deflation of fore balloon 35 through hollow push tubes 30. If desired, apparatus 5 may also comprise one or more instrument lumens 195 (Fig. 36) for slidably receiving instruments therein. Instrument lumens 195 may be disposed external to lumen 18 of sleeve 15 or within lumen 18 of sleeve 15.
  • endoscope 10 comprises a shaft 11 having a proximal end 12 and a distal end 13.
  • a handle 14 is provided at the proximal end of endoscope 10.
  • the distal end of endoscope 10 is configured to visualize the interior of a body lumen or body cavity when the distal end of the endoscope is positioned in the body lumen or body cavity.
  • endoscope deflecting device 505 comprises a proximal end 510, a distal end 515 and a hollow shaft 520 extending between the proximal end and the distal end.
  • Distal end 515 comprises an adjustable ramp 522 and
  • proximal end 510 comprises an actuator (i.e., a handle 555, a lever 560 and a cable 550) for pivoting adjustable ramp 522 between a first position and a second position, as will be discussed in further detail below.
  • actuator i.e., a handle 555, a lever 560 and a cable 550
  • Hollow shaft 520 of endoscope deflecting device 505 is configured to be slidably received within lumen 18 of sleeve 15 of apparatus 5, with distal end 515 of hollow shaft 520 configured to be selectively disposed within, and projected from, the distal end of sleeve 15.
  • the lumen 524 of hollow shaft 520 is sized to receive endoscope 10, with endoscope 10 configured to be slidably received within handle 555 and lumen 524 of hollow shaft 520, so that the distal end of endoscope 10 can be selectively disposed within, and projected from, the distal end of hollow shaft 520.
  • the internal diameter of lumen 18 of sleeve 15 can be sized to be larger than the outer diameter of hollow shaft 520 so that when hollow shaft 520 is disposed within lumen 18 of sleeve 15, a gap exists between the inner wall of lumen 18 of sleeve 15 and the exterior of hollow shaft 520.
  • the internal diameter of lumen 524 of hollow shaft 520 can be sized to be larger than the outer diameter of endoscope 10 so that when endoscope 10 is disposed within lumen 524 of hollow shaft 520, a gap exists between the inner wall of lumen 524 of hollow shaft 520 and the exterior of endoscope 10.
  • the gap between the inner wall of lumen 18 of sleeve 15 and the exterior of hollow shaft 520 and/or the gap between the inner wall of lumen 524 of hollow shaft 520 and the exterior of endoscope 10 may be used to pass one or more instruments (e.g., a grasper) into the surgical site.
  • instruments e.g., a grasper
  • hollow shaft 520 of endoscope deflecting device 505 comprises a flexible coil 525 which is embedded in the side wall of hollow shaft 520.
  • Flexible coil 525 enables hollow shaft 520 to be flexible enough to maneuver within the anatomy during use, while also providing sufficient structural integrity to hollow shaft 520 to support endoscope 10 when endoscope 10 is disposed within lumen 524 of hollow shaft 520.
  • hollow shaft 520 may comprise regularly-spaced visual markers (not shown), e.g., in the manner of a ruler, so that a user can visualize how far distal end 515 of hollow shaft 520 extends out of lumen 18 of sleeve 15 of apparatus 5.
  • the visual markings are preferably disposed on the proximal end of hollow shaft 520 (i.e., so as to be visible to the user outside of the patient’s anatomy).
  • the regularly-spaced visual markers may be disposed on the distal end of hollow shaft 520 (i.e., so as to be visible to an endoscope disposed within lumen 524 of hollow shaft 520).
  • an inner sleeve 530 extends within lumen 524 of hollow shaft 520 for receiving endoscope 10.
  • Inner sleeve 530 provides a smooth surface within lumen 524 so as to reduce the friction between the outer surface of endoscope 10 and the inner wall of lumen 524 when endoscope 10 is moved within lumen 524 of hollow shaft 520.
