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Methods, devices, tools and assemblies for treating a patient to effect weight loss. One method embodiment involves passing a device including an expandable member in a collapsed configuration and a buoyancy member through an opening in the skin of a patient and into the abdominal cavity of the patient, and anchoring at least a portion of the expandable member, relative to at least one structure in the abdominal cavity. Devices including at least one expandable member and at least one buoyancy member are provided.
1. A method of treating a patient, said method comprising:
making an incision in the skin of the patient;
establishing a delivery tract, from outside of the patient, through the incision, subcutaneous tissues and abdominal wall to provide an access opening into the abdominal cavity, including inserting a cannula from outside of the patient and dilating an opening from said incision through the abdominal wall of the patient, so that a distal end portion of said cannula extends into the abdominal cavity and a proximal end of said cannula extends out of the patient;
inserting a device temporarily mounted to a distal end portion of a device delivery tool through the opening and the delivery tract and into the abdominal cavity of the patient; and
attaching the device to the abdominal wall at a location adjacent said distal end portion of said device delivery tool, by operation of said device delivery tool at a proximal end portion of said device delivery tool, outside the body of the patient,
wherein the device comprises an expandable main body portion, said method further comprises expanding said expandable main body portion after said inserting the device into the abdominal cavity.
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7. A method of treating a patient, said method comprising:
making an incision in the skin of the patient;
establishing a delivery tract, from outside of the patient, through the incision, subcutaneous tissues and abdominal wall to provide an access opening into the abdominal cavity, including inserting a cannula from outside of the patient so that a distal end portion of said cannula extends into the abdominal cavity and a proximal end portion of said cannula extends out of the patient;
passing a device through said cannula and into the abdominal cavity of the patient, wherein the device includes at least one reinforced attachment tab extending from an expandable main body portion thereof;
positioning and expanding the expandable main body portion so that said at least one reinforced attachment tab approximates an interior surface of the abdominal wall of the patient; and
attaching said at least one attachment tab to the interior surface of the abdominal wall, by operation of a proximal end portion of a device delivery tool, at a location removed from an opening through the abdominal wall established by said delivery tract.
8. The method of
9. The method of
This application is a continuation of co-pending application Ser. No. 11/716,986, filed Mar. 10, 2007, which claims the benefit of U.S. Provisional Application No. 60/877,595, filed Dec. 28, 2006, and this application is a continuation-in-part application of co-pending application Ser. No. 11/407,701, filed Apr. 19, 2006, each of which are incorporated herein by reference thereto, in their entireties, and to which applications we claim priority under 35 USC �120, and 35 USC �119, respectively.
This application also hereby incorporates herein by reference thereto, in its entirety, co-pending application Ser. No. 11/716,985filed on Mar. 10, 2007, and titled "Devices and Methods for Treatment of Obesity".
The present invention relates to treatment of obesity, more particularly to implantable devices and methods of implanting the devices in the abdominal cavity to treat an obese patient.
Obesity has become a major health concern, both nationally and internationally. The National Center for Health Statistics (NCHS) estimates that over 120 million Americans are overweight, including about 56% of the adult population. Of these, about 52 million are considered obese, as measured by a body mass index (BMI) of 30 or greater. In Europe, an estimated 77 million people are obese, as measured by the same standard. This problem is not limited to western nations, as many developing countries are reported to have obesity rates over 75% of the adult population.
Co-morbidities that are associated with obesity include, but are not limited to type II Diabetes, high blood pressure, sleep apnea, stroke and arthritis, the symptoms of which often tend to be lessened or alleviated upon loss of weight by a person so affected.
In the U.S., options for treatment of obesity are currently quite limited. Current treatment methodologies typically rely upon surgically introducing a "malabsorptive" environment in the gastro-intestinal tract, a restrictive environment, or a combination of these. One available treatment method is gastric bypass surgery and another is referred to as gastric banding (one of these techniques is referred to as the LAPBAND™ procedure). These procedures are limited to only those patients with a BMI over 40 (or over 35, with co-morbidities present).
Gastric bypass procedures incur a great deal of morbidity and create a malabsorptive state in the patient by bypassing a large portion of the intestines. Serious side effects, such as liver failure have been associated with this procedure, as well as chronic diarrhea. Another surgical procedure that has a high degree of morbidity associated with it is known as the "Gastric Bypass Roux-en-Y" procedure. This procedure reduces the capacity of the stomach by creating a smaller stomach pouch. The small space holds only about one ounce of fluid. A tiny stomach outlet is also surgically created to slow the speed at which food leaves the stomach. Staples are used to create a small (15 to 20 cc) stomach pouch, with the rest of the stomach being stapled completely shut and divided from the stomach pouch. The small intestine is divided just beyond the duodenum, brought up, and connected to the newly formed stomach pouch. In addition to the considerable morbidity associated with this procedure, other disadvantages include "dumping syndrome", where stomach contents are literally "dumped" rapidly into the small intestine which may lead to nausea, weakness, sweating, faintness, and diarrhea; hernias resulting from the surgery; gallstones; leakage of the connection between the pouch and the intestine; stretching of the pouch that was formed; nutritional deficiencies; and possible dehiscence of the staples.
The LAPBAND™ is a band that, when placed, encircles the fundus-cardia junction and is inflatable to constrict the same. It does not reduce the volume of the stomach, but rather restricts passage of food into the stomach, the theory being that the patient will feel satiety with a much smaller volume of food than previously. Although the LAPBAND™ procedure is less invasive than a gastric bypass procedure, it also typically achieves less weight loss. Further, it is not a simple procedure and requires a substantial amount of training by a surgeon to become proficient in performing the procedure. Also, a substantial amount of dissecting and suturing is required because the pathway by which the band is introduced is not an existing pathway, and must be established by dissection. Great care is required to avoid blood vessels and nerves that may be in the intended pathway to be created by the dissection. After placing the band around the fundus-cardia junction, the ends of the band must be connected together and then it must be cinched down into place. Additionally, complications such as erosion at the fundus-cardia junction, slippage of the band from its intended location, nausea/vomiting, gastroesophageal reflux, dysphagia and lack of effectiveness in causing weight loss have been reported.
Intragastric balloons have also been placed, in an attempt to fill a portion of the volume in the stomach, with the theory being that it will then require less food than previously, to give the patient a sensation of fullness or satiety. This procedure involves delivery of a balloon (typically, transorally) to the interior of the stomach and inflation of the balloon to take up a portion of the volume inside the stomach. However, intragastric balloons may also lead to complications such as obstruction, vomiting and/or mucosal erosion of the inner lining of the stomach. The balloon can break down over extended exposure to the stomach's acids, and in some cases, after breaking down, the balloon translated through the intestines and caused a bowel obstruction.
Gastrointestinal sleeves have been implanted to line the stomach and/or a portion of the small intestines to reduce the absorptive capabilities of the small intestine and/or to reduce the volume in the stomach, by reducing the available volume to the tubular structure of the graft running therethrough. Although weight loss may be effective while these types of devices are properly functioning, there are complications with anchoring the device within the stomach/GI tract, as the stomach and GI tract function to break down things that enter into them and to move/transport them through. Accordingly, the integrity of the anchoring of the device, as well as the device itself may be compromised over time by the acids and actions of the stomach and GI tract.
A sleeve gastrectomy is an operation in which the left side of the stomach is surgically removed. This results in a much reduced stomach which is substantially tubular and may take on the shape of a banana. This procedure is associated with a high degree of morbidity, as a large portion of the stomach is surgically removed. Additionally, there are risks of complications such as dehiscence of the staple line where the staples are installed to close the surgical incisions where the portion of the stomach was removed. Further, the procedure is not reversible.
In the laparoscopic duodenal switch, the size of the stomach is reduced in similar manner to that performed in a sleeve gastrectomy. Additionally, approximately half of the small intestine is bypassed and the stomach is reconnected to the shortened small intestine. This procedure suffers from the same complications as the sleeve gastrectomy, and even greater morbidity is associated with this procedure due to the additional intestinal bypass that needs to be performed. Still further, complications associated with malabsorption may also present themselves.
An inflatable gastric device is disclosed in U.S. Pat. No. 4,246,893, in which a balloon is inserted anteriorly of the stomach and posteriorly of the left lobe of the liver. The balloon is then inflated to compress the stomach so that it fills with less food that would ordinarily be possible. Not only does this device compress the stomach, but it also compresses the liver, as seen in
Brazzini et al. in WO2005/18417 discloses at least two or more expandable devices used to treat obesity, in which the devices are inserted through the abdominal wall and anchored against the external surface of the stomach wall by an anchoring mechanism that extends through the stomach wall and fixes to the internal surface of the stomach wall.
U.S. Patent Publication No. 2005/0261712 to Balbierz et al. describes capturing a device against the outer surface of the stomach wall to form a restriction that appears to function similarly to the restriction imposed by the LAPBAND™. The anchoring of the devices disclosed relies upon placement of features against the internal wall of the stomach to form an interlock with the device which is placed against the external wall of the stomach.
U.S. Patent Publication Nos. 2005/0267533 and 2006/0212053 to Gertner disclose devices for treatment of obesity that use one or more anchoring mechanisms that are passed through the wall of the stomach to establish an anchor.
U.S. Pat. No. 6,981,978 to Gannoe discloses devices for reducing the internal cavity of the stomach to a much smaller volume, which may be used to carry out a bypass procedure. Stapling is employed to isolate the smaller volume in the stomach, and thus the same potential disadvantages are present as with other stapling procedures described herein.
