WO2002060328A1 - Apparatus and method for stapling and resectioning gastro-esophageal tissue - Google Patents
Apparatus and method for stapling and resectioning gastro-esophageal tissue Download PDFInfo
- Publication number
- WO2002060328A1 WO2002060328A1 PCT/US2002/003069 US0203069W WO02060328A1 WO 2002060328 A1 WO2002060328 A1 WO 2002060328A1 US 0203069 W US0203069 W US 0203069W WO 02060328 A1 WO02060328 A1 WO 02060328A1
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- WIPO (PCT)
- Prior art keywords
- tissue
- jaws
- staple
- stapling
- staples
- Prior art date
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Classifications
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/10—Surgical instruments, devices or methods, e.g. tourniquets for applying or removing wound clamps, e.g. containing only one clamp or staple; Wound clamp magazines
- A61B17/105—Wound clamp magazines
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/068—Surgical staplers, e.g. containing multiple staples or clamps
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/068—Surgical staplers, e.g. containing multiple staples or clamps
- A61B17/072—Surgical staplers, e.g. containing multiple staples or clamps for applying a row of staples in a single action, e.g. the staples being applied simultaneously
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/068—Surgical staplers, e.g. containing multiple staples or clamps
- A61B17/072—Surgical staplers, e.g. containing multiple staples or clamps for applying a row of staples in a single action, e.g. the staples being applied simultaneously
- A61B17/07207—Surgical staplers, e.g. containing multiple staples or clamps for applying a row of staples in a single action, e.g. the staples being applied simultaneously the staples being applied sequentially
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/32—Surgical cutting instruments
- A61B17/3205—Excision instruments
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B1/00—Instruments for performing medical examinations of the interior of cavities or tubes of the body by visual or photographical inspection, e.g. endoscopes; Illuminating arrangements therefor
- A61B1/273—Instruments for performing medical examinations of the interior of cavities or tubes of the body by visual or photographical inspection, e.g. endoscopes; Illuminating arrangements therefor for the upper alimentary canal, e.g. oesophagoscopes, gastroscopes
- A61B1/2736—Gastroscopes
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/00234—Surgical instruments, devices or methods, e.g. tourniquets for minimally invasive surgery
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/00234—Surgical instruments, devices or methods, e.g. tourniquets for minimally invasive surgery
- A61B2017/00238—Type of minimally invasive operation
- A61B2017/00278—Transorgan operations, e.g. transgastric
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B2017/00743—Type of operation; Specification of treatment sites
- A61B2017/00818—Treatment of the gastro-intestinal system
- A61B2017/00827—Treatment of gastro-esophageal reflux
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/068—Surgical staplers, e.g. containing multiple staples or clamps
- A61B17/072—Surgical staplers, e.g. containing multiple staples or clamps for applying a row of staples in a single action, e.g. the staples being applied simultaneously
- A61B2017/07214—Stapler heads
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/068—Surgical staplers, e.g. containing multiple staples or clamps
- A61B17/072—Surgical staplers, e.g. containing multiple staples or clamps for applying a row of staples in a single action, e.g. the staples being applied simultaneously
- A61B2017/07214—Stapler heads
- A61B2017/07221—Stapler heads curved
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/28—Surgical forceps
- A61B17/29—Forceps for use in minimally invasive surgery
- A61B2017/2901—Details of shaft
- A61B2017/2905—Details of shaft flexible
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/28—Surgical forceps
- A61B17/29—Forceps for use in minimally invasive surgery
- A61B17/2909—Handles
- A61B2017/2912—Handles transmission of forces to actuating rod or piston
- A61B2017/2923—Toothed members, e.g. rack and pinion
Definitions
- the present invention relates to endoscopic devices for performing localized resections of gastro- esophageal lesions.
- Endoscopic surgical stapling apparatus are known in the art and are utilized to provide a variety of surgical procedures.
- U.S. Patent No. 5,040,715 to Green, et al discloses an endoscopic stapling device configured to be inserted through a small entrance wound in the abdominal cavity to place rows of staples in body tissue. This device has a limited range of motion in that the stapling assembly at the distal end of the instrument can only be rotated about the central axis of the instrument .
- the present invention is directed to a system for stapling tissue comprising a flexible endoscope and an operative head including a pair of opposed, curved tissue clamping jaws sized to pass through an esophagus, the jaws being moveable with respect to one another between an open tissue receiving configuration and a closed tissue clamping configuration, a first one of the curved jaws including a stapling mechanism and a second one of the jaws including a staple forming anvil surface, the stapling mechanism including staple slots through which staples are fired arranged in a row extending from a proximal end of the first jaw to a distal end thereof in combination with a control handle which, when the operative head is in an operative position within one of a patient's stomach and esophagus, remains outside the patient, the control handle including a first actuator for moving the jaws relative to one another and a second actuator for operating the stapling mechanism.