  • the distal end of hollow shaft 520 can be bendable and/or steerable relative to the distal end of sleeve 15 when the distal end of hollow shaft 520 is disposed distal to the distal end of sleeve 15.
  • the distal end of hollow shaft 520 can be bent or steered by endoscope 10 when endoscope is positioned within hollow shaft 520.
  • the distal end of hollow shaft 520 can be bent or steered by a cable (not shown) secured to the distal end of hollow shaft 520.
  • hollow shaft 520 may be selectively rotated relative to lumen 18 of sleeve 15 of apparatus 5 by selectively rotating hollow shaft 520 (e.g., by rotating handle 555 so as to effect rotation of hollow shaft 520).
  • visual markers may be provided on the outer surface of hollow shaft 520, whereby to provide a visual indication of the rotational disposition of hollow shaft 520 (and hence, endoscope 10) relative to sleeve 15 of apparatus 5.
  • adjustable ramp 522 of hollow shaft 520 is configured to be moved between a first position, which extends along the longitudinal axis of hollow shaft 520 (Fig. 44), and a second position, which extends at an angle to the longitudinal axis of hollow shaft 520 (Fig. 45), so that when endoscope 10 is disposed within lumen 524 of hollow shaft 520, and the distal end of endoscope 10 is disposed adjacent to adjustable ramp 522, moving adjustable ramp 522 from its first position to its second position will cause the distal end of endoscope 10 to move away from the longitudinal axis of hollow shaft 520. In this way, distal end 515 of hollow shaft 520 can be used to bend or steer the distal end of endoscope 10 when endoscope 10 is disposed within lumen 524 of hollow shaft 520.
  • adjustable ramp 522 comprises a pivotable portion 535 and a fixed portion 540.
  • Pivotable portion 535 is connected to fixed portion 540 by a hinged joint 545.
  • a cable 550 connects pivotable portion 535 to handle 555 so that when lever 560 of handle is pulled proximally, cable 550 will be moved proximally, thereby lifting pivotable portion 535 upward.
  • adjustable ramp 522 may be varied, as desired, in order to adjust the angle of adjustable ramp 522 relative to the longitudinal axis of hollow shaft 520 (and hence to vary the angle of deflection of the distal end of endoscope 10 when endoscope 10 is disposed within lumen 524 of hollow shaft 520).
  • handle 555 preferably also includes a locking ratchet mechanism 556 (Fig. 47A) for selectively locking lever 560 (and hence, cable 550) in a desired position (i.e., in the position that achieves the desired angle of deflection of the distal end of the endoscope).
  • a locking ratchet mechanism 556 for selectively locking lever 560 (and hence, cable 550) in a desired position (i.e., in the position that achieves the desired angle of deflection of the distal end of the endoscope).
  • lever 560 may be pulled proximally so as to move cable 550 proximally, whereby to lift pivotable portion 535 to the desired degree, and lever 560 may thereafter be selectively locked against movement using locking ratchet mechanism 556, so that the desired position of pivotable portion 535 may be maintained.
  • lever 560 may be released from locking ratchet mechanism 556 and lever 560 and cable 550 may be moved distally so as to return pivotable portion 535 to its first position
  • hollow shaft 520 comprises a guide tube 565 for receiving cable 550.
  • Guide tube 565 extends from handle 555, along the length of hollow shaft 520 to fixed portion 540 at the distal end of hollow shaft 520, and opens at a hole 570 formed in fixed portion 540 (Fig. 43), so that cable 550 may pass through guide tube 565 as it extends from handle 555 to fixed portion 540.
  • system 500 may be used to visualize a body lumen or a body organ within the body, with hollow shaft 520 being used to steer the endoscope within the body. More particularly, in a preferred method of use, endoscope 10 is inserted into lumen 524 of hollow shaft 520, and then hollow shaft 520 (carrying endoscope 10) is inserted into the lumen of sleeve 15 of apparatus 5 (Fig. 48). Apparatus 5, endoscope 10 and endoscope deflecting device 505 are then inserted as a unit into a body lumen or a body organ of a patient, and hollow shaft 520 may be used to steer the distal end of endoscope 10 within the body.