U.S. Pat. No. 6,186,149 to Pacella et al. describes an occluder device that can be used as a dietary control device (see
Gastric reduction techniques have been attempted, such as by inserting instruments trans-orally and reducing the volume of the stomach by stapling portions of it together. However, this technique is prone to failure due to the staples pulling through the tissues that they are meant to bind.
Techniques referred to as gastric pacing endeavor to use electrical stimulation to simulate the normal feedback mechanisms of a patient that signal the brain that the patient is full, or satiated. While these techniques are less invasive than some of the other existing treatments, statistics to date have shown that the amount of weight lost by using such techniques is less than satisfactory.
Currently marketed drugs for weight loss, such as XENICAL�, MERIDIA� and Phen fen have largely failed, due to unacceptable side effects and complications, and sometimes to an ineffective amount of weight loss. Other drugs that are on the horizon include ACCOMPLIA� and SYMLIN�, but these are, as yet, unproven.
The risk and invasiveness factors of currently available surgeries are often too great for a patient to accept to undergo surgical treatment for his/her obesity. Accordingly, there is a need for less invasive, yet effective surgical treatment procedures for morbidly obese patients (patients having a BMI of 35 or greater). Also, since the current surgical procedures are currently indicated only for those patients having a BMI of 40 or greater, or 35 or greater when co-morbidities are present, it would be desirable to provide a surgical procedure that would be available for slightly less obese patients, e.g., patients having a BMI of 30 to 35 who are not indicated for the currently available surgical procedures. It would further be desirable to provide a surgical procedure that would be indicated for obese patients having a BMI in the range of 30-35, as well as for more obese patients.
The present invention provides methods, devices, tools and assemblies for treating a patient to assist with weight loss. One method embodiment involves passing a device including an expandable member in a collapsed configuration and a buoyancy member into the abdominal cavity of the patient, and anchoring at least a portion of the expandable member, relative to at least one structure in the abdominal cavity.
A method of treating a patient is provided that includes the steps of: passing a device into the abdominal cavity of the patient, wherein the device includes at least one attachment member extending from a main body portion thereof; positioning an inferior portion of the device in the abdominal cavity; and anchoring that at least one attachment member to an inner surface of the abdominal wall.
A method of treating a patient is provided that includes steps of: passing a guide rail into the abdominal cavity of the patient; passing an anchoring frame, guided by the guide rail, into the abdominal cavity; anchoring the anchoring frame to at least one structure in the abdominal cavity; passing a device, guided by the guide rail, into the abdominal cavity; and attaching the device to the anchoring frame.
A method of treating a patient is provided that includes steps of: passing a guide rail into the abdominal cavity of the patient, wherein the guide rail is selected from one of: at least one guidewire; at least one flexible wire facilitating viewing out of a distal end portion thereof from a proximal end portion thereof; at least one rod; or a flexible steerable catheter; passing an anchoring frame, guided by the guide rail, into the abdominal cavity; anchoring the anchoring frame to at least one structure in the abdominal cavity; passing a device, guided by the guide rail, into the abdominal cavity; and attaching the device to the anchoring frame.
A method of treating a patient is provided, including steps of: passing an anchoring frame into the abdominal cavity of the patient; delivering anchoring members, attached to the anchoring frame, through at least one structure in the abdominal cavity that the anchoring frame is to be anchored to, through the skin and out of the patient; fixing the anchoring members externally of the abdominal cavity to anchor the anchoring frame to the at least one structure in the abdominal cavity; passing a device, into the abdominal cavity; and attaching the device to the anchoring frame.
A method of treating a patient is provided, including steps of: passing a buoyancy member into the abdominal cavity of the patient; anchoring the buoyancy member to at least one structure in the abdominal cavity; passing a device into the abdominal cavity; and attaching the device to the buoyancy member.
A method of treating a patient is provided, including steps of: passing a device including an expandable member having at least one trans-abdominally detectable marker; advancing the device into the abdominal cavity of the patient while tracking and guiding the advancing by trans-abdominally detecting the location of the at least one marker, relative to the patient's anatomy, as the device is advanced; and anchoring at least a portion of the expandable member, relative to at least one structure in the abdominal cavity.
A method of monitoring functionality of a device implanted in the abdominal cavity of a patient to enhance weight loss is provided, including: providing a handheld monitoring device outside of the patient; and wirelessly communicating with at least one sensor on the device located in the abdominal cavity.
A method of treating a patient is provided, including: providing a device implanted in the abdominal cavity of the patient, wherein the device occupies a space in the abdominal cavity to perform at least one of: prevention of expansion of the stomach of the patient into the space and compression of a portion of the stomach; wherein the device includes at least one electrode on a surface thereof in contact with the stomach of the patient, said at least one electrode being electrically connected to a stimulation signal controller; and delivering a stimulation signal from the controller to the at least one electrode to stimulate at least one contraction of at least one muscle in the stomach.
A method of treating a patient is provided, including: passing a device into the abdominal cavity of the patient; anchoring at least a portion of the device, relative to at least one structure in the abdominal cavity; and occupying a space in the abdominal cavity with the device to substantially restrict expansion of the fundus of the stomach, and restraining the stomach to a shape resembling a tube, but wherein at least a portion of the antrum is left unrestrained.
A method of treating a patient is provided, including: passing a device into the abdominal cavity of the patient; anchoring at least a portion of the device, relative to at least one structure in the abdominal cavity; and occupying a space in the abdominal cavity with the device to substantially restrict expansion of the fundus of the stomach, and restraining the stomach to a shape resembling a tube, but wherein a small pouch is left unrestrained at a superior end portion of the stomach.
An implantable device for treatment of a patient to assist weight loss is provided, wherein the device includes: an expandable member configured to be positioned in an abdominal cavity of the patient, the expandable member configured to be expanded from a contracted configuration to an expanded configuration after placement of the device in the abdominal cavity, and to substantially maintain a size and shape of the expanded configuration. The expandable member, in the expanded configuration, has a buoyancy characteristic relative to its surrounding when implanted in the abdominal cavity. The device further includes a buoyancy member having a buoyancy characteristic different from the buoyancy characteristic of the expandable member, to alter a combined buoyancy characteristic of the device.
A method of making an implantable device for treatment of a patient to assist weight loss is provided, wherein the device includes an expandable member configured to be positioned in an abdominal cavity of the patient, the expandable member configured to be expanded from a contracted configuration to an expanded configuration after placement of the device in the abdominal cavity, and to substantially maintain a size and shape of the expanded configuration, and a buoyancy member fixed to the expandable member and contained within an internal cavity of the expandable member. The method of making includes: providing a mold having a shape of the buoyancy member integral with a shape of the expandable member; molding a wall of polymeric material over the mold; removing the molded wall of material from the mold; inverting a molded buoyancy member portion of the wall into an internal cavity defined by a molded expandable member portion of the wall; and sealing a slit remaining from the inverting.
An anchoring frame deployment tool is provided that includes: a recess or cavity formed in a distal portion shaped and dimensioned to receive an anchoring frame therein; needles and a driving mechanism for driving the needles through the distal portion and the anchoring frame; wherein the needles have sufficient length to extend through an abdominal wall of a patient and out through the skin of the patient when the anchoring frame is contacted to an inner wall surface of the abdominal wall.
An anchoring frame for anchoring a device to an internal structure in a patient's body is provided, including: a plurality of beams linked to be compressed into a narrow configuration and expanded to an expanded configuration; and a mechanical linking feature on each of at least two of the beams, the mechanical linking features configured to mechanically engage with mating features on the device.
An assembly of mating engagement members for engaging an intra-abdominal, extra-gastric implant device with an anchoring frame is provided, wherein the assembly includes: a rail having a series of transversely placed openings along a length thereof; a channel configured to receive the rail and having at least one detent configured to pass through a wall of the rail through one of the openings; and an actuator for preventing the at least one detent from passing through the wall when in a first configuration; and allowing passage of the at least one detent through the wall when in a second configuration.
These and other features of the invention will become apparent to those persons skilled in the art upon reading the details of the methods, devices, tools and assemblies as more fully described below.
Before the present devices methods and instruments are described, it is to be understood that this invention is not limited to particular embodiments described, as such may, of course, vary. It is also to be understood that the terminology used herein is for the purpose of describing particular embodiments only, and is not intended to be limiting, since the scope of the present invention will be limited only by the appended claims.
Where a range of values is provided, it is understood that each intervening value, to the tenth of the unit of the lower limit unless the context clearly dictates otherwise, between the upper and lower limits of that range is also specifically disclosed. Each smaller range between any stated value or intervening value in a stated range and any other stated or intervening value in that stated range is encompassed within the invention. The upper and lower limits of these smaller ranges may independently be included or excluded in the range, and each range where either, neither or both limits are included in the smaller ranges is also encompassed within the invention, subject to any specifically excluded limit in the stated range. Where the stated range includes one or both of the limits, ranges excluding either or both of those included limits are also included in the invention.
Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. Although any methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, the preferred methods and materials are now described. All publications mentioned herein are incorporated herein by reference to disclose and describe the methods and/or materials in connection with which the publications are cited.
It must be noted that as used herein and in the appended claims, the singular forms "a", "an", and "the" include plural referents unless the context clearly dictates otherwise. Thus, for example, reference to "a conduit" includes a plurality of such conduits and reference to "the expandable member" includes reference to one or more expandable members and equivalents thereof known to those skilled in the art, and so forth.
The publications discussed herein are provided solely for their disclosure prior to the filing date of the present application. Nothing herein is to be construed as an admission that the present invention is not entitled to antedate such publication by virtue of prior invention. Further, the dates of publication provided may be different from the actual publication dates which may need to be independently confirmed.
