PENTAX Medical Video Upper GI Scopes (EG Family)

K190799 · Pentax of America, Inc. · FDS · Nov 12, 2019 · Gastroenterology, Urology

Device Facts

Record IDK190799
Device NamePENTAX Medical Video Upper GI Scopes (EG Family)
ApplicantPentax of America, Inc.
Product CodeFDS · Gastroenterology, Urology
Decision DateNov 12, 2019
DecisionSESE
Submission TypeTraditional
Regulation21 CFR 876.1500
Device ClassClass 2
AttributesTherapeutic

Indications for Use

This instrument is intended to be used with a PENTAX video processor (including light source), documentation equipment, monitor, Endotherapy Device such as a Biopsy Forceps, and other ancillary equipment for endoscopy and endoscopic surgery within the upper digestive tract including the esophagus, stomach, and duodenum.

Device Story

Flexible endoscope for visualization and surgical intervention in upper digestive tract (esophagus, stomach, duodenum). Device comprises insertion portion (distal end with objective lens, light guide, air/water nozzles, instrument channel), control body (angulation levers, suction controls, remote buttons), and PVE connector to video processor. CCD at distal end captures reflected light; video processor converts data to image for monitor display. Used by physicians in clinical settings. Device is reusable; requires manual pre-cleaning, cleaning, and high-level disinfection or sterilization between procedures. This submission updates reprocessing instructions for clarity; no changes to device design, intended use, or technological characteristics.

Clinical Evidence

No clinical data. Bench testing only. Reprocessing validation data provided, including soil accumulation and cleaning efficiency studies, to demonstrate that the scopes can be reprocessed safely and effectively.

Technological Characteristics

Flexible endoscope; insertion portion, control body, PVE connector. Fiberoptic illumination; CCD image sensor. Reusable semi-critical device. No changes to dimensions (depth of field, distal end width, insertion tube width, instrument channel width, total length) or materials compared to predicate. Connectivity via electrical contacts and light guide plug to PENTAX video processor. High-level disinfection or sterilization required.

Indications for Use

Indicated for endoscopic examination and surgery within the upper digestive tract, including the esophagus, stomach, and duodenum, in patients requiring such procedures.

Regulatory Classification

Identification

An endoscope and accessories is a device used to provide access, illumination, and allow observation or manipulation of body cavities, hollow organs, and canals. The device consists of various rigid or flexible instruments that are inserted into body spaces and may include an optical system for conveying an image to the user's eye and their accessories may assist in gaining access or increase the versatility and augment the capabilities of the devices. Examples of devices that are within this generic type of device include cleaning accessories for endoscopes, photographic accessories for endoscopes, nonpowered anoscopes, binolcular attachments for endoscopes, pocket battery boxes, flexible or rigid choledochoscopes, colonoscopes, diagnostic cystoscopes, cystourethroscopes, enteroscopes, esophagogastroduodenoscopes, rigid esophagoscopes, fiberoptic illuminators for endoscopes, incandescent endoscope lamps, biliary pancreatoscopes, proctoscopes, resectoscopes, nephroscopes, sigmoidoscopes, ureteroscopes, urethroscopes, endomagnetic retrievers, cytology brushes for endoscopes, and lubricating jelly for transurethral surgical instruments. This section does not apply to endoscopes that have specialized uses in other medical specialty areas and that are covered by classification regulations in other parts of the device classification regulations.

Special Controls

*Classification* —(1)*Class II (special controls).* The device, when it is an endoscope disinfectant basin, which consists solely of a container that holds disinfectant and endoscopes and accessories; an endoscopic magnetic retriever intended for single use; sterile scissors for cystoscope intended for single use; a disposable, non-powered endoscopic grasping/cutting instrument intended for single use; a diagnostic incandescent light source; a fiberoptic photographic light source; a routine fiberoptic light source; an endoscopic sponge carrier; a xenon arc endoscope light source; an endoscope transformer; an LED light source; or a gastroenterology-urology endoscopic guidewire, is exempt from the premarket notification procedures in subpart E of part 807 of this chapter subject to the limitations in § 876.9.(2) Class I for the photographic accessories for endoscope, miscellaneous bulb adapter for endoscope, binocular attachment for endoscope, eyepiece attachment for prescription lens, teaching attachment, inflation bulb, measuring device for panendoscope, photographic equipment for physiologic function monitor, special lens instrument for endoscope, smoke removal tube, rechargeable battery box, pocket battery box, bite block for endoscope, and cleaning brush for endoscope. The devices subject to this paragraph (b)(2) are exempt from the premarket notification procedures in subpart E of part 807of this chapter, subject to the limitations in § 876.9.

