MAUDE Adverse Event Report: TORAX MEDICAL, INC. LINX REFLUX MANAGEMENT SYSTEM; ANTI-REFLUX IMPLANT

Model Number	LXC15
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Dysphagia/ Odynophagia (1815)
Date of Event	10/12/2016
Type of Reportable Event	Serious Injury
Event or Problem Description
Following a laparoscopic anti-reflux procedure, a patient experienced moderate dysphagia leading to linx device explant.The linx device was used as part of the anti-reflux procedure.Uneventful anti-reflux procedure and device implant on (b)(6) 2013.Prior to explant patient received two dilations to treat dysphagia symptoms with little effect.Uneventful device explant (b)(6) 2016.Linx device found in the correct position/geometry.Fundoplication performed immediately after device explant.Patient reported as doing well after device explant.
Event or Problem Description
Following a laparoscopic anti-reflux procedure, a patient experienced moderate dysphagia leading to linx device explant.The linx device was used as part of the anti-reflux procedure.Uneventful anti-reflux procedure and device implant on (b)(6) 2013.Prior to explant patient received two dilations to treat dysphagia symptoms with little effect.Uneventful device explant (b)(6) 2016.Linx device found in the correct position/geometry.Fundoplication performed immediately after device explant.Patient reported as doing well after device explant.

• Brand Name: LINX REFLUX MANAGEMENT SYSTEM
• Common Device Name: ANTI-REFLUX IMPLANT
• Manufacturer (Section D): TORAX MEDICAL, INC.; 4188 lexington avenue north; shoreview MN 55126
• MDR Report Key: 6092985
• Report Number: 3008766073-2016-00089
• Device Sequence Number: 1602627
• Product Code: LEI
• UDI-Device Identifier: 00855106005165
• UDI-Public: 00855106005165
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: P100049
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2013
• Device Explanted Year: 2016
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 12/28/2016

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?: No
• Operator of Device: Physician
• Device Expiration Date: 06/11/2017
• Device Model Number: LXC15
• Device Lot Number: 4853
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 12/16/2016
• Type of Report(Section G): FDA Requested
• Initial Date Received by Manufacturer: 10/12/2016
• Supplement Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 11/10/2016
• Supplement Report FDA Received Date: 01/10/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Hospitalization; Disability
• Patient Age: 64 YR