  • endoscope 10 and hollow shaft 520 may be used to access and/or visualize the bile duct of a patient, with hollow shaft 520 being used to deflect the endoscope into the bile duct from the duodenum.
  • apparatus 5 (with aft balloon 20 and fore balloon 35 deflated), endoscope 10 and hollow shaft 520 of endoscope deflecting device 505 are advanced as a unit through the upper gastrointestinal tract of the patient (i.e., down the esophagus, through the stomach and into the duodenum) until fore balloon 35 is disposed distal to the bile duct and aft balloon 20 is disposed proximal to the bile duct.
  • aft balloon 20 and fore balloon 35 are inflated so as to seal aft balloon 20 and fore balloon 35 to the gastrointestinal tract, whereby to provide stability for endoscope 10 and hollow shaft 520 within the gastrointestinal tract (Fig. 50).
  • inflated fore balloon 35 has been sealed to the gastrointestinal tract distal to the bile duct, with the inflated fore balloon 35 creating a substantially full-diameter seal across the gastrointestinal tract, and aft balloon 20 has been sealed to the gastrointestinal tract proximal to the bile duct, with the inflated aft balloon 20 acting with sleeve 15 and endoscope 10 to create another substantially full-diameter barrier across the gastrointestinal tract, whereby to provide an isolated therapeutic zone distal and proximal to the bile duct.
  • hollow shaft 520 (carrying endoscope 10 within) may be advanced out of the distal end of sleeve 15 and turned towards the bile duct.
  • Trigger 560 may then be pulled back so as to cause pivotable portion 535 to move up to a desired angle, thereby causing the distal end of endoscope 10 to move up within the duodenum and into the bile duct.
  • Endoscope 10 can then be used to visualize the interior of the bile duct (Fig. 53).
  • instruments can be advanced through the endoscope, through the gap between the inner wall of lumen 18 of sleeve 15 and the exterior of hollow shaft 520, through the gap between the inner wall of lumen 524 of hollow shaft 520 and the exterior of endoscope 10 and/or through instruments lumens 195 provided on apparatus 5, to perform a procedure within the bile duct.
  • apparatus 5 endoscope 10 and hollow shaft 520 of endoscope deflecting device 505 are withdrawn from the anatomy.
  • this is done by returning endoscope 10 and adjustable ramp 522 of hollow shaft 520 to a straight configuration, deflating fore balloon 35 and aft balloon 20, and then withdrawing apparatus 5, endoscope 10 and hollow shaft 520 as a unit from the anatomy.
  • apparatus 5 it may be desirable to reduce the outer diameter of apparatus 5, particularly when apparatus 5 is to be maneuvered through the upper gastrointestinal tract of a patient. In this circumstance, and when it is not necessary to create a sealed therapeutic zone between an inflated aft balloon and an inflated fore balloon, hollow push tubes 30 and/or fore balloon 35 can be removed from apparatus 5.
  • apparatus 5 without hollow push tubes 30 and/or fore balloon 35 can be used with endoscope 10 to access and/or visualize the bile duct of a patient, with hollow shaft 520 being used to deflect the endoscope into the bile duct from the duodenum.
  • apparatus 5 (without push tubes 30 and/or fore balloon 35), endoscope 10 and hollow shaft 520 of endoscope deflecting device 505 are advanced as a unit (with aft balloon 20 deflated) through the upper gastrointestinal tract of the patient (i.e., down the esophagus, through the stomach and into the duodenum) until aft balloon 20 is disposed proximal to the bile duct (Fig. 54).
  • Aft balloon 20 is then inflated so as to seal aft balloon 20 to the gastrointestinal tract proximal to the bile duct (Fig. 55), whereby to provide stability for sleeve 15 (and hence endoscope 10). If desired, inflated aft balloon 20 may be pulled proximally to enhance the seal of aft balloon 20 to the gastrointestinal tract.
