MAUDE Adverse Event Report: PENTAX Medical Corporation PENTAX Medical; DEC HD VIDEO DUODENOSCOPE

Model Number	ED34-I10T2
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	08/31/2026
Type of Reportable Event	Malfunction
Event or Problem Description
The time of event is unknown.There was no report of patient harm.Distal body peeled off (black glue).
Additional Manufacturer Narrative
Effective on august 1, 2026, mdr-related activities and responsibilities were transferred to pentax medical corporation as part of a corporate restructuring.This report is being submitted by pentax medical corporation.In accordance with 21 cfr 803.3(m), because this corporate restructuring does not affect the manufacturing site, the fda registration number previously assigned for this site (#9610877) continues to be used.The product was returned to pentax medical for repair: our technician checked the returned unit and confirmed that the objective gluing missing.Based on the result, we concluded that it was caused due to the physical damage applied on the objective gluing.As a result of confirming the detail a gfe, no response was obtained, so we cannot deny the possibility of the glue falls.Therefore, based on the technical report "hr-rpt-0974 (distal end)" and/or the risk analysis results, it was evaluated to submit mdr.

• Brand Name: PENTAX Medical
• Common Device Name: DEC HD VIDEO DUODENOSCOPE
• Manufacturer (Section D): PENTAX Medical Corporation; tsutsujigaoka 1-1-110; akishima-shi, tokyo 196-0 012; JA 196-0012
• Manufacturer (Section G): PENTAX Medical Corporation; tsutsujigaoka 1-1-110; akishima-shi, tokyo 196-0 012; JA 196-0012
• Manufacturer Contact: paresh patel ; 3 paragon drive; montvale, NJ 07645 ; +1(800)431-5880
• MDR Report Key: 50797939
• Report Number: 9610877-2026-51957
• Device Sequence Number: 10571510
• Product Code: FDT
• UDI-Device Identifier: 04961333233007
• Combination Product (Y/N): N
• Initial Reporter State: NC
• Initial Reporter Country: US
• PMA/510(K) Number: K192245
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 09/17/2026

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
• Operator of Device: Health Professional
• Device Model Number: ED34-I10T2
• Was Device Available for Evaluation?: Yes
• Date Returned to Manufacturer: 08/31/2026
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 08/31/2026
• Initial Report FDA Received Date: 09/17/2026
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 03/17/2020
• Is the Device Labeled for Single Use? (Y/N): No
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Sex: Unknown