A "compliant" material refers to a material that is stretchable or expandable. This expansibility allows the material to increase in dimension substantially more than a noncompliant or semi-compliant material, prior to failure. For example, when formed as a balloon structure, a compliant material comprises an expansibility property of being able to increase its radius, beyond its formed radius, under pressure applied into the balloon, by 100 percent or more, without rupturing.
A "noncompliant" material refers to a material that, when formed as a balloon structure, can increase its radius beyond its formed radius, under pressure applied into the balloon, only up to about 10 percent or less prior to rupturing.
A "semi-compliant" material refers to a material that, when formed as a balloon structure, can increase its radius beyond its formed radius, under pressure applied into the balloon, by an amount between about 10 percent and about 100 percent, prior to rupturing.
The "wall" of the stomach refers to all of the layers that make up the stomach wall, including the mucosa, submucosa, muscular layers and serosa. A "layer", "layer of the stomach wall" or "stomach wall layer" refers to a mucosal layer, submucosal layer, muscular layer or serosal layer.
A "proximal" end of an instrument is the end that is nearer the surgeon when the surgeon is using the instrument for its intended surgical application.
A "distal" end of an instrument is the end that is further from the surgeon when the surgeon is using the instrument for its intended surgical application.
An "internal body structure" when referred to as a structure to which a device is to be anchored, refers to a structure internal to the skin of a patient, and which can be within the abdominal cavity of the patient, or just outside of it, such as including the outer surface of a wall that partially defines the abdominal cavity. Structures to which a device can be anchored include, but are not limited to: one or more ribs, the intercostal muscles, the abdominal surface of the diaphragm, the stomach (but where the anchor does not pass through the wall of the stomach), the anterior abdominal wall, the posterior abdominal wall and the lateral abdominal wall, the esophagus, the angle of his in the stomach, the gastro-intestinal junction, the gastro-esophageal junction, the columnar ligaments of the diaphragm near the gastro-esophageal junction, the superior aspect of the omentum, peritoneum, liver, connective tissues, ligaments, and blood vessels.
An "internal abdominal structure" refers to an internal body structure that is within the abdominal cavity of the patient, including the abdominal wall. For example, attachment to an inner wall surface of the abdominal wall is an attachment to an internal abdominal structure.
The preferred embodiments of the present invention prevent the possible issue of erosion caused by an expandable member, by not requiring anchoring to the stomach, and further, by not requiring a substantial compression force to be applied when the stomach is not full of food. By allowing the stomach to move freely in the constrained spaced provided by the expandable member, the stomach's possible expansion size will be decreased, but there will be less opportunity for the formation of pressure necrosis since no one region will be subjected to concentrated forces. With the device in place, there is substantially no distensibility of the stomach as normal exists with an unconstrained stomach. With distensibility restricted and gastric volume reduced, as the patient ingests food, the intra-gastric pressure will rise to a level sufficient to produce satiety without distension or volume expansion of one or more regions of the stomach. The device occupies so much volume in the abdominal cavity that the stomach does not substantially depart from the shape set by the device even when filled with food. Another physiological benefit of the device is that the stomach's ability to relax in response to ingestion of food is reduced or eliminated, through producing earlier satiety. One additional physiological benefit of the expandable member may further be to substantially reduce the actual volume of the stomach itself, remodeling the organ as the muscle contracts into its new shape over the period of weeks or months (just as the heart remodels when constrained from over-expansion). Remodeling the stomach allows the expandable member to be implanted temporarily. The preferred embodiments also are positioned in a location to substantially fill the space normally occupied by the fundus, thus moving the stomach medially and wedging the stomach between the expandable member and the medial and anterior aspects of the liver, and the spine posteriorly. This position also ensures that the expandable member is almost entirely maintained underneath the diaphragmatic umbrella beneath the ribs on the left side, thus concealing the expandable member, and preventing it from producing an unsatisfactory cosmetic result. Further, the preferred embodiments can have elements for anchoring on one or more locations along the abdominal cavity wall to prevent migration. Further, the preferred embodiments are provided with an outer surface that is very atraumatic. Embodiments described may include at least one expandable member, preferably an inflatable member, made of a material or material composite that is impermeable to fluid, which may be substantially impermeable to gas and is at least impermeable to liquid, as well as embodiments having at least two expandable members, with one expandable member being inflated with a gas and another expandable member being inflated with a liquid. Other embodiments include an expandable member and a buoyancy member that may or may not be expandable, and which adds buoyancy to the device. For example, a buoyancy member may be included with a liquid-filled expandable member of a device, that by itself, has negative buoyancy, so that the buoyancy member provides positive buoyancy to bring the combined buoyancies of these components of the device nearer to a neutral buoyancy, when implanted into the abdominal cavity of a patient. It can be beneficial to make the combined buoyancy slightly positive in the abdominal cavity to help prevent the device from migrating down in the patient.
The devices described herein can be provided as versatile devices. For example, the same device with an expandable member can be implanted and attached to either in a laparoscopic surgical procedure, an oral trans-gastric procedure, or a variation of percutaneous procedures in which non general anesthesia and little or no insufflation are used. The device can be implanted and anchored directly to at least one internal abdominal structure, or alternatively, can be implanted by fixing to an anchoring frame having been anchored to at least one internal abdominal structure.
Abdominal Cavity Anatomy
At least some embodiments of devices described herein can be implanted percutaneously, with a relatively quick and simple procedure that requires no general anesthesia and wherein only a single, small opening in a patient is required to deliver the device, which typically has a single expandable member that is self anchoring or can be easily anchored to maintain the simplicity and minimal invasiveness of the procedure.
In other embodiments, configurations of expandable members are provided, where a device can contain one or more expandable members and one or more steps of implantation and anchoring may be performed laparoscopically with remaining steps being performed percutaneously. Further alternatively, implantation and anchoring a device may be performed with most if not all steps being performed laparoscopically or orally through a trans-gastric procedure. Any of the devices described herein can, of course, be implanted using open surgical procedures. Devices that can be implanted percutaneously can alternatively be implanted using laparoscopic procedures.
Devices described herein can be implanted permanently, but are also configured for reversibility, to facilitate relatively simple removal procedures, should it be desired to remove a device. Alternatively, devices according to the present invention can be implanted temporarily, such as over a period of months, and then removed or disabled when further treatment is no longer required, or to allow an alternative treatment to be applied.
Device Body Configurations
Main body 10 m,10 em includes curved left and right sides 101 and 10 r, respectively (
Device 10 sizes will likely vary depending on the size of the skeletal system of the patient into which device 10 is to be implanted, particularly the size of the rib cage. Further variations may be made to tweak or adjust the amount of restriction along any desired location of the stomach that interfaces with device 10. One typical variation is in the length and/or size (diameter or expandability capacitance) of the inferior portion 10 i. In some embodiments, the inferior portion 10 i of the expandable member 10 em may be made longer than shown in
At least a portion of main body member 10 m may be expandable. The entire main body 10 m may be made of an expandable member 10 em. When in an expanded configuration, expandable member 10 em can optionally only abut or lie adjacent to the pre-prandial stomach wall, without imparting any significant deformation forces thereto. However, when the patient eats and the stomach begins to fill, expandable member 10 em in this case prevents the stomach 120 from expanding into the volume occupied by expandable member 10 em. In such a case, the stomach 120 becomes "deformed" as it attempts to expand and can only expand in a limited fashion, if at all, around a portion of the perimeter of expandable member 10 em. Thus, upon expanding the device 10, the device 10 expands in the space(s) normally occupied by the stomach 120 as the stomach 120 expands when receiving food. Thus device 10 exerts pressure on, or at least prevents expansion of the fundus and optionally, the antrum. In embodiments where the expandable device 10 is not attached to the stomach, the stomach is free to perform its normal function of mixing food in the stomach for digesting and pushing food out of the stomach. During all of this movement the stomach may slip behind, beside or on top of the expandable device, but the internal volume of the stomach will be held to its smaller volume as the expandable device 10 em is occupying the space into which the stomach would normally expand. Further details of methods for treatment of obesity, including procedures for implanting devices described herein are described below.
As noted above, an expandable device 10 can be implanted adjacent a surface of the stomach wall, either in contact therewith or at a predetermined distance therefrom, to prevent expansion of the stomach 120 into a volume occupied by the expandable device 10. Alternatively, some embodiments of the devices described herein can be configured and placed to exert an external compression on one or more locations of the stomach to deform the stomach wall, thereby decreasing the internal volume of the cavity within the stomach that accepts food and liquid intake.
In one embodiment, expandable member 10 em shown in
At least a portion of the expandable member 10 em shown in
When an expandable member is inflated solely with a pressurized gas, although this reduces the overall weight and density of the device 10, it may tend to be overly buoyant when implanted in a patient. Because a patient is made up primarily of water, the air, carbon dioxide, or other pressurized gas in expandable member tends to be very buoyant relative to its surroundings in the abdominal cavity, which are primarily water. Depending upon the orientation of the patient's abdominal cavity at any particular time, the buoyancy of such a device 10 may establish a force that tends to drive device 10 toward a location away from its intended, predefined location, and may cause the device 10 to tend to migrate away from its intended location to a less desirable position. Also, in the case of a device 10 having multiple expandable members where one is gas filled and one is liquid filled, the buoyancy of the gas filled expandable member may cause it to pull away from a liquid filled expandable member, particularly if the liquid filled expandable member is anchored to an internal structure, and this may cause undesirable results such as unwanted separation of the expandable members and/or failure of one or more of the expandable members.