- FIG. 1 shows a perspective view of a system according to an illustrative embodiment of the present invention along with a partially cross-sectional view of a patient showing a target portion of tissue to be resected;
- Fig. 2a shows the system of Fig. 1 inserted into the patient's body via the mouth
- Fig. 2b shows a display of the image of a stapling apparatus of the system of Fig. 1 provided to a user;
- Fig. 2c shows a cross-sectional view of the patient's esophagus with the stapling apparatus of Fig. 3 in position adjacent to the target portion of tissue;
- Fig. 3 shows a perspective view of the system of Fig. 1 with jaws of the stapling apparatus open;
- Fig. 4 shows a partially cross-sectional view of a proximal end of the stapling apparatus of Fig. 3 showing control cables for operating the jaws configured as when the jaws are open;
- Fig. 5 shows a perspective view of the system of Fig. 1 with jaws of the stapling apparatus closed with a lower actuator lever on a control handle being actuated;
- Fig. 6 shows a partially cross-sectional view of the control handle of the system of Fig. 5 showing a coupling between control cables for operating the jaws and the lower actuator lever on the control handle;
- Fig. 7 shows a partially cross-sectional view of a proximal end of the stapling apparatus of Fig. 5 showing control cables for operating a stapling pusher of the stapling apparatus configured as when the lower actuator lever is actuated;
- Fig. 8 shows a perspective view of the system of Fig. 1 with jaws of the stapling apparatus closed with an upper actuator lever on the control handle being actuated
- Fig. 9 shows a partially cross-sectional view of a portion of the control handle of the system of Fig. 8 showing a coupling between control cables for operating the jaws and the upper actuator lever on the control handle;
- Fig. 10 shows a partially cross-sectional view of a proximal end of the stapling apparatus of Fig. 5 showing control cables for operating a stapling pusher of the stapling apparatus configured as when the upper actuator lever is actuated;
- Fig. 11 shows a partially cross-sectional view of a stapling assembly of the system of Fig. 1 grasping esophageal tissue;
- Fig. 12 shows a partially cross-sectional view of the stapling assembly of the system of Fig. 1 illustrating a mechanism for grossly approximating the jaws of the stapling assembly;
- Fig. 13 shows a partially cross-sectional view of the stapling assembly illustrating a mechanism for finely approximating the jaws in an initial position
- Fig. 14 shows a perspective view of an I-beam member of the fine approximation mechanism of Fig. 13;
- Fig. 15 shows a partially cross-sectional view of the stapling assembly with the fine approximation mechanism in a partially advanced position
- Fig. 16 shows a perspective view of the stapling assembly with a C-shaped clamp member thereof in an initial position
- Fig. 17 shows a perspective view of the C-shaped clamp member of Fig. 16 rotated 180° removed from the jaws;
- Fig. 18 shows a cross-sectional view of the stapling assembly with the C-shaped clamp member in a partially advanced position
- Fig. 19 shows an alternate embodiment of the system according to the present invention with a lateral endoscope receiving lumen
- Fig. 20 shows the system of Fig. 19 with an endoscope received therein;
- Fig. 21 shows a system in accord with the present invention positioned within the stomach to perform a procedure for the treatment of reflux
- Fig. 22 shows a system in accord with the present invention positioned within the stomach to perform a stomach reduction procedure.
- a method and apparatus for resectioning anastomized lumenal tissue is disclosed in U.S. Patent No. 5,868,760 to McGuckin et al . , the disclosure of which is hereby incorporated by reference in its entirety.
- the disclosed apparatus includes a flexible tubular body and a distal operating capsule that may be inserted through either a naturally occurring body orifice or a surgical incision and guided to an operative site endoscopically or using radiologic imaging guidance.
- the target tissue is stapled, cut and captured within the operating capsule for removal from the body.
- the healthy tissue is thereby anastomized by surgical staples.
- FIG. 1 shows a system for resecting esophageal tissue according to an illustrative embodiment of the present invention.
- a surgical stapling apparatus designated generally by the reference numeral 10, is utilized in conjunction with an endoscope 20 for providing remote vision of an operative area and to assist in guiding the stapling apparatus 10 to the operative area.
