MAUDE Adverse Event Report: COOK ENDOSCOPY TRI-TOME PC PROTECTOR; KNS, UNIT, ELECTROSURGICAL, ENDOSCOPIC (WITH OR WITHOUT ACCESSORIES)

Catalog Number TRI-25M-P

Device Problem Malposition of Device (2616)

Patient Problem No Consequences Or Impact To Patient (2199)

Event Date 11/29/2020

Event Type  malfunction  

Manufacturer Narrative

Initial reporter occupation: unknown.Investigation evaluation: our evaluation of the photos provided confirmed the report of incorrect cutting wire orientation.The photos provided show the device exiting the endoscope with the cutting wire facing 10 o'clock (appropriate orientation is approximately 11:00 - 1:00 o'clock).Twisting of the tubing was also observed at the distal end.The device history record for the lot number said to be involved was reviewed.The device history record contains a nonconformance that could potentially be related to the cutting wire not orienting as intended.The device goes through various inspections prior to leaving the facility.These inspections would have removed any nonconforming devices prior to distribution.A discrepancy or anomaly was not observed with the product that was released for distribution.Investigation conclusion: we could not conduct a complete investigation because the product said to be involved was not returned for evaluation.A definitive cause for the reported observation could not be determined.The instructions for use include the following system preparation "upon removing device from package, uncoil and straighten sphincterotome.Carefully remove precurved stylet from cannulating tip.Note: do not apply manual pressure to tip or cutting wire of sphincterotome to influence orientation, as this may result in damage to device.Note: do not exercise handle while device is coiled or precurved stylet is in place as this may cause damage to sphincterotome and render it inoperable." prior to distribution, all tri-tome pc protectors are subjected to a visual inspection and functional test to ensure device integrity.Corrective action: a review of the complaint history was conducted.The likelihood of occurrence is considered rare.Corrective action is not warranted at this time based on the quality engineering risk assessment.Quality assurance will continue to monitor for complaint trends and reassess the risk assessment results as post market feedback continues to become available.

Event Description

During an endoscopic retrograde cholangiopancreatography (ercp), the physician used a tri-tome pc protector sphincterotome.The physician detected that the device misoriented to the left.Another of the same device was used to complete the procedure.A section of the device did not remain inside the patient¿s body.The patient did not require any additional procedures due to this occurrence.According to the initial reporter, the patient did not experience any adverse effects due to this occurrence.

Manufacturer Narrative

Initial reporter occupation: unknown investigation evaluation: our evaluation of the photos provided confirmed the report of incorrect cutting wire orientation.The photos provided shows the device in vivo exiting the endoscope with the cutting wire facing 10 o'clock (appropriate orientation is approximately 11:00 - 1:00 o'clock).Twisting of the tubing was also observed at the distal end.An evaluation of the returned device could not confirm the report of incorrect cutting wire orientation.During our laboratory analysis, the sphincterotome was advanced through a duodenoscope that is placed in a simulated biliary position.The duodenoscope has an accessory channel that is 4.2 mm in diameter (model number olympus tjf-160v).The catheter exited the endoscope with the cutting wire facing 11 o¿clock.Prior to being bowed, the distal end entered the simulated papilla.The device was then bowed and the cutting wire was facing 12 o'clock (appropriate orientation is approximately 11:00 - 1:00 o'clock).The sphincterotome catheter was subjected to a close visual examination and twisting of the tubing was observed at the distal end.A discrepancy or anomaly that could have contributed to the reported event was not observed during our laboratory analysis of the returned product.The device history record for the lot number said to be involved was reviewed.The device history record contains a nonconformance that could potentially be related to the cutting wire not orienting as intended.The device goes through various inspections prior to leaving the facility.These inspections would have removed any nonconforming devices prior to distribution.A discrepancy or anomaly was not observed with the product that was released for distribution.Investigation conclusion: a definitive cause for this observation could not be determined because the actual use conditions could not be duplicated in the laboratory setting.Due to a variety of clinical conditions such as patient anatomy, endoscope position or progression of disease state, we could not reproduce the actual conditions of product usage during our laboratory analysis.This limits our ability to conclusively determine a cause.The instructions for use include the following system preparation "upon removing device from package, uncoil and straighten sphincterotome.Carefully remove precurved stylet from cannulating tip.Note: do not apply manual pressure to tip or cutting wire of sphincterotome to influence orientation, as this may result in damage to device.Note: do not exercise handle while device is coiled or precurved stylet is in place as this may cause damage to sphincterotome and render it inoperable." prior to distribution, all tri-tome pc protectors are subjected to a visual inspection and functional test to ensure device integrity.Corrective action: a review of the complaint history was conducted.The likelihood of occurrence is considered rare.Corrective action is not warranted at this time based on the quality engineering risk assessment.Quality assurance will continue to monitor for complaint trends and reassess the risk assessment results as post market feedback continues to become available.

• Brand Name: TRI-TOME PC PROTECTOR
• Type of Device: KNS, UNIT, ELECTROSURGICAL, ENDOSCOPIC (WITH OR WITHOUT ACCESSORIES)
• Manufacturer (Section D): COOK ENDOSCOPY; 4900 bethania station rd; winston-salem NC 27105
• MDR Report Key: 11076580
• MDR Text Key: 233815185
• Report Number: 1037905-2020-00572
• Device Sequence Number: 1
• Product Code: KNS
• UDI-Device Identifier: 10827002491974
• UDI-Public: (01)10827002491974(17)220905(10)W4258009
• Combination Product (y/n): N
• PMA/PMN Number: K901443
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: distributor,foreign
• Type of Report: Initial,Followup
• Report Date: 02/01/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Expiration Date: 09/05/2022
• Device Catalogue Number: TRI-25M-P
• Device Lot Number: W4258009
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 01/07/2021
• Initial Date Manufacturer Received: 12/05/2020
• Initial Date FDA Received: 12/28/2020
• Supplement Dates Manufacturer Received: 01/07/2021
• Supplement Dates FDA Received: 02/01/2021
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Treatment: OLYMPUS ENDOSCOPE, TJF-260V