Stomach tissue can manipulated and fastened with a tissue grasper (357) and a tissue shaper (352) to form folds in the stomach. The tissue grasper and the tissue shaper can rotate and translate relative to one another. The tissue grasper has a plurality of vacuum orifices to adhere the tissue grasper to tissue. When tissue is drawn into the tissue shaper, a tissue piercing element (398) is moved from a stored position to a working position and used to pierce tissue.
