MAUDE MDR 5050289

MDR report key
5050289
Report number
3006722112-2015-00291
Event key
0
Event type
3
Date received
2015-09-02
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
0
Health professional
3
Initial report to FDA
3
Event location
3

Manufacturer Contact#

Contact
LAURA LEBOEUF
Address
1120 S CAPITAL OF TEXAS HWY BULDING 1, SUITE 300 AUSTIN TX 78748 US
Phone
855-855-8555
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1LAP-BAND AP ADJUSTABLE GASTRIC BANDING SYSTEM (SMALL)IMPLANT, INTRAGASTRIC FOR MORBID OBESITYALLERGAN (COSTA RICA)LTIAB-202602673475R N

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12015-09-020

Event Narratives#

N

Patient 1

TAPER II. THE REPORTER OF THE COMPLAINT WAS ASKED TO RETURN THE PRODUCT FOR ANALYSIS AS WELL AS TO INDICATE THE PRODUCT SERIAL NUMBER, DATE OF EVENT, IMPLANT DATE AND EXPLANT DATE. THE INFORMATION HAS NOT YET BEEN RECEIVED BY ALLERGAN. BASED UPON THE MODEL NUMBER PROVIDED BY THE REPORTER THE CONNECTOR TYPE IS ASSUMED TO BE A TAPER II. VISUAL EXAMINATION MAY DETERMINE THE CONNECTOR TYPE ASSOCIATED WITH THIS REPORT. ALLERGAN HAS NOT RECEIVED THE PRODUCT AT THIS TIME. THEREFORE NO ANALYSIS OR TESTING HAS BEEN DONE. DEVICE LABELING ADDRESSES THE POSSIBLE OUTCOME OF A DAMAGED DEVICE: "THE LAP-BAND AP SYSTEM IS FOR SINGLE USE ONLY. DO NOT USE A BAND, ACCESS PORT, NEEDLE OR CALIBRATION TUBE WHICH APPEARS DAMAGED (CUT, TORN, ETC.) IN ANY WAY. DO NOT USE ONE OF THEM IF THE PACKAGE HAS BEEN OPENED OR DAMAGED, OR IF THERE IS ANY EVIDENCE OF TAMPERING. IF PACKAGING HAS BEEN DAMAGED, THE PRODUCT MAY NOT BE STERILE AND MAY CAUSE AN INFECTION." "CAUTION: THE BAND, ACCESS PORT AND CALIBRATION TUBE MAY BE DAMAGED BY SHARP OBJECTS AND MANIPULATION WITH INSTRUMENTS. A DAMAGED DEVICE MUST NOT BE IMPLANTED. FOR THIS REASON, A STAND-BY DEVICE SHOULD BE AVAILABLE AT THE TIME OF SURGERY."

D

Patient 1

HEALTHCARE PROFESSIONAL REPORTED "PRODUCT WAS FAULTY." NO FURTHER DETAILS AT THIS TIME.