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

Model Number	LS12
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Erosion (1750)
Date of Event	03/01/2017
Type of Reportable Event	Serious Injury
Event or Problem Description
Following a laparoscopic anti-reflux procedure, a patient experienced pain and dysphagia symptoms leading to endoscopic visualization of 2-3 linx device beads within the esophageal lumen and subsequent device removal.The linx device was used as part of the anti-reflux procedure.Anti-reflux procedure including linx device implantation occurred without issue on (b)(6) 2012 by dr.(b)(6) at (b)(6) school of medicine.Patient began experiencing dysphagia in (b)(6) 2017.Endoscopy confirmed 2-3 linx device beads visible at the patient's posterior side of the esophagus.Entire linx device endoscopically removed without issue on (b)(6) 2017 by dr.(b)(6) at (b)(6) medical center.Patient reported as doing well after device explant.
Event or Problem Description
Following a laparoscopic anti-reflux procedure a patient experienced pain and dysphagia symptoms leading to endoscopic visualization of 2-3 linx device beads within the esophageal lumen and subsequent device removal.The linx device was used as part of the anti-reflux procedure.-anti-reflux procedure including linx device implantation occurred without issue on (b)(6) 2012 by dr.(b)(6) at (b)(6).-patient began experiencing dysphagia in (b)(6) 2017.-endoscopy confirmed 2-3 linx device beads visible at the patient's posterior side of the esophagus.-entire linx device endoscopically removed without issue on (b)(6) 2017 by dr.(b)(6) at (b)(6).-patient reported as doing well after device explant.
Additional Manufacturer Narrative
(b)(4).Follow up 2: a notification was received for this device that a form 3500a report for this same event was submitted by a representative at bidmc (user facility).
Event or Problem Description
Following a laparoscopic anti-reflux procedure a patient experienced pain and dysphagia symptoms leading to endoscopic visualization of 2-3 linx device beads within the esophageal lumen and subsequent device removal.The linx device was used as part of the anti-reflux procedure.-anti-reflux procedure including linx device implantation occurred without issue on (b)(6) 2012 by dr.(b)(6) at (b)(6).-patient began experiencing dysphagia in (b)(6) 2017.-endoscopy confirmed 2-3 linx device beads visible at the patient's posterior side of the esophagus.-entire linx device endoscopically removed without issue on (b)(6) 2017 by dr.(b)(6) at (b)(6).-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 n; shoreview MN 55126
• MDR Report Key: 6439236
• Report Number: 3008766073-2017-00040
• Device Sequence Number: 18983377
• Product Code: LEI
• UDI-Device Identifier: 00855106005011
• UDI-Public: 00855106005011
• Combination Product (Y/N): N
• Initial Reporter State: MA
• Initial Reporter Country: US
• PMA/510(K) Number: P100049
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2012
• Device Explanted Year: 2017
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 05/03/2017

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: 05/17/2016
• Device Model Number: LS12
• Device Lot Number: 3570
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 04/18/2017
• Type of Report(Section G): FDA Requested
• Initial Date Received by Manufacturer: 03/01/2017
• Supplement Date Received by Manufacturer: Not provided; Not provided
• Initial Report FDA Received Date: 03/28/2017
• Supplement Report FDA Received Date: 04/25/2017; 05/17/2017
• 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: 44 YR