- An endoscopic grasping device 30 extends through a lumen in the endoscope 20 for use at the surgical site as would be understood by those of skill in the art.
- MRI Magnetic Resonance Imaging
- the stapling apparatus 10 includes a proximal handle portion 12, an elongated flexible body portion 14 extending from the handle portion 12 and a generally C-shaped stapling assembly 16 operatively associated with a distal end of the flexible body portion 14.
- the flexible body portion 14 and the stapling assembly 16 are preferably dimensioned and configured to traverse the natural curvature of the esophagus .
- the stapling assembly As shown in Figs . 2b and 2c and described in detail below, the stapling assembly
- jaws 17 are described herein as rotating relative to one another • between the open and closed positions, that these jaws 17 may be coupled by a mechanism which allows them to move linearly with respect to one another or in any other manner so long as they move between a first position in which the jaws 17 are separated from one another to receive tissue and a second position in which the jaws 17 are clamped together to hold tissue tightly therebetween for stapling.
- the system may operate with any of a variety of commercially available medical endoscopes which may include, for example, a proximal handle portion 22, an elongated flexible body portion 24 through which one or more interior lumena extend for accommodating, for example, a fiber optic bundle or other image transmission structure, a working channel for the grasping device 30, etc.
- a fiber optic bundle or other image transmitting structure
- the tissue grasping device 30 may include a handle portion 32, an elongated flexible body portion 34 and a pair of opposable jaws 36a and 36b.
- the surgical stapling apparatus 10 and the flexible endoscope 20 are introduced into a patient's mouth and advanced into the esophagus to the operative site S under visual guidance from the endoscope 20.
- the operator maneuvers the stapling assembly 16 into a desired position relative to the tissue to be resected (how is this maneuvering done?) .
- the jaws 17 of the stapling assembly 16 are then opened to a tissue receiving position as shown in Fig. 3 and the grasping device 30 is advanced from the distal end of the endoscope 20.
- the jaws 36a and 36b are rotated away from one another by manipulation of the grasper handle portion 32 and the tissue T to be resected is grasped by closing the jaws 36a, 36b.
- the grasping device 30 is then withdrawn into the working channel of the endoscope 20 to pull the tissue T into position between the jaws 17 of the stapling assembly 16 and the jaws 17 are closed to clamp the tissue T in place between the staple carrying portion 40 and the staple forming portion 50.
- the tissue T is preferably drawn between the jaws 17 so that a margin of healthy tissue is positioned between the staple carrying portion 40 and the staple forming portion 50 to ensure that all of the diseased or damaged tissue T is removed.
- this may be visually confirmed through the use of the vision system of the endoscope as shown in Fig. 2b.
- an illustrative embodiment of the system according to the present invention includes an actuation cable 44 to facilitate gross approximation of the jaws 17 via actuation of an actuator knob 38.
- the actuation cable 44 may be secured to the one of the jaws 17 including, for example, the staple carrying portion 40 and is operatively coupled to the other jaw 17 including the staple forming portion 50 by a member 85 which may, for example, be a spindle, capstan or other member around which the cable 44 passes to change direction to generate the clamping force to draw the jaws 17 together.
- a member 85 which may, for example, be a spindle, capstan or other member around which the cable 44 passes to change direction to generate the clamping force to draw the jaws 17 together.
- an overhanging flange 98 at a proximal end of the staple carrying portion 40 acts as a tissue shield preventing the target tissue T from entering into the joint between the jaws 17.
- the lower clamping handle 12a is actuated in the direction of the arrow in Fig. 5 to cause the integral gear rack 62a to turn pinion gear 62b which rotates elongated drive cable 64.
- the drive cable 64 is coupled to a drive screw 63 so that rotation of the drive cable 64 rotates the drive screw 63 moving the clamping member 60 distally as shown in Fig. 18.
- the stapling assembly 16 may be actuated to fire staples through the clamped tissue while simultaneously cutting away the tissue T from the stapled and anastamized tissue.
- the user actuates the stapling assembly 16 to drive staples through the margin of healthy tissue in one or more arcuate bands located radially outward of a line of tissue cutting.
- the stapling operation may be separated from the tissue cutting operation so that no tissue is cut until the entire stapling operation has been successfully concluded.
- the operator drives an I-beam member 70 through the stapling assembly 16 by operating the clamping handle 12b in the direction of the arrow in Fig. 8, causing gear rack 72a to rotate pinion gear 72b which rotates a staple driving drive cable 74 as shown in Fig. 9.
