MAUDE Adverse Event Report: APOLLO ENDOSURGERY, INC. LAGB SYSTEM 10CM; ADJUSTABLE GASTRIC BAND

Model Number	B-2220
Medical Device Problem Code	Device Slipped (1584)
Health Effect - Clinical Codes	Dysphagia/ Odynophagia (1815); Regurgitation (2259)
Date of Event	01/16/2017
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Unknown taper.Medwatch sent to fda on 03/01/2017.The reporter of the event was asked to return the product for analysis.To date, apollo has not received the device.If returned, visual examination may confirm or determine another taper type associated with this event.Device labeling addresses the reported event as follows: precautions: over-dissection of the stomach during placement may result in slippage or erosion of the band and require reoperation.Adverse events: it is important to discuss all possible complications and adverse events with your patient.Complications which may result from the use of this product include the risks associated with the medications and methods utilized in the surgical procedure, the risks associated with any surgical procedure and the patient's degree of intolerance to any foreign object implanted in the body.Ulceration, gastritis, gastroesophageal reflux, heartburn, gas bloat, dysphagia, dehydration, constipation, and weight regain have been reported after gastric restriction procedures.Band slippage and/or pouch dilatation can occur.Gastroesophageal reflux, nausea and/or vomiting with early or minor slippage may be successfully resolved by band deflation in some cases.More serious slippages may require surgery to reposition and/or remove the band.Immediate re-operation to remove the band is indicated if there is total stoma-outlet obstruction that does not respond to band deflation or if there is abdominal pain.Warnings: patients should be advised that the lap-band ap system is a long-term implant.Explant (removal) and replacement surgery may be indicated at any time.Medical management of adverse reactions may include explantation.Revision surgery for explantation and replacement may also be indicated to achieve patient satisfaction.
Event or Problem Description
Reported as: the patient's lap-band system was explanted due to "gastric prolapse, gerd, dysphagia.".
Additional Manufacturer Narrative
Taper ii.Device evaluation summary: the device was returned to the apollo device analysis laboratory on 21/feb/2017.A visual examination was performed and determined the connector type to be taper ii.Needle marks and brown discoloration was noted on the port septum.Scratch marks were noted on one port hole and on the port base.Port base was noted to be discolored, slight yellow in color.The port tubing was noted to be discolored, and was light brown in appearance.The lap-band ring was noted to be in two pieces, separation was near the buckle.The buckle was noted to be partially separated.White particles were noted on the outer surface of the band shell.Slight brown discoloration was noted on the belt and the band tubing.An air leak test was not feasible as the band ring was in two separate pieces.A fill inspection test was performed and no blockage was noted.Under microscopic analysis, the band, end of the port and band tubing were noted to have surgical cuts, consistent with removal of the device.Also under microscopic analysis, multiple needle punctures were noted on the port septum.

• Brand Name: LAGB SYSTEM 10CM
• Common Device Name: ADJUSTABLE GASTRIC BAND
• Manufacturer (Section D): APOLLO ENDOSURGERY, INC.; 1120 s capitol of texas hwy; bldg 1, ste 300; austin TX 78746
• MDR Report Key: 6368804
• Report Number: 3006722112-2017-00064
• Device Sequence Number: 13563788
• Product Code: LTI
• UDI-Device Identifier: 10811955020169
• UDI-Public: (01)10811955020169(11)030228(17)050227(10)559397
• Combination Product (Y/N): N
• Initial Reporter State: MI
• Initial Reporter Country: US
• PMA/510(K) Number: P000008
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2003
• Device Explanted Year: 2017
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 06/05/2017

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: 02/27/2005
• Device Model Number: B-2220
• Device Catalogue Number: B-2220
• Device Lot Number: 559397
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 02/21/2017
• Type of Report(Section G): FDA Requested
• Initial Date Received by Manufacturer: 02/02/2017
• Supplement Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 03/01/2017
• Supplement Report FDA Received Date: 06/07/2017
• 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: Required Intervention
• Patient Age: 54 YR
• Patient Weight: 163