Accordingly, it may be desirable to provide a device that has a density that is closely matched to the density of its surroundings when implanted in the abdominal cavity. Assuming that the abdominal cavity has a density of saline and is made entirely of saline, then an expandable member 10 em filled with saline would be substantially neutrally buoyant when implanted within the abdominal cavity and would not exert any positive or negative buoyancy forces when implanted therein. At the other end of the spectrum, if the abdominal cavity were completely filled with fat, then a device having an expandable member 10 em inflated with an oil matching the density of the fat could be implanted so as not to create any negative or positive buoyancy forces when implanted in the abdominal cavity. In reality, a typical abdominal cavity of a patient will include both water(saline) and fat, with relative amounts (percentages) of fat varying from patient to patient. Accordingly, device 10 can be designed to have a density somewhere in between the density of saline and that of fat, with the amount of buoyancy being relatively greater for those abdominal cavities having relatively more fat that those having relatively less fat.
A conduit 12 1 can be provided in fluid communication with buoyancy member 10 bm as shown in
Further alternatively, conduit 12 1 may extend inside of expandable member 10 em, as illustrated in phantom lines in
In one particular embodiment, expandable member 10 em is formed of silicone and buoyancy member 10 bm is formed of silicone. However, buoyancy member may include at least one layer, or may be coated with a material that reduces the permeability of buoyancy member 10 bm to gas when buoyancy member 10 bm is in the expanded configuration shown in
As shown in
Alternatively, this embodiment, or any other embodiment described herein, may be configured to have a slightly positive buoyancy. This slight (e.g., less than 0.2 pounds positive buoyancy when implanted, typically much less than 0.2 pounds but greater than zero pounds) buoyancy tends to right the device in a situation where the positive buoyancy is applied in a superior portion of the expandable member and the patient is in an upright sitting or standing position, for example. An alternative technique for adding buoyancy, such as to adjust a displaced device, or that can even be utilized at the original implantation of the device, is to input a small quantity of gas into the liquid filled expandable member 10 em. This can be done at the time that the expandable member 10 em is filled with liquid, or, for example, on a subsequent patient visit. When done subsequently, the physician may optionally withdraw a small amount of liquid to provide space to be occupied by the small gas volume.
Accordingly, depending on the relative volumes and densities of expandable member 10 em and buoyancy member 10 bm, device 10 can: 1) reduce the overall density to reduce the relative "weight" of the implant within the abdomen (i.e., a neutrally buoyant implant will neither sink nor float but maintain a relatively stable position relative to the surroundings in the abdominal cavity); 2) achieve neutral buoyancy within the abdomen; or 3) achieve a slightly positive buoyancy that helps orient the device 10 upwards into a desired position and orientation (e.g., located against the fundus and the diaphragm).
In one particular embodiment, the buoyancy member 10 bm of
Accordingly, buoyancy member can be compressed to its compressed configuration and expandable member 10 em can be compressed around buoyancy member 10 bm where expandable member 10 em is also in a compressed, non-expanded configuration, so that device 10 is reduced significantly in cross-sectional dimension for insertion into a patient. For example, device 10 in the compressed configuration may resemble a cylinder. After passing device 10 through a small opening in the patient and into the abdominal cavity (such as through a sheath, for example, or by manually inserting the device 10, while maintaining compression on the device as it is being stuffed through the small opening) conduit 12 that is in fluid communication with expandable member 10 em has a proximal end portion that remains extending out of the patient. Also, a removable conduit 12 1 (shown in phantom lines in
In general, for devices 10 described herein, the pressure within expandable member 10 em will vary depending upon the material used to form the wall of the expandable member 10 em, as well as the geometry of the expandable member 10 em, and whether gas or liquid is used to inflate the expandable member 10 em. For example, an expandable member 10 em made of silicone that is inflated with saline typically has an internal pressure ranging from about 0.25 pounds per square inch (psi) to about 1.0 psi, depending upon the degree of inflation. Because saline is relatively incompressible, expandable member 10 em will hold its volume under the pressures of the abdomen. Alternatively, if expandable member 10 em is filled with a gas, the pressure may be increased to ensure that the abdominal pressures do not compress the shape of expandable member 10 em, thereby deforming it. The means pressures in the abdomen typically range between about 0 psi to about 0.4 psi. If a person is jumping or coughing, abdominal pressures may spike as high as about 4.0 psi. The buoyancy member 10 bm needs to be designed to that its shape can withstand the sum of the pressure of expandable member 10 em and the at least the mean abdominal pressure (or, preferably, peak abdominal pressure). This can be achieved by designing buoyancy member 10 bm to have sufficient structural strength to withstand the sum of these pressures. One approach in such design is to provide buoyancy member 10 bm with a hard plastic shell that is structurally strong enough to withstand about 5 psi compression forces. Another approach is to design buoyancy member 10 bm as flexible membrane that self expands via a compressible foam. In this case, the foam, upon expanding the flexible membrane of buoyancy member 10 bm, draws air into a chamber defined by the flexible membrane as the foam expands into it. In this type of design, the structure of buoyancy member 10 bm needs to withstand the means pressures (e.g., about 2 psi) and, during pressure spikes, buoyancy member 10 bm may deform and rebound after expiration of the spike, due to the elastic properties of the foam. Further alternatively, buoyancy member 10 bm may be inflated with a gas. In this arrangement, the gas within buoyancy member 10 bm needs to be able to maintain a pressure to withstand the peak sums of pressures within expandable member 10 em and the abdomen, for example, about 5 psi.
It is further noted that none of the alternative arrangements described with regard to
It is further noted that the shape of buoyancy member 10 bm shown in
Once the total number of buoyancy members desired have been loaded into tubular member 10 bmt, the ends of tubular member 10 bmt are sealed off, as illustrated in the completed buoyancy member 10 bm shown in
Upon placement of device 10 in a desired location in the abdominal cavity, expandable portion 10 bme can be expanded with a pressurized gas source via conduit 12 1. Alternatively, the conduit can simply allow air into expandable portion 10 bme as portion 10 bmr springs open and expands portion 10 bme, such that a source of pressurized gas would not be required to inflate the buoyancy member 10 bm in this embodiment. It is noted that conduit 12 1 can be a permanently placed conduit or it may be configured to be removable after inflating expandable portion 10 bme, wherein it (and expandable portion 10 bme as well as expandable member 10 em) can be configured in any of the manners described in previous embodiments having removable conduits. Expandable member 10 em can be inflated with liquid, such as saline or the like, via conduit 12 2.
This arrangement should not require periodic refills of gas into buoyancy member 10 bm or should at least reduce the frequency with which gas refills are necessary, since substantially rigid portion 10 bmr maintains the volume of its shape, thereby maintaining at least a predetermined minimum volume of gas within the buoyancy member 10 bm. Accordingly, even if there is some gas leakage out of expandable portion 10 bme, expandable portion 10 bme will never shrink down to a size less than the volume occupied by substantially rigid portion 10 bmr, since substantially rigid portion 10 bmr is sufficiently rigid to withstand deformation forces that can be provided thereagainst by expandable portion 10 bme and/or the liquid pressure of the liquid within expandable member 10 em. Buoyancy member 10 bm may be free-floating, as illustrated, or may be fixed at one or more locations to expandable member 10 em according to any of the techniques described previously. Also, the shapes of expandable portion 10 bme and substantially rigid portion 10 bmr are not limited to those shown, but may vary. As one non-limiting example, expandable portion 10 bme may be substantially cylindrical to follow the contours of a tubular substantially rigid portion 10 bmr.
The foam used to make buoyancy member may be a silicone foam, or made from polyethylene or other biocompatible polymer for example. In each case, the foam is a closed-cell foam having a skin, so that the cells of the foam are closed and encapsulate air or other biocompatible gas therein, to ensure that the buoyancy properties of the foam are maintained and the buoyancy member 10 bm can therefore hold open a volume of gas and displace the liquid in expandable member 10 em. It should be noted that some manufacturers denote a "sponge" as a closed-cell material, and other denote a closed-cell material as a "foam". Alternatively, an open-cell material may be used, when a layer of encapsulation is established around this open-cell sponge or foam. The encapsulation layer may be dip-molded onto the open-cell structure, or can be manufactured separately and then assembled around the open-cell structure. Such a configuration utilizes the open-cell foam or sponge to provide structural support to hold open the encapsulation layer. The encapsulation layer provides a barrier between the gas contained within the open-cell foam/sponge and the saline or other liquid contained in the expandable member 10 em outside of the buoyancy member 10 bm. An encapsulation layer may be provided over a closed-cell foam/sponge using any of the same techniques described above. Various different structural arrangements and shapes of foam as well as sponge-like structural arrangements that can be used to make buoyancy member 10 bm are discussed in more detail below. Buoyancy member 10 bm may be free-floating, as illustrated in
In one particular embodiment, the foam is a silicone foam made from silicone typically made to make a silicone sheet, but with a foaming agent (sodium bicarbonate, about 1% to about 5% by weight, typically about 5%) mixed with the silicone to make a slurry. This slurry can be described as having a consistency like peanut butter and the slurry is packed into a mold and then heated at about 150� C. for about an eighty minute cycle. The foaming agent, during the heat cycle, converts to water vapor, carbon dioxide and ammonia, thereby ensuring the biocompatibility of the resulting foam product. The mold is then removed from the heat and allowed to cool. After cooling, the foam product is removed from the mold and finished by removing any flash that may have formed. The finished product is a closed-cell foam that includes a skin layer both inside and outside. In another embodiment, the foam is polyethylene, which is expanded via high pressure carbon dioxide. The infusion of the carbon dioxide creates air pockets that form the foam, leaving a material that remains polyethylene which is therefore biocompatible.