In combination with the general controls of the FD&C Act, the integrated operating table-electromechanical surgical system is subject to the following special controls: 1. (1) Premarket clinical performance testing, or a combination of premarket clinical performance testing and postmarket surveillance (in accordance with special control (2)), must include the following: 1. (i) Objective performance measures (e.g., rate and number of conversions to other surgical modalities, rate of device related adverse events (including tissue injury, hematoma, and increased blood loss), and their severity, cause, and outcomes) must be reported with relevant descriptive comparator performance measures. 2. (ii) The data must demonstrate the performance of the device for providing accurate and precise control of attached surgical instruments in range of clinical conditions relevant to the device's intended use. 3. (iii) The test dataset must include data collected from a patient population representative of the intended patient population under anticipated conditions of use. 2. (2) Data obtained from postmarket surveillance must demonstrate, in consideration of the premarket data obtained in accordance with special control (1), that the device performs in accordance with special control (1), unless FDA determines, based on the totality of the premarket data, that data from postmarket surveillance is not required to demonstrate that the device performs as intended. Such postmarket surveillance must be conducted per a protocol determined appropriate by FDA to demonstrate that the device performs as intended (in consideration of the premarket data obtained in accordance with special control (1)), and must include initiation, enrollment, and reporting requirements to ensure timely periodic updates to FDA on post-market surveillance progress and outcomes. 3. (3) Animal performance testing must evaluate the extent of port site trauma due to repositioning of table during surgical procedures when utilizing robotic minimally invasive and laparoscopic approaches 4. (4) The device manufacturer must develop, and update as necessary, a device-specific use training program that ensures proper device setup/use/shutdown, accurate control of instruments to perform the intended surgical procedures, troubleshooting and handling during unexpected events or emergencies, and safe practices to mitigate use error. 5. (5) The device manufacturer may only distribute the device to facilities that implement and maintain the device-specific use training program and ensure that users of the device have completed the device-specific use training program. (6) Human factors assessment must demonstrate that the user can correctly use the device system across all intended use environments with the provided instructions and training materials, including patient access during normal operating conditions and emergency situations, and effects arising from the integrated nature of the operating table and robotic surgical arms. (7) Labeling must include: (i) A detailed summary of clinical performance testing conducted with the device, including study population, results, adverse events, and comparisons to any comparator groups identified; (ii) A statement in the labeling that the safety and effectiveness for the representative specific procedures was based on evaluation of the device as a surgical tool and did not include evaluation of outcomes related to the treatment of the patient's underlying disease or condition, unless FDA determines that it can be removed or modified based on clinical performance data submitted to FDA; (iii) Identification of compatible devices; (iv) The list of surgical procedures for which the device has been determined to be safe with clinical justification; (v) Reprocessing instructions for reusable components; (vi) A shelf life for any sterile components; (vii) A description of the device-specific use training program; (viii) A statement that the device is only for distribution to facilities that implement and maintain the device-specific use training program and ensure that users of the device have completed the device-specific use training program; and (ix) A summary of any completed postmarket surveillance data collected as required by special control (2), including updated labeling to accurately reflect outcomes observed in postmarket surveillance. (8) Non-clinical performance testing must demonstrate that the device performs as intended under anticipated conditions of use and must include: (i) Device motion accuracy and repeatability; (ii) System testing; (iii) Instrument reliability; (iv) Crosstalk; (v) Table motion control; (vi) Thermal effects on tissue; (vii) User-device interface performance; (viii) Workspace access testing; and (ix) Performance testing with compatible devices. (9) Software verification, validation, and hazard analysis must be performed. (10) Electromagnetic compatibility and electrical, thermal, and mechanical safety testing must be performed. (11) Performance data must demonstrate the sterility of all patient-contacting device components. (12) Performance data must support the shelf life of the device components provided sterile by demonstrating continued sterility and package integrity over the labeled shelf life. (13) Performance data must validate the reprocessing instructions for the reusable components of the device. (14) Performance data must demonstrate that all patient-contacting components of the device are biocompatible. (15) Performance data must demonstrate that all patient-contacting components of the device are non-pyrogenic. (16) The device manufacturer must submit a report to the FDA annually on the anniversary of initial marketing authorization for the device, until such time as FDA may terminate such reporting, which comprises the following information: (i) Cumulative summary, by year, of complaints and adverse events since date of initial marketing authorization; and (ii) Identification and rationale for changes made to the device, labeling, or device specific use training program, which did not require submission of a premarket notification during the reporting period.

Predicate Devices

Reference Devices

Submission Summary (Full Text)

