MAUDE Adverse Event Report: AOMORI OLYMPUS CO., LTD. SINGLE USE ELECTROSURGICAL KNIFE KD-612

Model Number	KD-612L
Medical Device Problem Code	Detachment of Device or Device Component (2907)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	07/27/2023
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The device was not returned to olympus for evaluation.A review of the device history record found no deviations that could have caused or contributed to the reported issue.The subject device was manufactured on september, 2022 based on the provided 3 digit lot information but the exact manufacture date could not be identified since the subject device was not returned.Based on the results of the investigation, a definitive root cause cannot be identified.It is likely the malfunction is a result of a force to perform tissue incision being applied to the tip, high heat caused by spark discharge being locally applied to the tip and the electrode causing the adhesive strength of the adhesive agent affixing the cutting knife and the tip to decrease, or a spark discharge between the tissue and the electrode occurred during output activation caused by the high-frequency output being set too high, the output setting for activation being too high, the electrosurgical unit was used in the coagulation mode, or the output activation time was too long.This issue is addressed in the instructions for use (ifu) under section 10.3 operation ¿ cutting.-when the electrosurgical unit is used in the coagulation mode, crack/detachment of the tip or deformation/break of the cutting knife or the electrode could occur, for example when the high-frequency output is set too high or the length of the contact between the cutting knife and tissue is too short.During treatment, always ensure that the slider slides on the handle smoothly and that the electrosurgical knife observed in the endoscopic image is normal.Should cracks or detachment of the tip or deformation/break of the cutting knife be detected during use, immediately shut off the power supply, discontinue the procedure, pull the slider and withdraw the endoscope from the patient with the cutting knife retreated in the insertion portion of this instrument.Do not continue using an abnormal electrosurgical knife to prevent perforation or bleeding.If the tip or cutting knife is detached be sure to collect it using grasping forceps.-aspirate fluids such as mucus that adhere to the electrode and/or the cutting knife, outer sheath and body cavity tissues.Patient injury such as punctures, hemorrhages, mucous membrane damage and thermal injury of tissue could result if output is activated when in contact with these adhering fluids.When current is discharged while the cutting knife is being separated from the mucosa under wet situation, it may break the cutting knife or crack the tip.-always operate the electrosurgical unit at the minimum output level and for the minimum time necessary to successfully complete the procedures.Excessive output level and time may occur in patient injury, such as perforations, bleeding or mucous membrane damage.Application of high-voltage waveforms for extended periods increase the likelihood that it may break the cutting knife or crack the tip.When a high-voltage waveform has to be used, minimize the duration of current application.-electrosurgical unit: voltage intensities of various waveforms soft coagulation < cut / pulse cut < forced coagulation -do not activate output continuously but activate it intermittently.Continuous activation may cause patient injury, such as bleeding, mucous membrane damage, or thermal injury of non target tissue.Crack/detachment of the tip or deformation/break of the cutting knife or electrode may also occur.-do not activate output when the electrode and cutting knife are not in contact with the target tissue.Crack/detachment of the tip or deformation/break of the cutting knife or electrode may occur.Olympus will continue to monitor the field performance of this device.
Event or Problem Description
The customer reported to olympus the insulated tip of the single use electrosurgical knife kd-612 broke off in a patient¿s stomach after the first cut during an endoscopic submucosal excavation (ese) procedure.The tip was immediately retrieved, and the procedure was completed.There was no damage or harm to the patient as a result of the device breaking and being retrieved.
Additional Manufacturer Narrative
This supplemental report is being submitted to provide additional information based on the information supplied by the customer.Please refer to the following sections for the new information from the customer: b5.
Event or Problem Description
The device breaking off caused a minor 15-minute delay while the patient was under general anesthesia which had no negative impact on the patient.The procedure was completed using a second single use electrosurgical knife.The patient was discharged as planned with no extended hospital stay as a result of the device malfunction, and was reported to be in good health.

• Brand Name: SINGLE USE ELECTROSURGICAL KNIFE KD-612
• Common Device Name: SINGLE USE ELECTROSURGICAL KNIFE
• Manufacturer (Section D): AOMORI OLYMPUS CO., LTD.; 2-248-1 okkonoki; kuroishi-shi, aomori 036-0 357; JA 036-0357
• Manufacturer (Section G): AOMORI OLYMPUS CO., LTD.; 2-248-1 okkonoki; kuroishi-shi, aomori
• Manufacturer Contact: todd brill ; 800 west park drive; westborough, MA 01581 ; 5082077661
• MDR Report Key: 17821710
• Report Number: 9614641-2023-01410
• Device Sequence Number: 2343092
• Product Code: KNS
• UDI-Device Identifier: 04953170453922
• UDI-Public: 04953170453922
• Combination Product (Y/N): N
• Initial Reporter Country: CH
• PMA/510(K) Number: K092309
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Other,Foreign,User Facility
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 10/10/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Operator of Device: Lay User/Patient
• Device Model Number: KD-612L
• Device Lot Number: 29K
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 08/30/2023
• Supplement Date Received by Manufacturer: 10/10/2023
• Initial Report FDA Received Date: 09/26/2023
• Supplement Report FDA Received Date: 10/10/2023
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Sex: Unknown