Buoyancy member 10 bm is typically fixed to expandable member 10 em along the entire length of buoyancy member 10 bm. In the example shown, buoyancy member 10 bm is fixed to an internal surface of expandable member 10 em. Buoyancy member 10 bm may be made of any of the foams described above with regard to
Alternatively, a sealing layer or skin can be molded over the foam buoyancy member by liquid injection molding (LIM). Using this approach, after the foam molded product is removed from its mold, it is inserted into a second mold that is slightly larger than the mold used to mold the foam product, but the same overall shape. Liquid silicone is then injected into the second mold in the space that surrounds the mold to thereby mod a skin layer between the foam product and the walls of the second mold. This process may be advantageous in that it can provide greater control over the consistency of the thickness of the skin layer over the foam product, and a single molding step may be performed, rather than repeated dipping steps.
Alternatively, an encapsulation layer may be fabricated separately, for example, by LIM or dip-molding. This layer can be assembled around the foam shape, and sealed off to provide complete encapsulation.
Alternatively, the gap 10 bma between the walls 10 bmw leading to opening 10 bmi can be greatly reduced by molding in a shape illustrated in the cross-sectional view of
The embodiment of
The bending strength of buoyancy member 10 bm may be modified and tailored by making one or more tubes 10 bmt discontinuous and by altering the lengths of the discontinuous tube(s) 10 bmt as illustrated in
An alternative method of partially or completely foam filling a buoyancy member includes molding the buoyancy member 10 bm in the desired shape, bonding all but an inferior portion of the wall edges 10 bmw to an inner surface of expandable member 10 em, and then inserting a foam insert, either shaped to completely fill the molded buoyancy member 10 bm or to provide structural supports (struts, tubes, or the like), after which the remaining inferior portion of the wall edge 10 bmw can be sealed to the inner surface of the expandable member 10 em.
Although appearing flat in the two dimensional illustrations of
Reinforcement layer 160 may be made, for example, of silicone sheeting reinforced with a strengthening material such as woven polyester, polytetrafluoroethylene, or the like. A margin of unreinforced silicone can be maintained all around the edges of the sheet to facilitate bonding to expandable member 10 em and to avoid stress concentration at the edges. Bonding can be performed, for example, using room temperature vulcanizing silicone adhesive, or vulcanizing a sheet or cut form of unvulcanized rubber, for example. Alternatively, reinforcement layer 160 may be made from a different polymer, such as polyurethane, for example, and reinforced with polyester mesh, for bonding onto a expandable member 10 em having a polyurethane outer wall surface.
Alternative formulations from which expandable member 10 em may be made include, but are not limited to: polyurethane compositions including silicon-containing chain extenders, such as taught in U.S. Pat. Nos. 6,420,452 and 6,437,073, for example, or segmented block polyurethane copolymers, such as taught in U.S. Pat. No. 5,428,123, or other combined polymer compositions of polyurethane and silicone resulting in less permeability (to gas and/or liquid) than that of polyurethane used alone, or silicone used alone. Additionally, these improved barrier (resistance to permeation) properties can be achieved with a thinner wall thickness than would be required if using polyurethane alone, or silicone alone. Optionally, buoyancy member 10 bm may also be made from any of these same materials. U.S. Pat. Nos. 6,420,452; 6,437,073; and 5,428,123 are hereby incorporated herein, in their entireties, by reference thereto.
To facilitate anchoring of device 10, device 10 may be provided with one or more attachment tabs 150. Attachment tab(s) 150 fan out like wings from the surface of expandable member 103 m to provide a much broader attachment surface area compared to what would be provided by simply attaching the portion of the expandable member 10 em, from which they extend, to a structure.
Alternatively, multiple attachment tabs 150 can be placed at locations around expandable member 10 em to extend from and substantially cover areas covered by the larger single attachment tab 150 shown in
Tab 150 will typically be formed from a reinforced sheeting, such as polyester-reinforced silicone sheeting, polypropylene-reinforced silicone sheeting or polyethylene-reinforced polyurethane sheeting for example, or any other biocompatible fabric that can be sandwiched between two layers of biocompatible polymers or rubbers. One or more patches 152 of tissue ingrowth enhancing material, such as a expanded polytetrafluoroethylene, polytetrafluoroethylene, polyester, etc, in felt or velour configuration, or polypropylene mesh, for example, can be bonded onto the reinforced sheeting so that, when placed in contact with tissue, tissue is encouraged to grow into the patches. An additional tissue ingrowth enhancing patch 152, such as the circular one illustrated in
Tab(s) 150 can be fixed to an internal abdominal structure (such as an internal surface of the abdominal wall for example) using staples or tacks in a manner as described in co-pending application Ser. No. (Ser. No. not yet assigned), which was incorporated by reference above, or sutures, or Q-ring fixation members that are configured like the coil portion of key ring, that can be threaded into and through the tab 150 and tissue for anchoring these together, or hooks, barbs, corkscrew type anchoring members, or other known anchoring arrangements.
After insertion of device 10 through an incision in the patient and into the abdominal cavity, the inferior portion can be generally located against the internal abdominal structure that it is to be anchored to by forming a puncture aligned with that location and retracting loop 170 therethrough to pull the inferior portion of device 10 into contact with the internal abdominal structure, as was described above. It is noted that positioning loop 170 is not shown in
After fixing loop 70 to the outer surface of the abdominal wall 127 and/or fascia 127 f and removing the excess loop portion extending proximally of the fixation point, as described above, an additional puncture 204 is formed in a general location overlying a location from which one end of suture 180 exits tab 150. The end is retrieved using graspers, or other minimally invasive retrieval instrument and pulled out of the patient's abdominal cavity and through the abdominal wall, optionally all the way out of the patient. Assuming there is at least one knot 182 formed in suture to prevent it from sliding out of tab(s) 150, then the retraction of the first end of the suture can be done without concern for holding the other free end of the suture. In this case, once the first free end of suture 180 has been drawn out of the abdominal cavity through puncture 204, a second puncture 206 is formed in a location overlying a general location from which the other end of suture 180 exits tab 150. the other one end of suture 180. This second end of suture is then retracted out of the abdominal cavity through puncture 206. Alternatively, first and second ends of the suture 180 can be retracted out of the abdominal cavity simultaneously through punctures 204 and 206, respectively. Either way, the two free ends of suture 180 are then tied down together as close to fascia 127 f as possible. The knot formed between the two ends of the suture 180 is pushed down through the fat to be tied off at a location abutting, or as close to the fascia 127 f as possible. This procedure is repeated for each suture 180, wherein additional pairs of punctures are created for retracting each additional pair of free ends of each additional suture 180, respectively.
In an alternative procedure, when pairs of sutures are provided, as in the arrangement shown in
Alternatively, one or more of sutures 180 can be replaced by additional positioning loops 170 that are fixed to tab(s) 150 in locations where the ends of sutures 180 would otherwise extend out of tab(s) 150. Anchoring of the tab(s) 150 can then be performed by pulling loops 170 out of the abdominal cavity and tying them together in any of the manners described above with regard to sutures 180.
Further alternatively, it is noted that device 10 can be generally positioned for anchoring the inferior portion of device 10 without the use of positioning loop 170, with or without assistance of positioning tab(s) 154, and still anchor tab(s) using sutures 180 in any of the manners described above.
Alternatively to separately manufacturing a buoyancy member 10 bm and expandable member 10 em and then inserting (either with or without fixing to the expandable member) buoyancy member 10 bm into expandable member 10 em (either before or after insertion of expandable member 10 em into the abdominal cavity), buoyancy member 10 bm may be manufactured integrally with expandable member 10 e.
By pushing on the portion of the product that will form buoyancy member 10 bm in the direction of the arrows shown in
This technique is not limited to formation of a buoyancy member 10 bm having a teardrop or eggplant-like shape, but can be applied to many other shapes of buoyancy members. Likewise, the shape of expandable member 10 em is not limited to the shape shown. Further, this method is not limited to the placement of buoyancy member 10 bm as an internal spine as shown.
A delivery tract is then opened from opening 223 through the subcutaneous tissues and abdominal wall to provide an access opening into the abdominal cavity. For example, the delivery tract may be formed by starting with a small incision 223, 225 and then inserting a small port under visual guidance (for example, with VISIPORT™, or the like) to provide safe access into the abdominal cavity. Alternatively, the delivery tract can be made with a cannula and a veress-style needle within it which is subsequently exchanged, after access into the abdominal cavity, with a wire, such as guidewire 502 or a viewing wire to allow exchange of the cannula and insertion of a larger bore access sheath over a dilator over the wire. Once the delivery tract has been established, device 10 in a compact configuration is inserted through opening 223 and advanced along the tract, through the opening in the abdominal wall and placed in the abdominal cavity.
When the expandable member 10 em has been completely inserted into the abdominal cavity (which can be verified by laparoscope or by other indirect visualization apparatus for a percutaneous step, or both), and optionally any buoyancy member 10 bm or insert for a buoyancy member 10 bm has been inserted into the expandable member 10 em, (in those arrangements where a buoyancy member 10 bm or portion of a buoyancy member 10 bm is inserted after placement of expandable member 10 em into the abdominal cavity) then cannula or sheath 17, if used, is removed from the patient and a puncture or very small incision is made in the skin 125 at a location that generally overlies a location of the abdominal wall that the surgeon wants to anchor an inferior portion of expandable member 10 em to. The opening through which device 10 is inserted may range from about 5 mm up to about 5 cm, or up to about 7 cm. The punctures are much smaller that the opening through which the device 10 is passed.
Graspers 784 or other instrument are then inserted through incision or puncture 225, as illustrated in
When positioning loop 170 has been anchored externally of the abdominal cavity, additional punctures or small incisions are made in order to perform the procedural steps for tying off the sutures 180 (or additional loops 170 if they are provided to substitute for sutures 180).