  • inflated aft balloon 20 acts with sleeve 15 and endoscope 10 to stabilize sleeve 15 (and hence endoscope 10) within the gastrointestinal tract and to create a substantially full-diameter barrier across the gastrointestinal tract, whereby to prevent fluid or debris (e.g., saline, blood, blood clots, etc.) from flowing “upstream” into the stomach and/or esophagus (i.e., refluxing).
  • fluid or debris e.g., saline, blood, blood clots, etc.
  • hollow shaft 520 (carrying endoscope 10 within) may be advanced out of the distal end of sleeve 15 and turned towards the bile duct. Trigger 560 may then be pulled back so as to cause pivotable portion 535 to move up to a desired angle, thereby causing the distal end of endoscope 10 to move up within the duodenum and into the bile duct. Endoscope 10 can then be used to visualize the interior of the bile duct.
  • instruments can be advanced through the endoscope, through the gap between the inner wall of lumen 18 of sleeve 15 and the exterior of hollow shaft 520, through the gap between the inner wall of lumen 524 of hollow shaft 520 and the exterior of endoscope 10 and/or through instruments lumens 195 provided on apparatus 5, to perform a procedure within the bile duct.
  • apparatus 5 endoscope 10 and hollow shaft 520 of endoscope deflecting device 505 are withdrawn from the anatomy.
  • endoscope 10 and adjustable ramp 522 of hollow shaft 520 are returned to a straight configuration, deflating aft balloon 20, and then withdrawing apparatus 5, endoscope 10 and hollow shaft 520 of endoscope deflecting device 505 as a unit from the anatomy.
  • a novel system 500A and method for using the same which may be used for treating diseases and/or infections of the upper gastrointestinal tract, and/or for visualizing the bile duct of the biliary system.
  • System 500A generally comprises a novel apparatus 5A for securing system 500A in the anatomy, endoscope 10 (as previously discussed above), and a novel endoscope deflecting device 505A for selectively pivoting the distal end of an endoscope, as will hereinafter be discussed in further detail.
  • Apparatus 5 A is generally similar to apparatus 5 discussed above, except that push tubes 30 and fore balloon 35 have been omitted from apparatus 5 A.
  • apparatus 5A generally comprises a sleeve 15A having a proximal end 16A, a distal end 17A and a lumen 18A (Fig. 63) extending therebetween.
  • an aft balloon 20A is secured to sleeve 15A proximate to distal end 17A of sleeve 15 A.
  • Aft balloon 20A can be formed in the same shape as aft balloon 20 described above (i.e., a generally toroidal shape), or in the same shape as fore balloon 35 described above (i.e., a “torus” shape when deflated to allow it to seat over the distal end of the sleeve/endoscope and a substantially “solid” shape when inflated to allow it to close off a body lumen or body cavity), or any other shape which will permit aft balloon 20A to atraumatically engage and form a sealing relationship with the side wall of a body lumen or body cavity within which apparatus 5A is disposed.
  • a base 25 A is secured to sleeve 15A at proximal end 16A of sleeve 15 A.
  • Base 25A comprises a central passageway 26A having a proximal opening 27A in fluid communication with lumen 18A of sleeve 15A when sleeve 15A is mounted to base 25A.
  • an endoscope seal 615 fluidically seals passageway 26A when endoscope 10 is not disposed within passageway 26A and lumen 18A of sleeve 15A and/or seals around the outer surface of endoscope 10 when endoscope 10 is disposed within passageway 26A and lumen 18 A.
  • An inflation/deflation line 45A extends between an inflation mechanism 40A and aft balloon 20A for selectively inflating/deflating aft balloon 20A, as will hereinafter be discussed in further detail.
  • inflation/deflation line 45A is mounted to the exterior surface of sleeve 15A (Fig. 63) so as to extend alongside sleeve 15A (and hence, alongside an endoscope disposed within sleeve 15 A).
