inforMED
MalfunctionODF

SPYGLASS DIRECT VISUALIZATION SYSTEM

Received Oct 5, 2017 · Event occurred Sep 3, 2017

Report 3005099803-2017-02914 · MDR key 6916793

Device

Generic name

Mini Endoscope, Gastroenterology-urology

Model number

M00546230

Catalog number

4623

Lot number

0000049757

Product problems

  • Device Contamination with Chemical or Other Material
  • Device Contamination with Chemical or Other Material

Patient

Not reported

  • No Consequences Or Impact To Patient
  • No Consequences Or Impact To Patient

Narrative

Additional Manufacturer Narrative

A VISUAL EXAMINATION OF THE RETURNED DEVICE FOUND THAT THE DEVICE APPEARED TO BE IN GOOD CONDITION WITH NO OBVIOUS VISUAL DEFORMITIES. A SPYBITE WAS USED TO VERIFY THE COMPLAINT; WHEN AN ATTEMPT WAS MADE TO PASS THE SPYBITE, IT MET RESISTANCE NEAR THE HANDLE AND THE DISTAL END, BUT THE SPYBITE WAS ABLE TO PASS IN BOTH CASES. A SPYGLASS WAS USED TO LOOK FOR FOREIGN MATERIAL IN BOTH THE WORKING CHANNEL AND THE OPTIC CHANNEL; NONE WAS FOUND. A GUIDEWIRE WAS INSERTED INTO THE DISTAL END OF THE WORKING CHANNEL AND THE GUIDEWIRE EXITED THE WORKING PORT WITHOUT ISSUE. THE INVESTIGATION CONCLUDED THAT PRODUCT ANALYSIS COULD NOT CONFIRM THAT FOREIGN MATTER WAS PRESENT IN EITHER THE WORKING CHANNEL OR THE OPTIC CHANNEL; HOWEVER, DIFFICULTY PASSING THE ACCESSORY WAS CONFIRMED WHEN RESISTANCE WAS MET IN THE HANDLE AND THE DISTAL END OF THE DEVICE. THE MOST PROBABLE ROOT CAUSE IS UNDETERMINABLE. A REVIEW OF THE DEVICE HISTORY RECORD (DHR) WAS PERFORMED; NO ANOMALIES WERE NOTED. A SEARCH OF THE COMPLAINT DATABASE REVEALED THAT NO SIMILAR COMPLAINTS EXIST FOR THE SPECIFIED LOT.

Description of Event or Problem

IT WAS REPORTED TO BOSTON SCIENTIFIC CORPORATION THAT A SPYGLASS DIRECT VISUALIZATION SYSTEM WAS USED DURING A SPYGLASS ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) PROCEDURE PERFORMED ON (B)(6) 2017. ACCORDING TO THE COMPLAINANT, DURING PREPARATION, THE FIBER WAS DIFFICULT TO ADVANCE AND THE CATHETER HAD FOREIGN MATTER WHICH BLOCKED THE VIEW OF THE DEVICE. THE FOREIGN MATTER COULD NOT BE CONFIRMED. THE PROCEDURE WAS COMPLETED WITH ANOTHER SPYGLASS DIRECT VISUALIZATION SYSTEM. THERE WERE NO PATIENT COMPLICATIONS REPORTED AS A RESULT OF THIS EVENT. THE PATIENT'S CONDITION AT THE CONCLUSION OF THE PROCEDURE WAS REPORTED TO BE STABLE.

Additional Manufacturer Narrative

THE DEVICE HAS BEEN RECEIVED FOR ANALYSIS. UPON COMPLETION OF THE FAILURE ANALYSIS OF THE COMPLAINT DEVICE, IF THERE IS ANY FURTHER RELEVANT INFORMATION FROM THAT REVIEW, A SUPPLEMENTAL MEDWATCH WILL BE FILED.

Description of Event or Problem

IT WAS REPORTED TO BOSTON SCIENTIFIC CORPORATION THAT A SPYGLASS DIRECT VISUALIZATION SYSTEM WAS USED DURING A SPYGLASS ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) PROCEDURE PERFORMED ON (B)(6) 2017. ACCORDING TO THE COMPLAINANT, DURING PREPARATION, THE FIBER WAS DIFFICULT TO ADVANCE AND THE CATHETER HAD FOREIGN MATTER WHICH BLOCKED THE VIEW OF THE DEVICE. THE FOREIGN MATTER COULD NOT BE CONFIRMED. THE PROCEDURE WAS COMPLETED WITH ANOTHER SPYGLASS DIRECT VISUALIZATION SYSTEM. THERE WERE NO PATIENT COMPLICATIONS REPORTED AS A RESULT OF THIS EVENT. THE PATIENT'S CONDITION AT THE CONCLUSION OF THE PROCEDURE WAS REPORTED TO BE STABLE.