After completing the tying off or otherwise securing of the sutures 180 and/or additional loops 170 is completed and suture material and/or suture loop material extending proximally from the ties is removed, the incisions/punctures 225 are closed, such as by suturing. An access member 80 can be installed according to any of the techniques and in any of the locations described in co-pending application Ser. No. (application Ser. No. not yet assigned), in provisional application Ser. No. 60/877,595, in U.S application Ser. No. 11/407,701, or as described herein. Buoyancy member 10 bm, if inflatable can then be inflated with a gas, and expandable member 10 em can be inflated with a liquid. Opening 223, as well as, optionally, any additional opening that may have been created for installation of access member 80 are then closed off, such as by suturing, to complete the procedure. Alternatively, the buoyancy member 10 bm can be integrated with/or double as an anchoring frame 600, as described in more detail below, which may allow for a smaller incision to be made in the patient, while still providing a buoyancy feature.
Next a powerful local anesthetic such as marcaine (bupivicaine) or other powerful anesthetic, optionally mixed with an epinephrine or other vasoconstrictor to reduce any bleeding that might result from mild trauma can be injected into the local area through the skin 125 of the patient 1 down to the muscular layer and to infiltrate the fat layer and entire local area (the anesthetic portion of the mixture may not be needed if the procedure is performed under general anesthesia). Injection may be performed using a syringe 219, as illustrated in
A dilator, such as an access sheath or cannula 535 having a tapering distal end portion that gradually increases in outside diameter from a distal end in a proximal direction can optionally be inserted over a guidewire 502, as illustrated in
An anchoring frame 600 and an anchoring frame delivery tool 630 on which anchoring frame 600 is mounted (in any of the manners described in application Ser. No. (application Ser. No. not yet assigned) are advanced over guidewire 502 and through dilator/port 535 (see
After anchoring the anchoring frame 600 to the abdominal wall 127, anchoring frame delivery tool is then removed from dilator/cannula 535 and off guidewire 502.
Once anchoring frame has been anchored to the target location, as illustrated in
Optionally, expandable member 10 em may be inflated at this stage to test the amount of displacement and positioning of the device 10 when in an expanded configuration, which may help to determine whether device 10 will perform as intended. One method of testing in this manner is with the use of an intra-gastric sizing device 310 (e.g. an intra-gastric balloon catheter) in a manner as described in U.S. application Ser. No. 11/407,701 and application Ser. No. (application Ser. No. not yet assigned). Additionally, or alternatively, testing may be performed by visually observing the effects of expansion, such as by inputting radiopaque fluid into the stomach 120, and/or by observing the expansion of the device when it is provided with one or more radiopaque indicators. Visualization, in such instances may be performed fluoroscopically or with other X-ray visualization, for example.
At this time, any extending conduit(s) 12 can be either clamped off to maintain the pressures within expandable member 10 em (and optionally buoyancy member 10 bm), or the pressures can be released, thereby allowing expandable members 10 em (and optionally, buoyancy member 10 bm) to at least partially deflate. It is easier procedurally to release the pressures and so this is typically done. However, the surgeon may choose to clamp off the conduit(s) to maintain at least partial pressure in at least the expandable member 10 em to help maintain it in the observed position/orientation. In any case, conduit(s) 12 is/are next trimmed to an appropriate length for connection with an adjustment member 80, as illustrated in
Conduit(s) 12 are connected to a mating connector on adjustment member 80 or to a deployment tool 370 configured to mate conduit 12 with adjustment member 80, and, after connection of conduit 12 to adjustment member 80, adjustment member deployment tool 370 is then used to anchor adjustment member 80 to the patient. Adjustment member 80 can be anchored using anchoring members that may be made as any of a number of different configurations, including, but not limited to: protruding pins, protruding staples, moly bolt, snap fit with portion placed against interior abdominal wall surface; extendable hooks actuated upon torquing a portion of the adjustment member 80 relative to another portion, etc. By advancing deployment tool 370 into the patient, the portion of conduit that had extended from the patient 1 is pushed back into the patient, until the adjustment member is positioned in the target location where it is intended to be anchored. This positioning can be verified using any of the previously described visualization techniques, or can be performed blindly, with feedback from palpitation, for example. In the example shown in
Once adjustment member 80 has been anchored in the desired location, deployment tool 370 is withdrawn and expandable member 10 em is inflated with liquid to expand it to the desired size or pressure, and buoyancy member 10 bm, if it is an inflatable variation can be inflated with gas to a desired pressure. This can be a re-inflation step if the expandable member 10 em (and optionally the buoyancy member 10 b had been previously inflated for testing and then deflated, or partially deflated. In this way, the patient can begin to experience beneficial weight loss from the effects of device 10 on the stomach 120 beginning immediately after completion of the procedure, unlike current procedures, which typically require around six weeks before a return visit to "complete" the procedure to make it effective in helping weight loss. The same type or types of monitoring can be used here, as described in application Ser. No. (application Ser. No. not yet assigned), to provide feedback as to when the expandable member 10 em and/or buoyancy member 10 bm has been expanded by the desired amount or pressure. Alternatively, expandable member may be left in an unexpanded or partially expanded configuration, with the patient being allowed to heal and then return to have the expandable members 10 em fully inflated. Further alternatively, device 10 may be implanted in combination with a constricting band, such as the LAPBAND™ or similar implant to improve results from such constricting band, or to make weight loss efficacious where prior implantation of such a constricting band has not been efficacious. For example, a constricting band generally useful for restricting the amount of solid food ingested by the patient 1. However, a patient 1 may "cheat" the effectiveness of a constricting band approach by drinking high caloric liquids, for example. For example, a patient could drink a thirty-two ounce milkshake and this would pass right through the constriction established by the constricting band. However, with device 10 implanted and expanded as described, the stomach is preventing from expanding, even by high caloric liquids.
Once the surgeon is satisfied that the expandable member 10 em has been expanded by the desired amount and, optionally, the buoyancy member has been inflated to the desired pressure, or, alternatively, if the expandable member 10 em is to be left in a contracted (unexpanded or partially expanded) state, the patient is closed, including, suturing the skin 125 at the site of the opening 227.
Any of the variations of the procedural steps described above may be executed under indirect visualization, such as fluoroscopic visualization, 3-dimensional navigation or other CT/MRI guidance, or three dimensional RF or electromagnetic visualization (e.g., using pre-existing or real-time data sets from MRI, cat scan, three-dimensional ultrasound or other three-dimensional data set). Further alternatively or additionally, any of these procedural steps may be directly visualized using a scope such as a laparoscope or other flexible or rigid endoscope. A scope may also be integrated into a tool used to perform one or more of these steps.
All tools referenced in the above procedure may include lumens to permit insertion of other tools and/or devices therethrough, including, but not limited to: endoscopes, wires, etc. and/or to allow delivery of suction, irrigation, and/or other substances. Alternatively to mounting the adjustment member 80 to conduit 12 in any of the manners described above, adjustment member may be pre-attached or integral with conduit 12.
No tissues around the stomach area are required to be dissected when performing the procedures described above with regard to
With regard to procedural embodiments involving the anchoring of anchoring frame 600 to an internal abdominal structure,
Shaft 634 articulates, via one or more articulating joints 644 to move distal end portion 634 d angularly relative to a portion of shaft 634 proximal of distal end portion 634 d. An articulation actuator 646 (see
Distal portion 634 d includes a recess, cavity or slot 650 configured to receive anchoring frame 600 therein. Thus, recess, cavity or slot 650 is shaped and dimensioned to receive anchoring frame 600 therein and to confine anchoring frame 600 from movements axially with respect to the longitudinal axis of distal portion 634 d. Frame 600 may be received in recess, cavity or slot 650 by friction fit and/or a releasable clamping mechanism 651 maybe optionally provided on opposite sides of slot, recess or cavity 650 for releasably clamping frame 600 wherein it is received therein, with clamping and releasing motions being controlled by clamp actuator 653.
In use, after insertion and placement of guidewire 502, such as in a procedure as described above, deployment tool 630 is passed over guidewire 502, with the proximal end of guidewire first being inserted into the distal end of shaft 634, through shaft 634 and handle 632 and proximally out of handle 632, as illustrated in
A window or opening 648 may be provided proximally of articulating joint 644 to enable viewing through the distal end of endoscope 537 that is positioned in shaft 634 at the location of opening/window 648 when endoscope 537 is inserted into tool 630. Window/opening 648 may be an opening (e.g., cutout), or may be a window, e.g., a cutout that is sealed over with a transparent material.
Visualization, whether indirect, direct, or indirect and direct, is performed to ensure that there is no tissue located between the anchoring site (e.g., anterior abdominal wall 127) and anchoring frame 600 (see
Needles 610 n are then disengaged from the needle delivery mechanism (e.g., push rods 631). Needles 601 n can be directly attached to sutures that reside within the channels of the delivery device (not shown). The back end of the sutures can be looped and held on a hook attached to a handle on the device to allow retraction of the needles into the device if initial deployment was not satisfactory. This hook mechanism can be actuated to release the sutures via a button on the handle when the needle locations are determined to be acceptable, allowing the suture/needle units to be pulled by the operation outward until they engage the anchoring platform. There are many other alternative mechanisms, widely known in the art, to grasp and release a thread like a suture, including mechanisms that cut the sutures from a fixed location, mechanisms that open up a clamp that was holding the sutures in a fixed location, mechanisms for releasing a lock on a spool where sutures are wrapped and initially retained within the deployment device, etc.