  • sleeve 15A may also comprise one or more instrument lumens 195 for slidably receiving instruments therein.
  • Instrument lumens 195 may be disposed external to lumen 18A of sleeve 15A or within lumen 18A of sleeve 15 A.
  • sleeve 15A is formed out of a flexible material having appropriate column strength to prevent sleeve 15A from collapsing upon endoscope 10 and/or endoscope deflecting device 505 A (e.g., kinking) as apparatus 5 A, endoscope 10 and/or endoscope deflecting device 505 A are positioned within, or withdrawn from, the anatomy of a patient.
  • endoscope 10 and/or endoscope deflecting device 505 A e.g., kinking
  • proximal end 16A of sleeve 15A may be secured to base 25 A via a sleeve attachment 610 (Figs. 62 and 70-72).
  • distal end 17A of sleeve 15A is formed with an atraumatic tip (e g., nose cone 605, see Figs. 61 and 62) in order to ensure that distal end 17A of sleeve 15A does not cause trauma to the anatomy (e.g., damage tissue) as sleeve 15A is being maneuvered through the body lumen or body cavity of the patient.
  • an atraumatic tip e g., nose cone 605, see Figs. 61 and 62
  • Forming distal end 17A of sleeve 15A with an atraumatic tip is particularly important with this form of the invention because push rods 30 and fore balloon 35 are no longer disposed at the distal end of sleeve 15A (and hence, neither push rods 30 nor fore balloon 35 are available to provide an atraumatic distal end to apparatus 5A when apparatus 5A is moved through the anatomy).
  • base 25A is generally similar to the aforementioned base 25 discussed above in that it provides a “handle” for the user to grip, however, the push tube handle 37 has been omitted from base 25 A since it is no longer necessary to provide a mechanism for moving the omitted push tubes 30 and fore balloon 15 relative to the distal end of the sleeve.
  • Base 25 A is configured to receive endoscope 10 within passageway 26A and help secure apparatus 5A to endoscope 10.
  • base 25 A preferably comprises a substantially rigid or semi-rigid structure which may be gripped by the physician (or other operator or user) and pulled proximally, whereby to allow the physician (or other operator or user) to insert the distal end of endoscope 10 into proximal opening 27A of base 25 A (penetrating/separating seal 615), and to pull sleeve 15A over the distal end of endoscope 10 and then proximally back along the length of endoscope 10, whereby to mount sleeve 15A to the outer surface of the shaft of the endoscope.
  • aft balloon 20A may comprise at least one radiopaque marker (not shown) on at least one of a proximal end and a distal end of aft balloon 20A.
  • both the proximal end and the distal end of aft balloon 20A comprise radiopaque markers.
  • a user is able to visualize (e.g., via fluoroscopy or other imaging means) the position of the proximal end of aft balloon 20A and the distal end of aft balloon 20A within the patient’s anatomy during a surgical procedure.
  • Endoscope deflecting device 505A comprises a proximal end 510A, a distal end 515A and a hollow shaft 520A defining a lumen 524A extending therebetween. See Fig. 80.
  • Distal end 515A comprises an adjustable ramp 522A and proximal end 510A comprises an actuator (e.g., a handle 555A, a lever 560A and two cables 550A) for selectively pivoting adjustable ramp 522A, as will be discussed in further detail below.
  • actuator e.g., a handle 555A, a lever 560A and two cables 550A
  • Endoscope deflecting device 505A is generally similar to endoscope deflecting device 505 discussed above except that, with endoscope deflecting device 505A, (i) hollow shaft 520A is formed from a single piece of flexible material having a plurality of slits formed along its length, (ii) the distal end of hollow shaft 520A comprises an adjustable ramp 522A which can be selectively pivoted at a plurality of pivot points, and (iii) two cables are connected to the adjustable ramp 522A for pivoting the adjustable ramp, as will be discussed in further detail below.
  • Hollow shaft 520A of endoscope deflecting device 505A comprises a single piece of flexible material having a plurality of slits 620 formed along the length of the hollow shaft. See Figs. 80 and 82-84.
