Notes: this report pertains to two spyscope ds ii, one spy ds controller and two jagwires used during the same procedure.It was reported to boston scientific corporation that two spyscope ds ii, one spy ds controller and two jagwire guidewires were used in the biliary tract during a cholangioscopic lithotripsy procedure performed on (b)(6) 2022.During the procedure, the physician put a spyscope and a jagwire into the biliary tract.During the exchange, the jacket on the guidewire stripped away from the inner shaft.The spyscope could not be back loaded over the guidewire.A new jagwire was used to cannulate again.When cannulation was done and the physician tried to exchange the wire, the wire stripped again.The physician took out the spyscope with the guidewire and decided not to proceed with the use of a guidewire.Then the spyscope was reinserted and during water injection, the spyscope stopped working.The spyscope was replaced with a second spyscope but the same problem occurred.It is unknown if the physician was blasting stones or injecting water when the second spyscope stop working.The procedure was changed to a regular endoscopic retrograde cholangiopancreatography (ercp).A plastic stent was placed.The procedure was not completed due to these events.
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