Next, the surgeon, pulls the needles 610 n the rest of the way out of the patient 1, and continues this retraction until knots or other anchors (e.g., T-bars, or the like) at the ends of sutures 59 are stopped against anchoring frame 600 Alternatively, sutures 59 may be looped 59 k through anchoring frame 600, so that adjacent pairs of needles 610 n are connected to opposite ends of a looped suture 59. The needles 610 n are removed from the sutures 59, leaving organized sutures precisely delivered through anchoring frame and the internal anchoring structure, precisely deliver through key strategic locations through anchoring frame 600 designed to optimally secure the anchoring frame 600 to the internal abdominal structure. Alternative embodiments may replace the sutures with other flexible members. For example, polypropylene mesh ribbons may be substituted. Further alternatively, a combination of sutures and mesh ribbons may be used, where the flexible member 59 begins as a suture where it connects with the needle, and transitions into a ribbon. An advantage of a combination such as this is that the sutures are more easily delivered out through the abdominal wall, while the ribbons provide potentially better fixation to the abdominal wall.
Sutures 59 may be fixed externally of the abdominal cavity by tying them down, according to a procedure similar to that described above with regard to
Needle 610 n may be alternatively connected to a mesh ribbon 59 r, as shown in
In order to provide a wider anchoring frame 600 platform that is not limited by the diameter of the opening through the patient through which the anchoring frame is delivered, anchoring frame 600 may be configured to be expandable, as illustrated in
Arms or beams 600 a are attached to a sheet of tissue ingrowth material 602 that folds up, as illustrated (in phantom) in
In either case, beams or arms 600 a are attached to ingrowth material 602,150,152 such as by snaps 600 s, or alternatively, by sutures, or other mechanical fixation means. Any of these connections may be supplemented using adhesives, or adhesives alone may be used to establish the connections. Although not required, it may be preferable to establish connections 600 s on both sides of needle openings 600 n through which the needles 610 n pass when performing the anchoring steps. This is illustrated in the longitudinal sectional views of a portion of an arm or beam 600 a and ingrowth sheet 602,150,152 in
Engagement member 10 e can be provided with locks 620 that automatically lock engagement member 10 e to engagement member 600 e thereby securing expandable member 10 em in a rotationally and translationally stable position relative to frame 600. In the example shown, locks 620 are spring loaded and are substantially flush with the channel 608 at distal ends thereof, but have proximal ends that angle into the channel 608. The proximal ends are depressed to be substantially flush with the channel 608 surface as engagement member 10 e, and particularly channel 608 is being slid over central rail 618 of engagement member 600 e, as the proximal ends of the locks 620 are pressed against the rail 618 surface. As the component become fully engaged, they are stopped in the direction of relatively sliding to achieve this engagement by stops provided on engagement member 600 e. Engagement member is locked and thereby prevented from sliding in the opposite direction when the proximal ends of locks 620 expand into mating recesses 620 r formed in rail 618. The arrangement of locks 620 and recesses 620 r can be reversed between the components 10 e and 600 e, as would be readily apparent to one of ordinary skill in the mechanical arts.
An adjustable locking mechanism 20 in this embodiment includes detents 622 that are configured and dimensioned to be received in locking holes or openings 624. When detents 622 are positioned through a pair of openings 624, this prevents further relative sliding between rail 618 and channel 608. An actuator 626 may be provided on either the anchoring frame 600/channel 608, whichever includes the engagement member having the detents 622 to, in a first position, temporarily lock the detents in a retracted configuration so that they cannot release and extend through openings 624, and, when slid to a second position, release the detents, which are biased, such as by spring-loading for example, so that they deploy to pass into a pair of openings 624 that they are aligned with. If the openings 624 are not aligned with the detents, the expandable member 10 em can be slid in one direction or the other, relative to anchoring frame 600 to engage the next adjacent pair of openings 624.
Alternatively, openings 624 may be beveled or tapered to that if detents 624 are only partially inserted into openings 624, as illustrated in
After placing expandable member 10 em into the abdominal cavity (in a non-expanded configuration), guidewire 502 or snare catheter 502 s is used to capture the free, proximal end of docking tether 59 d. The captured free end is then into the distal end opening of tubular member 10 bmt, through the annular space in tube 10 bmt and out of the proximal opening. Connector 59 c is then connected to mating connector 59 m, thereby locking the free end of docking tether 59 d to expandable member 10 em and anchoring expandable member 10 em to buoyancy member/anchoring frame 10 bm, 600 as illustrated in
On advantage of using a dual-function buoyancy member/anchoring frame 10 bm, 600 is that it is a low profile system, since the buoyancy member 10 bm and expandable member 10 em do not require simultaneous insertion into the abdominal cavity. Further, a dual-function buoyancy member/anchoring frame 10 bm, 600 is very lightweight and therefore may reduce potential complications during the tissue ingrowth period required for tissue for tissue from the anchored-to structure to grow into the anchoring frame. This can be particularly advantageous in situations where buoyancy member/anchoring frame 10 bm,600 is anchored by itself and allowed a tissue ingrowth period before fixing an expandable member thereto, or in situations where the expandable member 10 em is initially fixed to buoyancy member/anchoring frame 10 bm, 600, but is not inflated or only partially inflated with liquid during the tissue ingrowth period.
Markers 420 may be provided at various locations on device 10 that are trans-abdominally detectable, for example, using fluoroscopy (radiopaque markers), ultrasound (ultrasonically detectable markers), three-dimensional navigation (magnetic or RF sensors) for indirect visualization/tracking of device 10 during the implantation procedure, as well as after device 10 has been implanted and the procedure has been completed. These markers can be present on the surface of device 10 or may be embedded beneath one or more layers of material, or molded within a layer, for example. Additionally, or alternatively, visual indicators 422, such as text, arrows or other graphical markings or visually detectable indicators can be provided for direct viewing by laparoscopy, for example. Indicators 422 may also be provided with contrasting colors to make them easier to locate relative to the portion of device 10 that they are located on.
The material(s) making up all or a portion of device 10 may be doped with radiopaque material to facilitate identification thereof by indirect viewing such as fluoroscopy or other X-ray. Markers 420 and/or indicators 422 may also be used to assess function. For example, the markers 420 identified by "S" and "I" in
As one example of use of markers 420 for three-dimensional navigation of the delivery and placement of device 10 during an implantation procedure, a pre-existing "map" of the internal structures of a patient 1 may be provided in the way of a CT scan, for example, so that a surgeon can study this map prior to the procedure and identify the bony structures around the abdominal cavity, to be used as landmarks during the procedure to help in navigating/directing device 10 and associated tools to one or more desired target locations in the surgical site. Although soft tissues will be mobile, the surgeon can identify target locations relative to the bony landmarks.
At the beginning of the procedure, typically, prior to making an incision, the actual bony structures of the patient 1 (as visualized under fluoroscopy, for example, or palpation to identify pre-determined registration points) are registered to match the locations of the same structures on the pre-existing map, which can be displayed on a monitor, for example. During the procedure, the markers 420, whether detected by fluoroscopy, magnetic detection, RF detection, ultrasound detection, etc. are displayed on the monitor overlaid on the pre-existing map to which the bony structures of the patient 1 have been registered. Accordingly, the surgeon/user can view in real time, a three dimensional image of the location of markers 420 relative to the landmark bony structures, to guide the surgeon/user to deliver device 10 along a desired pathway and place and implant device 10 in the desired target location.
Not only can device 10 be navigated in this manner, but any other instruments or devices inserted into the patient 1 during the procedure, can also be navigated in similar fashion. For example, insertion and placement of guidewire 502, prior to insertion of device, can be guided and navigated by provided a distal tip or distal end portion of guidewire with a sensor 420. Other tools and devices can be navigated similarly.
Sensors 420 may be passive and/or active. For example, sensors 420 can simply be magnets or radiopaque markings, which are passive sensors that are detected by instrumentation outside of the body of the patient. Alternatively, sensors 420 may be active, such as sensors that transmit RF signals, or other electrical signals, for example. Further alternatively, sensors 420 may have both passive and active functions. A sensor may be "pinged" by instrumentation outside of the patient's body and reflected waves returned from the sensor being pinged can be triangulated by feedback from external sensors to determine the location of sensor 420. Sensor 420 may include an antenna and processor that can instruct it to emit a signal when a particular instruction has been received by the antenna. Any of the sensing and/or navigation methods described above can optionally also reference the stomach 120, such as by fluoroscopy or X-ray when radiopaque contrast fluid is inputted into the stomach.
One or more sensors 420 may also be used for the performance of one or more procedural steps robotically. As one non-limiting example of this,
While the present invention has been described with reference to the specific embodiments thereof, it should be understood by those skilled in the art that various changes may be made and equivalents may be substituted without departing from the true spirit and scope of the invention. In addition, many modifications may be made to adapt a particular situation, material, composition of matter, process, process step or steps, to the objective, spirit and scope of the present invention. All such modifications are intended to be within the scope of the claims appended hereto.