  • the single piece of flexible material is selected so as to provide sufficient structural integrity for supporting endoscope 10 (or a slightly smaller-sized endoscope 10A, see below) when endoscope 10 is disposed within lumen 524A of hollow shaft 520A, while the plurality of slits 620 provide hollow shaft 520A with the flexibility needed to maneuver endoscope deflecting device 505A within the anatomy (e.g., along a tortuous path of a body lumen) during use.
  • the flexible material selected to form hollow shaft 520A comprises polytetrafluoroethylene (PTFE).
  • Endoscope deflecting device 505A is sized to be received within passageway 26A of base 25 A and lumen 18A of sleeve 15 A.
  • Lumen 524A of hollow shaft 520A of endoscope deflecting device 505A is sized to receive endoscope 10 (or a smaller sized endoscope 10A) therein.
  • endoscope 10 (or smaller endoscope 10A) may be disposed within lumen 524A of hollow shaft 520A of endoscope deflecting device 505 A, and then sleeve 15A may be mounted over endoscope deflecting device 505 A (carrying endoscope 10 or endoscope 10A) such that distal end 515A of hollow shaft 520A of endoscope deflecting device 505 A and the distal end of endoscope 10 (or smaller endoscope 10A) extend distally beyond distal end 17A of sleeve 15A. See Fig. 91 .
  • hollow shaft 520A of endoscope deflecting device 505A may comprise regularly-spaced visual markers (not shown), e.g., in the manner of a ruler, so that a user can visualize how far distal end 515A of hollow shaft 520A extends distally out of lumen 18A of sleeve 15A of apparatus 5A.
  • the visual markings are preferably disposed on proximal end 510A of hollow shaft 520A (i.e., so as to be visible to the user outside of the patient’s anatomy).
  • the regularly-spaced visual markers may be disposed on distal end 515A of hollow shaft 520A (i.e., so as to be visible to an endoscope disposed within lumen 524A of hollow shaft 520A).
  • hollow shaft 520A may comprise visual markers (not shown) on the outer surface of hollow shaft 520A for providing a visual indication of the rotational disposition of hollow shaft 520A (and hence, an endoscope) relative to sleeve 15A of apparatus 5 A.
  • adjustable ramp 522A of hollow shaft 520A is configured to be moved between a first, straightened position, which extends generally parallel to the longitudinal axis of hollow shaft 520A (Fig. 80), and an angled (or arced) position, which extends at an angle (or arc) to the longitudinal axis of hollow shaft 520A (Figs. 80).
  • adjustable ramp 522A comprises two grooves 625 which form pivot points 630. See Figs. 83 and 84. However, it should be appreciated that, if desired, adjustable ramp 522A could comprise more than two grooves 625 in order to provide adjustable ramp 522A with the desired pivotability.
  • adjustable ramp 522A may further comprise one or more radiopaque markers so that a physician (or other operator or user) observing the surgical site via an endoscope or by radiological guidance (e.g., via X-ray, fluoroscopy or other imaging means) can ascertain the relative disposition of adjustable ramp 522A at the surgical site both longitudinally and/or circumferentially with respect to the side wall of the body lumen and/or other body cavity.
  • First and second cables 550A (Fig.
  • first and second cables 550A connect the distal end of adjustable ramp 522A to handle 555A so that when lever 560A of handle is pulled proximally, first and second cables 550A will be moved proximally, thereby causing adjustable ramp 522A to pivot at pivot points 630 and lift adjustable ramp 522A “upward” (i.e., pivoting ramp 522A relative to the longitudinal axis of endoscope deflecting device 505A).
  • the distal ends of first and second cables are passed through holes 635 (Fig. 89) formed in the distal end of adjustable ramp 522A.
  • one hole 635 is disposed on the left side of adjustable ramp 522A and one hole 635 is disposed on the right side of adjustable ramp 522A (e.g., such that the two holes 635 are diametrically-opposed to one another).
