This event was reported by the distributor.The physician is: (b)(4).(initial reporter address 2): (b)(6).(b)(4).The returned ultratome xl was analyzed, and a visual evaluation noted that the cutting wire was broken, blackened, and kinked.The working length was free from obvious kinks and bends; however, the distal pierced hole was slightly torn.These findings were consistent with the findings when the device was observed under magnification.Additionally, the tip of the device was cracked.No other problems with the device were noted.The product analysis revealed that the cutting wire was broken, blackened, and kinked.The cutting wire being blackened indicates that the device was energized.These conditions could have been generated if there was contact between the device and the scope during energization or if the generator exceeded the maximum of voltage during procedure.Energizing the device prior to performing sphincterotomy can also compromise the cutting wire's integrity and can cause a premature cutting wire fatigue, leading to a break.Upon removing the device from the endoscope, the cutting wire could have been kinked and the working length torn.Additionally, the tip of the device was cracked which could have been due to interaction with the scope, if attempts were made to advance the device through a difficult anatomy, or if the tip was hit against a hard surface.It is most likely that procedural or anatomical factors encountered during the use of the device could have affected the device performance and integrity.Based on all gathered information, the most probable root cause of this complaint is adverse event related to procedure.A review of the manufacturing documentation for this device revealed that no anomalies or deviations related to the event occurred during manufacturing.A labeling review was performed and, from the information available, this device was used per the instructions for use (ifu) / product label.
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