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Model Number G48278
Device Problem Entrapment of Device (1212)
Patient Problems Obstruction/Occlusion (2422); Foreign Body In Patient (2687)
Event Date 05/13/2019
Event Type  malfunction  
Manufacturer Narrative
Concomitant medical products: olympus lithotripter unknown model, olympus spiral tube cable unknown model, and boston scientific alliance handle. Investigation evaluation: a product evaluation was performed only by the photos provided with this report because the product said to be involved was not provided to cook for evaluation. A photo of the lot number was not provided. The first photo provided depicts the drive wire of the basket and bodily fluid. The second photo depicts the basket inside the patient. The basket is empty and the wires are deformed. The basket is connected to the drive wire at the edge of the photo. Without the product or substantial evidence to contradict the complaint, it is considered confirmed based solely on statements describing the event. The device history record for the lot number said to be involved was reviewed. A discrepancy or anomaly was not observed with the product that was released for distribution. Investigation conclusion: we could not conduct a complete investigation because the product said to be involved was not returned for evaluation. A definitive cause for the reported observation could not be determined. The instructions for (se (ifu) states, "potential complications associated with gastrointestinal endoscopy and ercp include, but are not limited to: pancreatitis, cholangitis, sepsis, perforation, hemorrhage, aspiration, fever, infection, hypotension, allergic reaction, respiratory depression or arrest, cardiac arrhythmia or arrest. " the report indicates that the patient had a perforation prior to the procedure. The ifu states, "other potential complications associated with use of an extraction basket include, but are not limited to: impaction of object, aspiration of foreign body, localized inflammation, pressure necrosis. " the ifu warns, "if a stone cannot be removed endoscopically with this basket, a compatible inflation/lithotripter device and/or the conquest ttc lithotriptor cable with soehendra lithotriptor handle are needed to mechanically crush stone and aid in removal. Basket wires may fragment and/or stone impaction may occur during lithotripsy, requiring surgical intervention. " prior to distribution, all fusion lithotripsy extraction basket are subjected to a visual inspection and functional testing to ensure device integrity. A review of the device history record confirmed that the lot said to be involved met all manufacturing requirements prior to shipment. Corrective action: a review of the complaint history was conducted. The likelihood of occurrence is considered rare. Corrective action is not warranted at this time based on the quality engineering risk assessment. Quality assurance will continue to monitor for complaint trends and reassess the risk assessment results as post market feedback continues to become available.
Event Description
During an endoscopic procedure, the physician used a cook fusion lithotripsy extraction basket (fs-lxb-3x6). The stones could not be broken in basket localization and handling proved very difficult. The following additional information was received on (b)(6) 2019: first, the customer tried to crush the stone with the fs-lxb-3x6 alone. Then, they put the handle [of the basket] into the another manufacturer's handle without success in breaking the stone. In the next step, they removed the handle and the sheath of the basket, put on another manufactures' cable and used another manufacturer's handle to crush the stone, again without success. They introduced a gastroscope parallel to the basket and removed the wires of the basket one by one so they could get the basket out. The following day they used an electrohydraulic probe to crush the stone. Additional information was received on (b)(6) 2019: the gallbladder was perforated by the stone itself. It got too big to be held by the gallbladder. The situation was that the stone created a closure of the duodenum because of its size. It was completely stuck in the duodenum. The stone extraction / lithotripsy was planned from the duodenum. The bile duct as well as the papilla were not touched by the procedure. The forceps were used to extract the wires of the basket. The following additional information was received on (b)(6) 2019: a foreign-body-removal method was not possible due to the size of the stone (it was stuck between the pylorus and the exit of the bulbus duodeni), so fracturing of the stone was inevitable. It was a spontaneous perforation of the gallbladder into the bulbus duodeni. Previous treatment had not been done, because the patient did not present herself before in that hospital. The situation was already in place when the patient was hospitalized. A section of the device did not remain inside the patient¿s body. A second endoscope was introduced parallel to the basket and forceps were used to remove the basket wires from the stone in order to remove the basket from the patient. According to the initial reporter, the patient did not experience any adverse effects due to this occurrence.
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Manufacturer (Section D)
4900 bethania station rd
winston-salem NC 27105
Manufacturer (Section G)
4900 bethania station rd
winston-salem NC 27105
Manufacturer Contact
scottie fariole
4900 bethania station rd
winston-salem, NC 27105
MDR Report Key8688489
MDR Text Key147645517
Report Number1037905-2019-00319
Device Sequence Number1
Product Code FFL
Combination Product (y/n)N
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type company representative,foreig
Reporter Occupation
Type of Report Initial,Followup
Report Date 05/17/2019
1 Device was Involved in the Event
1 Patient was Involved in the Event
Date FDA Received06/11/2019
Is this an Adverse Event Report? Yes
Is this a Product Problem Report? Yes
Device Operator
Device Expiration Date01/04/2022
Device Model NumberG48278
Device Catalogue NumberFS-LXB-3X6
Device Lot NumberW4163343
Was Device Available for Evaluation? Device Returned to Manufacturer
Date Returned to Manufacturer06/12/2019
Is the Reporter a Health Professional? Yes
Was the Report Sent to FDA?
Event Location No Information
Date Manufacturer Received06/12/2019
Was Device Evaluated by Manufacturer? Yes
Date Device Manufactured01/16/2019
Is the Device Single Use? Yes
Is This a Reprocessed and Reused Single-Use Device? No
Type of Device Usage Initial

Patient Treatment Data
Date Received: 06/11/2019 Patient Sequence Number: 1