  • cables 550A will be disposed on the left and right side of an endoscope disposed within hollow shaft 520A, and when the adjustable ramp 522A is moved upward, the endoscope extending out of the distal end of hollow shaft 520A will stay aligned with pivot points 630.
  • cables 550A are formed out of stainless steel. If desired, one or both of cables 550A may be provided with one or more radiopaque markers so that a physician (or other operator or user) observing the surgical site via endoscope 10 or by radiological guidance (e.g., via X-ray, fluoroscopy or other imaging means) can ascertain the relative disposition of cables 550A at the surgical site both longitudinally and/or circumferentially with respect to the side wall of the body lumen and/or other body cavity.
  • radiological guidance e.g., via X-ray, fluoroscopy or other imaging means
  • handle 555A preferably also includes a locking ratchet mechanism 556A (Figs. 102-105) for selectively locking lever 560A (and hence, cables 550A) in a desired position (i.e., in the position that achieves the desired angle of deflection of the distal end of the endoscope disposed within lumen 524A of endoscope deflecting device 505A).
  • locking ratchet mechanism 556A generally comprises a geared wheel 557A for selectively rotating a spindle 558A.
  • Cables 55OA are mounted to spindle 558A of ratchet mechanism 556A such that rotation of geared wheel 557A in a first direction causes increased tension (i.e., a proximally-directed force) in one or more cables 55OA as the one or more cables 550A are wound about spindle 558A, thereby effecting pivoting of adjustable ramp 522A and maintaining adjustable ramp 522A in a pivoted condition until locking ratchet mechanism 556A is unlocked, whereby to permit the geared wheel to rotate in a second, opposite direction so as to unspool the one or more cables 550A wound about spindle 558A, thereby eliminating the tension in cables 550A.
  • lever 560A may be pulled proximally so as to move cables 550A proximally, whereby to pivot adjustable ramp 522A to the desired degree, and lever 560A may thereafter be selectively locked against movement using locking ratchet mechanism 556A, so that the desired position of adjustable ramp 522A may be maintained. Subsequently, lever 560A may be released from locking ratchet mechanism 556A and lever 560A and cables 550A may be moved distally so as to return adjustable ramp 522A to its first (i.e., straightened) position.
  • system 500A may be used to visualize a body lumen or a body organ within the body, with hollow shaft 520A of endoscope deflecting device 505A being used to steer the endoscope within the body.
  • apparatus 5 A can be used with endoscope 10 to access and/or visualize the bile duct of a patient, with hollow shaft 520A of endoscope deflecting device 505A being used to deflect the distal end of endoscope 10 into the bile duct from the duodenum.
  • an endoscope that is sized to be received in the bile duct should be selected (e.g., an ultra-slim endoscope 10A) because a standard endoscope is too large to be received in the bile duct.
  • endoscope 10 refers to standard endoscopes as well as smaller-sized endoscopes 10A (e.g., endoscopes having a smaller diameter than endoscope 10), with the size of the endoscope being selected based on where in the anatomy the endoscope will be used to access and/or visualize the body lumen or body cavity, as will be readily apparent to one having ordinary skill in the art.
  • endoscope 10 refers to standard endoscopes as well as smaller-sized endoscopes 10A (e.g., endoscopes having a smaller diameter than endoscope 10), with the size of the endoscope being selected based on where in the anatomy the endoscope will be used to access and/or visualize the body lumen or body cavity, as will be readily apparent to one having ordinary skill in the art.
  • endoscope 10 e.g., a standard sized endoscope
  • apparatus 5A Fig. 106
  • apparatus 5 A and endoscope 10 are advanced as a unit (with aft balloon 20A deflated) through the upper gastrointestinal tract of the patient (i.e., down the esophagus, through the stomach and into the duodenum) until aft balloon 20A is disposed proximal to the bile duct (Fig. 107).
