BOSTON SCIENTIFIC CORPORATION SPYSCOPE DS; CHOLEDOCHOSCOPE AND ACCESSORIES, FLEXIBLE/RIGID
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Model Number M00546600 |
Device Problem
Material Protrusion/Extrusion (2979)
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Patient Problem
No Consequences Or Impact To Patient (2199)
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Event Date 12/05/2018 |
Event Type
malfunction
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Manufacturer Narrative
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(b)(4).Although the suspect device has been received, the evaluation has not been completed.Therefore, the cause of the reported malfunction has not been determined.Upon completion of the failure analysis of the complaint device, if there is any further relevant information from that review, a supplemental mdr will be filed.
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Event Description
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It was reported to boston scientific corporation that a spyscope digital access and delivery catheter was used in the duodenum during an endoscopic retrograde cholangiopancreatography (ercp) with spyglass procedure performed on (b)(6) 2018.According to the complainant, during the procedure, it was noticed that the working channel sleeve of the spyscope ds protruded.A spybite was inside the spyscope ds when the working channel sleeve protruded.There were no reported issues with the spybite.The procedure was completed with a second spyscope digital access and delivery catheter.There were no patient complications reported as a result of this event.The patient's condition at the end of the procedure was reported to be fine.
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Event Description
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It was reported to boston scientific corporation that a spyscope digital access and delivery catheter was used in the duodenum during an endoscopic retrograde cholangiopancreatography (ercp) with spyglass procedure performed on (b)(6) 2018.According to the complainant, during the procedure, it was noticed that the working channel sleeve of the spyscope ds protruded.A spybite was inside the spyscope ds when the working channel sleeve protruded.There were no reported issues with the spybite.The procedure was completed with a second spyscope digital access and delivery catheter.There were no patient complications reported as a result of this event.The patient's condition at the end of the procedure was reported to be fine.
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Manufacturer Narrative
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Problem code 2979 captures the reportable event of working channel sleeve protrusion.A visual assessment was performed.As received, the working channel sleeve (wcs) protruded.Maximum wcs protrusion was observed when the distal tip was articulated by turning the knobs in all directions.The distal tip was cut.The distal cap was removed.The catheter was cut open using the cutting fixture.The working channel sleeve was removed.Witness marks were noted on the pebax.The white and clear areas along bond a, appeared to show evidence of adhesion.The complaint was consistent with the reported complaint incident of working channel sleeve protruding.Based on investigation results, the underlying cause of working channel sleeve protrusion is an insufficient bond, particularly the second heat cycle of the working channel sleeve bonding process [bond b].Therefore,the complaint investigation conclusion code selected for the wcs protrusion issue is manufacturing deficiency, which indicates that problems were traced to the manufacturing process.An investigation is underway to address this issue.A dhr (device history record) review was performed and did not identify evidence of deviations or non-conformances in the manufacturing processes that could contribute to the complaint.The dhr review confirms that the accepted device met all manufacturing specifications.
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