The subject device was not returned to olympus medical systems corp.(omsc) for evaluation, because the subject device was discarded by the user.Therefore, the exact cause of the reported event could not be conclusively determined.The lot number of the subject device is unknown.As a result of checking the manufacturing record for past one year from the event date, it was found no irregularities.Based on the past similar cases, it was known that the failure of releasing the loop occurred since the loop was caught between the hook and the coil sheath after the loop was released in the tube sheath.The above device handling has warned in the instruction manual as follows.Do not try to forcibly withdraw the instrument from the endoscope when the loop cannot be detached from the instrument.Forcibly withdrawing the instrument could cause patient injury such as punctures, hemorrhages or mucous membrane damage.If the loop cannot be detached from the instrument, follow the procedures described in this section.If there are any deviations or crushed sections on the distal end of the coil sheath, it may not be possible to detach the loop from the instrument.Do not remove the loop from the hook while the coil sheath is not extended from the tube sheath.Otherwise, the loop may be tangled with the hook and become impossible to be removed.
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During an endoscopic therapy of the large intestine, the subject device was used.The user surrounded and ligated the target polyp with the loop.The user tried to release the loop from the subject device.However the loop could not be released and bleeding occurred.When the user moved the device back and forth, the loop was detached from the device.The user stopped bleeding with a clip.The subject device was discarded by the user.
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