inforMED
MalfunctionFDR

SINGLE USE 3-LUMEN SPHINCTEROTOME

Received May 19, 2015 · Event occurred Mar 27, 2015

Report 8010047-2015-00354 · MDR key 4798236

Device

Generic name

Sphincterotome

Model number

KD-V411M-0320

Lot number

K4Z18

Product problems

  • Break

Patient

Not reported

  • No Consequences Or Impact To Patient

Narrative

Description of Event or Problem

OLYMPUS MEDICAL SYSTEMS CORP (OMSC) WAS INFORMED THAT DURING ENDOSCOPIC SPHINCTEROTOMY, THE CUTTING WIRE BROKE. THE DOCTOR COMPLETED THE PROCEDURE WITH ANOTHER DEVICE. DURING THE INVESTIGATION, OMSC FOUND THE PLASTIC COATING ON THE CUTTING WIRE WAS PARTIALLY MISSING. THERE WAS NO REPORT OF PATIENT INJURY REGARDING THIS REPORT.

Additional Manufacturer Narrative

THE INVESTIGATION CONFIRMED THAT THE CUTTING WIRE WAS BROKEN AND THE BROKEN SECTION WAS MELTED AND BURNED. APPROXIMATELY COATING WAS MISSING FOR 4MM FROM THE BROKEN POINT. THERE WERE NO OTHER ABNORMALITIES RELATED TO THE BREAKAGE IN THE SUBJECT DEVICE. ALSO AS THE CHECKING OF THE MANUFACTURING RECORD OF THE SAME LOT, NOTHING ABNORMAL DETECTED. AS THE RESULTS OF THE INVESTIGATION, OMSC ASSUMES THAT THE DAMAGE OF THE COATING OCCURRED DUE TO CONTACTING W WITH THE FORCEPS ELEVATOR OF THE ENDOSCOPE. THE EXPOSED CUTTING WIRE FROM THE DAMAGED COATING CONTACTED OR CAME CLOSE TO THE METAL PART OF THE FORCEPS ELEVATOR WHILE ACTIVATING THE OUTPUT, WHICH CAUSED SPARK AND A PART OF THE CUTTING WIRE BECAME EXTREMELY HOT, RESULTING IN BREAKAGE. THE COATING BROKE OFF AND CAME OFF FROM THE CUTTING WIRE BECAUSE OF THE USER HANDLING AFTER THE CUTTING WIRE WE BROKEN. THIS REPORT IS BEING SUBMITTED AS A MEDICAL DEVICE REPORT IN AN ABUNDANCE OF CAUTION.