  • Aft balloon 20A is then inflated so as to seal aft balloon 20A to the gastrointestinal tract proximal to the bile duct (Fig. 108), whereby to provide stability for sleeve 15 A (and hence endoscope 10). If desired, inflated aft balloon 20A may be pulled proximally to enhance the seal of aft balloon 20A to the gastrointestinal tract.
  • inflated aft balloon 20A acts with sleeve 15A and endoscope 10 to stabilize sleeve 15A (and hence endoscope 10) within the gastrointestinal tract and to create a substantially full-diameter barrier across the gastrointestinal tract, whereby to prevent fluid or debris (e.g., saline, blood, blood clots, etc.) from flowing “upstream” into the stomach and/or esophagus (i.e., refluxing).
  • fluid or debris e.g., saline, blood, blood clots, etc.
  • Endoscope 10 is then removed from sleeve 15A leaving sleeve 15A in position within the gastrointestinal tract.
  • a second, smaller-sized endoscope 10A is then inserted into hollow shaft 520A of endoscope deflecting device 505A such that the distal end of endoscope 10A extends distally from distal end 515A of hollow shaft 520A of endoscope deflecting device 505 A.
  • Endoscope 10A and hollow shaft 520A of endoscope deflecting device 505A are then inserted into passageway 26A of base 25A and lumen 18A of sleeve 15 and advanced distally as a unit through sleeve 15A (i.e., down the esophagus, through the stomach and into the duodenum) until endoscope 10A and adjustable ramp 522 are disposed at the bile duct (Fig. 109).
  • hollow shaft 520A (carrying endoscope 10A within) may be advanced distally out of the distal end of sleeve 15A and turned towards the bile duct.
  • Trigger 560A may then be pulled so as to tension cables 550A, whereby to cause adjustable ramp 522A to move up to a desired angle, thereby causing the distal end of endoscope 10A to move “up” (i.e., to bend relative to the longitudinal axis of endoscope 10A) within the duodenum and into the bile duct.
  • Endoscope 10A can then be used to visualize the interior of the bile duct.
  • Endoscope deflecting device 505A may be adjusted as needed during visualization to further advance and guide endoscope 10A into the bile duct.
  • hollow shaft 520A may be longitudinally advanced, retracted or rotated within sleeve 15 A, and/or the angle of adjustable ramp 522A may be manipulated so as to adjust the angle of the distal end of endoscope 10A, as needed to advance and guide endoscope 10A into the bile duct.
  • instruments can be advanced through instrument channels provided in the endoscope, through the gap between the inner wall of lumen 18A of sleeve 15A and the exterior of hollow shaft 520A and/or through the gap between the inner wall of lumen 524A of hollow shaft 520A and the exterior of endoscope 10A.
  • apparatus 5 A, endoscope 10A and hollow shaft 520A of endoscope deflecting device 505A are withdrawn from the anatomy.
  • this is done by returning endoscope 10A and adjustable ramp 522A of hollow shaft 520A to a straight configuration, deflating aft balloon 20A, and then withdrawing apparatus 5 A, endoscope 10A and hollow shaft 520A of endoscope deflecting device 505A as a unit from the anatomy.

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Abstract

Appareil permettant d'accéder à une lumière corporelle comprenant : un arbre creux, la lumière de l'arbre creux étant conçue pour recevoir un endoscope, et l'extrémité distale de l'arbre creux comprenant une partie réglable qui est conçue pour être articulée entre (i) une configuration droite parallèle à un axe longitudinal de l'arbre, et (ii) une configuration inclinée dans laquelle la partie réglable est disposée selon un angle par rapport à l'axe longitudinal de l'arbre, ce qui permet de courber l'endoscope disposé à l'intérieur de la lumière de l'arbre creux ; un manchon conçu pour recevoir l'arbre creux et l'endoscope disposé à l'intérieur de celui-ci ; et un ballonnet monté sur le manchon.
PCT/US2023/021387 2022-05-06 2023-05-08 Procédé et appareil pour manipuler une paroi latérale d'une lumière corporelle WO2023215640A1 (fr)

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