- the drive cable extends through the flexible body portion 14 to a linear drive screw 76 which drives a flexible pusher 80 coupled to the I-beam member 70 as shown in Fig. 10.
- the I-beam member 70 includes upper and lower beam portions 82a, 82b, respectively, connected by a central web portion 84.
- a leading edge 84a of the central web portion 84 may preferably define a cutting blade for incising tissue as the I-beam member 70 is moved distally as described below.
- an arcuate channel 90 within which the central web portion 84 travels is defined in the opposing jaws 17 radially inward of the arcuate lines of staple carrying slots (not shown) .
- the staple slots may be arranged in any number of rows, for example, from one to five such rows may be included and the slots of these rows may be staggered so that to ensure that the opening created by the resection is completely sealed.
- the clamp member 60 includes a body portion 112 from which depend upper and lower clamping beams 114a and 114b, respectively, for urging the jaws 17 toward one another.
- the body 112 includes a radially depending driving stem 115 having a sloped leading edge configured to extend through an arcuate slot 116 formed in the staple carrying portion 40 for sequentially contacting each of a plurality of staple pushers 118.
- the staple pushers 118 are positioned so that, when contacted by the driving stem 115, each staple pusher 118 is driven through a corresponding one of the staple slots to drive a staple housed therein from the slot out of the staple carrying portion 40, through both thicknesses of the folded portion of tissue clamped between the jaws 17 and against the staple forming surface 50a of the staple forming portion 50 to couple the two thicknesses of tissue to one another.
- the clamping member 60 further includes an integral cutting blade 130 for forming an arcuate incision substantially concentric with and radially within an inner one of the arcs of staple slots. Furthermore, the cutting blade 130 is preferably positioned so that it trails the leading edge 115 so that tissue is stapled before it is cut.
- actuation of the upper actuation handle 12b causes the I-beam member 70 to move through the stapling assembly 16 to sequentially fire arcuate rows of staples while simultaneously cutting tissue away from the esophagus radially within the rows of staples.
- the sloped leading edge of the upper beam portion 82a contacts sequentially each of a plurality of staple pushers 118 to drive them through their respective staple slots to drive the staples housed therein from each slot out of the staple carrying portion 40, through both thicknesses of the folded portion of tissue clamped between the jaws 17 and into the staple forming pockets 122 formed in the staple forming surface 50a of the staple forming portion 50 to couple the two thicknesses of tissue to one another.
- the leading edge 84a of the central web portion 84 is proximal to the sloped leading edge, the incision trails the stapling action so that only tissue within the arc that has previously been stapled is severed.
- a stapling assembly 16' may include an endoscope receiving lumen 140 through which the endoscope 20 may be slidably inserted. This allows an operator to use to steering and vision capability of the endoscope 20 to locate the operative site S. Once the distal end of the endoscope 20 is positioned adjacent to the site S, the stapling assembly 16' may be slid along the endoscope 20 to the operative site S and the steering capability of the distal end of the endoscope 20 may be employed to achieve a desired position and orientation of the stapling assembly 16 ' relative to the tissue T.
- the construction of the rest of the system of Figs. 19 and 20 may be substantially in accord with that of any of the previously described embodiments.
- the system according to the present invention may also be used to perform resections within the stomach.
- the stapling apparatus 10 may be used to correct gastro- esophageal reflux ("GERD") or to perform a stomach reduction procedure.
- a system according to the invention may be inserted through the esophagus into a patient's stomach and the operator may position the jaws 17 under visual control via the endoscope 20 adjacent to a junction between the esophagus and the stomach.
- the operator then uses the steering capability of the endoscope 20, received within the endoscope lumen 140 to direct the jaws 17 toward a portion of stomach tissue to be fastened to the esophagus.
- the operator grasps a portion of the stomach using the grasping device 30 and urges the tissue T toward the esophagus to create a fold of tissue with an outside surface of the stomach tissue adjacent to or in contact with an outer surface of the esophagus. This fold is then clamped by the jaws 17 and stapled together to... (how does this treat GERD - i ⁇ this a fundoplicati ⁇ n with wrapping of the fundus around the esophagus? Is tissue resected? More details please - are any structural changes to the device required?) .
- an operator inserts a system according to the present invention into the stomach via the esophagus as described above in regard to Fig. 21 and locates a portion of tissue to be folded over on itself to reduce the size of the stomach.
- This tissue T is grasped by the grasping device 30 and drawn between the jaws 17 which clamp the tissue T together folded onto itself and staples the fold together.
- the folded tissue radially within the staples may, if desired, be left in place without resection so that the operation may be reversed at a later date.