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Build a bare metal server with your choice of processor(s), hard drive configuration, RAM, port speed, and more.order hourly Order monthly
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Dallas—June 3, 2008—SoftLayer received its first delivery of servers under a new server packaging program that reduces packing materials by 80-percent. The program was created through several months of close collaboration between SoftLayer and its server manufacturer, Supermicro (NASDAQ: SMCI)."From the shipment of our first server in 2006, SoftLayer has actively recycled all its data center materials. But with our rate of growth, it was essential we do even more," stated Joshua Rushe, Vice President of Operations at SoftLayer. "We looked for a way to go beyond recycling and reduce the production of unnecessary material. We hope this program sets a new industry standard that will help reduce the total environmental impact of data centers worldwide."SoftLayer's reduced packaging program provides multiple environmental benefits. It eliminates more than 8 pounds of packing material per server, as well as the shipment of user manuals and unnecessary components, thereby greatly reducing the volume of materials produced or recycled. Moreover, these measures reduce the total shipping "footprint," enabling the same sized shipping containers to carry more units and reducing the amount of fuel consumed and carbon emissions produced when shipping.The United States Environmental Protection Agency (EPA) estimates that recycling one ton of cardboard and paper products leads to saving:
Headquartered in Dallas, SoftLayer is the innovation leader in Cloud, Dedicated, and Managed Hosting, and the largest private hosting company in the world. SoftLayer provides cloud, dedicated, and seamlessly integrated computing environments, with world-class data centers in Dallas, Houston, San Jose, Seattle, and Washington D.C., and network Points of Presence nationwide. The company integrates and automates all elements of its platform, empowering enterprises of any size with complete control, security, scalability, and ease-of-management via a leading Customer Portal and Open API. For more information, please visit www.softlayer.com or call 866.398.7638.
Mark Quigley
Director - Corporate Communications
+1 214 442 1842

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AG Chris Koster Files to Deny Release of "Mike" Anderson But Suggests Path to Parole
Koster cites a past case in Cole County (also involving an "Anderson," bizarrely enough) wherein an inmate was erroneously released on an appellate bond and then was re-arrested after some time free. The inmate argued he should be credited for the time he was out erroneously, because it wasn't his fault he was improperly released. The trial court in that case granted he should get credit for that time.
Anderson is in the wrong form of action and the wrong venue for the relief granted in Anderson v. Crawford. Rule 91 habeas corpus actions are generally limited to suit seeking immediate discharge from confinement, and the director of a department may only be sued in Cole County. But if Anderson re-files this matter as a declaratory judgment action and names the Director [of the Missouri Department of Corrections] as the defendant, the Director consents to the venue in this Court. If this Court accepts the facts as set out in this pleading, the Director takes no position on whether this Court should declare Anderson entitled to credit on his sentence from the time the opinion issues in his direct appeal. If the Court grants time served from the issuance of the opinion in 2002, Anderson would have served his 11.5-year mandatory-minimum prison term under Mo. Rev. Stat. 558.019 and 571.015 and be immediately eligible for parole consideration.
That sounds awfully promising -- but it also means the decision to credit Anderson with the time he was out improperly is now up to Judge T. Lynn Brown of Mississippi County. And even if Anderson is given credit for 11.5 years, he will then be at the mercy of the parole board, which Koster acknowledges has "almost unlimited discretion."
We've reached out to Anderson's attorney to see what he makes of this, and we'll update when we hear back.
Meanwhile, the story has been featured on several national television news shows, including the TODAY Show and CBS News, and a petition asking for Anderson's release has surpassed 20,000 signatures.
Chris Koster Final Response to Show Cause Order on Cornealious "Mike" Anderson
Follow Jessica Lussenhop on Twitter at @Lussenpop. E-mail the author at firstname.lastname@example.com.
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The unsung beauty and diversity of flies drives our Diptera curator to research their lifestyles and improve their image.
A childhood spent outdoors meant Dr McAlister was often climbing and falling out of trees, which gave her ample opportunities to study the local insects.
She later formalised this interest by volunteering with the Countryside Wardens and studying biology at university, where an enthusiastic lecturer would scoop up flies in nets and describe all their weird and wonderful lifestyles.
During her PhD work on insects Dr McAlister made contact with a fly expert at the Museum and became fascinated by the collections. She volunteered to work on them before landing a permanent job as the Curator of Diptera.
Flies have a bad reputation since most people only think of houseflies throwing up on their food or mosquitoes ruining a nice summer's day. But Dr McAlister says that really they are fascinating creatures and many are misunderstood. For example hoverflies, which superficially look like bees, are some of the UK's top pollinators, helping to propagate crops and flowers.
'They're ubiquitous. They're found in every environment, you can even get marine flies. Flies do everything; they fill every ecological role, and are found in every ecological niche.'
They can also be beautiful, says Dr McAlister, like the bumblebee robberfly (Laphria flava). 'But even though they're cute and fluffy, don't be fooled by their appearance,' she says. The robberflies are predators, capturing other insects before dissolving their insides and sucking them out.
As well as looking after our fly collections and adding new species, Dr McAlister is involved in a range of innovative research projects, including investigating forests in Ethiopia as reserves for pollinators, looking at potential new crops high up in Peru, and studying viruses in mosquitoes in the Camargue, France.
When not scouring the world for new flies and a better understanding of their role in the environment, Dr McAlister tries to 'spread the fly love' and quash our knee-jerk reaction to swat!
What happens behind the scenes in the Museum's Life Sciences Department? Curator Erica McAlister has about 30,000 species of fly to look after, and fieldwork trips at home and abroad. Her life is never dull!Follow the blog


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Special Events
Join us for a special evening with harpist Bridget Kibbey
Saturday, February 7 at 6:00 p.m.
Bellarmine Hall
Tickets: $60
Enjoy the warm and inviting Bellarmine Hall on this wintry evening filled with food, wine, friends, and the exquisite music of harpist Bridget Kibbey! This intimate event will serve as a fundraiser for the Quick Center for the Arts.
Lauded for her enthralling artistry and virtuosity, harpist Bridget Kibbey is gaining a reputation for showcasing the broad range of her instrument through multi-genre performances. As noted by The New York Times, she "makes it seem as though her instrument has been waiting all its life to explode with the gorgeous colors and energetic figures she was getting from it."
To purchase tickets*, please visit our box office or call (203) 254-4010.


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Posts of June 2010
GLORY GLORY, a new play by a Cal medievalist, opens in SF June 18June 5, 2010 in news
Though the campus might be quiet during the summer, English Department students are keeping busy. Matthew Sergi, a doctoral candidate in the department, is presenting his new play in San Francisco — two weekends only!: Read details…View This Article →


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Martinez Supports Tougher Corruption Penalties
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SANTA FE, N.M. – Martinez, a former prosecutor, joined Republican lawmakers at a news conference on Thursday to support the legislation. Fighting corruption was a centerpiece issue of the governor's campaign last year.
The bill by Republican Rep. Nate Gentry of Albuquerque will strip government officials of their public pensions if they're convicted of corruption.
Former State Treasurer Robert Vigil continues to receive his state pension despite a conviction of attempted extortion.
Martinez also supports legislation to establish a division in the Department of Public Safety to investigate public corruption cases.


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Just a note to say that I'm back from windy Wellington and have been busy turning my mad laptop ramblings from the Webstock Conference into blog posts and articles since I got back. You can read coverage of some sessions already on my SiteProNews blog and I'll post others here shortly, including some of the more interesting things I learned and all the goss on my catch up with Jill Whalen. Stay tuned!
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News Room
Yokohama Tire Corporation to Give Away $5,000 Worth of 101ZL™ Tires and iPads at the Mid-America Trucking Show, Booth 14124
March 28, 2011
FULLERTON, CA (March 22, 2011) – Yokohama Tire Corporation is giving away 101ZL™ premium steer tires and iPads each day at the Mid-America Trucking Show (MATS) in Louisville, Kentucky, March 31-April 2. "All MATS attendees have to do is stop at our booth (14124) and register to win," said Rick Phillips, Yokohama director of commercial sales. "It's that easy and the prizes are notable."
Three pairs of 101ZL tires (including free installation and valve stems at the Yokohama dealer of their choice) and three iPads will be given away during the show's run, worth an estimated $5,000. "We gave away tires last year to one lucky attendee, and it was so popular, we decided to expand on it," said Phillips. "There will be three tire winners and three iPad winners named during the show."
The 101ZL, on the EPA's SmartWay list of low rolling resistance tires, is available in four sizes (295/75R22.5, 11R22.5, 11R24.5 and 285/75R24.5). The premium steer tire is designed for long-haul operations and features enhanced durability, excellent longevity and outstanding fuel efficiency, according to Phillips. "It's ideal for fleet owners and truck operators. The tires last longer and help preserve the environment via the fuel saved."
Yokohama Tire Corporation is the North American manufacturing and marketing arm of Tokyo, Japan-based The Yokohama Rubber Co., Ltd., a global manufacturing and sales company of premium tires since 1917. Servicing a network of more than 4,500 points of sale in the U.S., Yokohama Tire Corporation is a leader in technology and innovation. The company's complete product line includes the dB Super E-spec™ – the world's first tire to use orange oil to reduce petroleum – as well as tires for high-performance, light truck, passenger car, commercial truck and bus, and off-the-road mining and construction applications. For more information on Yokohama's extensive product line, visit www.yokohamatire.com.
Yokohama is a strong supporter of the tire care and safety guidelines established by the Rubber Manufacturers Association and the National Highway Transportation and Safety Administration. Details can be found at the "Tire Safety" section at www.yokohamatire.com.


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Links to Related Materials
The Angie Debo Collection
The Special Collections and University Archives Department of the Oklahoma State University Library houses papers, correspondence, and photographs donated by Angie Debo. The website dedicated to her materials provides additional information on her life and career along with detailed finding aids and further links to other relevant collections within the Library.
The McCasland Digital Collection of Early Oklahoma and Indian Territory Maps
Angie Debo's historical research spanned Oklahoma's story both before and after statehood, during times when the boundaries of various territories in the region were shifting on a regular basis and the ownership of areas was changing. The McCasland Collection at the Oklahoma State University Library contains almost 2,000 historical maps covering many of the same time periods that Debo discussed, and this cartographic archive in turn provides researchers with a context for Debo's discussions. The maps can either be searched by keyword or browsed.
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