- the stapling apparatus 10 need not include a tissue cutting mechanism. Rather, the stapling apparatus 10 need only include structure for approximating the jaws 17 and for driving staples through the gripped fold of tissue. In this case, the C-shaped clamp member 60 would be constructed without the cutting blade 130.
Abstract
Description
Claims
Priority Applications (5)
Application Number | Priority Date | Filing Date | Title |
---|---|---|---|
EP02707678A EP1359851B1 (en) | 2001-01-31 | 2002-01-31 | Apparatus for stapling and resectioning gastro-edophageal tissue |
JP2002560526A JP4202138B2 (en) | 2001-01-31 | 2002-01-31 | Apparatus and method for stapling and ablating gastroesophageal tissue |
AU2002242071A AU2002242071B2 (en) | 2001-01-31 | 2002-01-31 | Apparatus and method for stapling and resectioning gastro-esophageal tissue |
CA2435522A CA2435522C (en) | 2001-01-31 | 2002-01-31 | Apparatus for stapling and resectioning gastro-esophageal tissue |
DE60237753T DE60237753D1 (en) | 2001-01-31 | 2002-01-31 | APPARATUS FOR COLLIFORING AND RESEARING MAGENTAL DISHES TISSUE |
Applications Claiming Priority (2)
Application Number | Priority Date | Filing Date | Title |
---|---|---|---|
US26546901P | 2001-01-31 | 2001-01-31 | |
US60/265,469 | 2001-01-31 |
Publications (1)
Publication Number | Publication Date |
---|---|
WO2002060328A1 true WO2002060328A1 (en) | 2002-08-08 |
Family
ID=23010567
Family Applications (1)
Application Number | Title | Priority Date | Filing Date |
---|---|---|---|
PCT/US2002/003069 WO2002060328A1 (en) | 2001-01-31 | 2002-01-31 | Apparatus and method for stapling and resectioning gastro-esophageal tissue |
Country Status (6)
Country | Link |
---|---|
US (8) | US6835199B2 (en) |
EP (1) | EP1359851B1 (en) |
JP (1) | JP4202138B2 (en) |
AU (1) | AU2002242071B2 (en) |
CA (1) | CA2435522C (en) |
WO (1) | WO2002060328A1 (en) |
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EP1967144A3 (en) * | 2007-01-11 | 2010-04-07 | Ethicon Endo-Surgery, Inc. | Improved buttress material for use with a surgical stapler |
US7704264B2 (en) | 1999-06-25 | 2010-04-27 | Usgi Medical, Inc. | Apparatus and methods for forming and securing gastrointestinal tissue folds |
US7703459B2 (en) | 2004-03-09 | 2010-04-27 | Usgi Medical, Inc. | Apparatus and methods for mapping out endoluminal gastrointestinal surgery |
US7708181B2 (en) | 2008-03-18 | 2010-05-04 | Barosense, Inc. | Endoscopic stapling devices and methods |
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US7954682B2 (en) | 2007-01-10 | 2011-06-07 | Ethicon Endo-Surgery, Inc. | Surgical instrument with elements to communicate between control unit and end effector |
US7954684B2 (en) | 2007-06-22 | 2011-06-07 | Ehticon Endo-Surgery, Inc. | Surgical stapling instrument with a firing member return mechanism |
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US20160151065A1 (en) | 2016-06-02 |
US20020143346A1 (en) | 2002-10-03 |
JP4202138B2 (en) | 2008-12-24 |
US9439650B2 (en) | 2016-09-13 |
US7090684B2 (en) | 2006-08-15 |
EP1359851B1 (en) | 2010-09-22 |
US20060241692A1 (en) | 2006-10-26 |
US20190388094A1 (en) | 2019-12-26 |
US6835199B2 (en) | 2004-12-28 |
AU2002242071B2 (en) | 2006-10-19 |
EP1359851A1 (en) | 2003-11-12 |
US20130228610A1 (en) | 2013-09-05 |
US20170273687A1 (en) | 2017-09-28 |
US9271727B2 (en) | 2016-03-01 |
CA2435522C (en) | 2010-02-23 |
US20050033320A1 (en) | 2005-02-10 |
US10675033B2 (en) | 2020-06-09 |
JP2005505309A (en) | 2005-02-24 |
US8424741B2 (en) | 2013-04-23 |
CA2435522A1 (en) | 2002-08-08 |
US20190069897A1 (en) | 2019-03-07 |
US10136892B2 (en) | 2018-11-27 |
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