{0}------------------------------------------------ Image /page/0/Picture/0 description: The image contains the logo of the U.S. Food and Drug Administration (FDA). On the left is the Department of Health & Human Services logo. To the right of that is the FDA logo, which is a blue square with the letters "FDA" in white. To the right of the blue square is the text "U.S. FOOD & DRUG ADMINISTRATION" in blue. November 12, 2019 PENTAX of America, Inc. William Goeller Vice President. Quality and Regulatory Affairs 3 Paragon Drive Montvale, NJ 07645-1782 K190799 Re: Trade/Device Name: PENTAX Medical Video Upper GI Scopes (EG Family) Regulation Number: 21 CFR 876.1500 Regulation Name: Endoscope and Accessories Regulatory Class: II Product Code: FDS Dated: October 23, 2019 Received: October 24, 2019 Dear William Goeller: We have reviewed your Section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments, or to devices that have been reclassified in accordance with the provisions of the Federal Food, Drug, and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA). You may, therefore, market the device, subject to the general controls provisions of the Act. Although this letter refers to your product as a device, please be aware that some cleared products may instead be combination products. The 510(k) Premarket Notification Database located at https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm identifies combination product submissions. The general controls provisions of the Act include requirements for annual registration, listing of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration. Please note: CDRH does not evaluate information related to contract liability warranties. We remind you, however, that device labeling must be truthful and not misleading. If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to additional controls. Existing major regulations affecting your device can be found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register. Please be advised that FDA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part {1}------------------------------------------------ 801); medical device reporting of medical device-related adverse events) (21 CFR 803) for devices or postmarketing safety reporting (21 CFR 4, Subpart B) for combination products (see https://www.fda.gov/combination-products/guidance-regulatory-information/postmarketing-safety-reportingcombination-products); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820) for devices or current good manufacturing practices (21 CFR 4. Subpart A) for combination products; and, if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21 CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to https://www.fda.gov/medical-device-safety/medical-device-reportingmdr-how-report-medical-device-problems. For comprehensive regulatory information about medical devices and radiation-emitting products, including information about labeling regulations, please see Device Advice (https://www.fda.gov/medicaldevices/device-advice-comprehensive-regulatory-assistance) and CDRH Learn (https://www.fda.gov/training-and-continuing-education/cdrh-learn). Additionally, you may contact the Division of Industry and Consumer Education (DICE) to ask a question about a specific regulatory topic. See the DICE website (https://www.fda.gov/medical-device-advice-comprehensive-regulatoryassistance/contact-us-division-industry-and-consumer-education-dice) for more information or contact DICE by email (DICE@fda.hhs.gov) or phone (1-800-638-2041 or 301-796-7100). Sincerely, for Martha W. Betz, Ph.D. Acting Assistant Director DHT3A: Division of Renal, Gastrointestinal, Obesity and Transplant Devices OHT3: Office of Gastrorenal, ObGyn, General Hospital and Urology Devices Office of Product Evaluation and Quality Center for Devices and Radiological Health Enclosure {2}------------------------------------------------ # Indications for Use 510(k) Number (if known) K190799 Device Name PENTAX Medical Video Upper GI Scopes (EG Family) Indications for Use (Describe) This instrument is intended to be used with a PENTAX video processor (including light source), documentation equipment, monitor, Endotherapy Device such as a Biopsy Forceps, and other ancillary equipment for endoscopy and endoscopic surgery within the upper digestive tract including the esophagus, stomach, and duodenum. | Type of Use (Select one or both, as applicable) | | |-----------------------------------------------------------------------------------|----------------------------------------------------------------------------------| | <div> <span> ☑ Prescription Use (Part 21 CFR 801 Subpart D) </span> </div> | <div> <span> ☐ Over-The-Counter Use (21 CFR 801 Subpart C) </span> </div> | ### CONTINUE ON A SEPARATE PAGE IF NEEDED. This section applies only to requirements of the Paperwork Reduction Act of 1995. #### *DO NOT SEND YOUR COMPLETED FORM TO THE PRA STAFF EMAIL ADDRESS BELOW.* The burden time for this collection of information is estimated to average 79 hours per response, including the time to review instructions, search existing data sources, gather and maintain the data needed and complete and review the collection of information. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden, to: > Department of Health and Human Services Food and Drug Administration Office of Chief Information Officer Paperwork Reduction Act (PRA) Staff PRAStaff@fda.hhs.gov "An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB number." 42 {3}------------------------------------------------ # PENTAX Medical Video Upper G.I. (EG Family) Optimized IFU Traditional 510(k) Submission #### 510(k) Summary #### SUBMITTER l. PENTAX of America, Inc., HOYA Corporation PENTAX Division 3 Paragon Drive Montvale, New Jersey 07645-1782 Phone: 201-571-2318 Ext 2318 Fax: 201-571-2340 Contact: William Goeller Date Prepared: March 14, 2019 #### II. DEVICE The purpose of this 510(k) is to obtain clearance for revised reprocessing instructions which include optimized manual pre-cleaning instructions for the PENTAX Medical Video Upper GI Scopes (EG Family), its components, and its accessories. There are no other changes to the reprocessing instructions for use, nor are there any changes to the design, intended use, or indications for use of the EG Family of endoscopes. | Device Name | PENTAX Medical Video Upper GI Scopes (EG Family) | |----------------------|--------------------------------------------------| | 510(k) Number | K190799 | | Common Name | Gastroscope And Accessories, Flexible/Rigid | | Classification Name | Endoscope and accessories | | Regulation No. | 21 CFR 876.1500 | | Device Class | 2 | | Product Code | FDS | | Classification Panel | Gastroenterology/ Urology | Table 5.1: Regulatory Classification of PENTAX Medical Video Upper GI Scopes. #### III. PREDICATE DEVICES The predicate device for this submission is also the subject of this submission, the PENTAX Medical Video Upper G.I. scopes (EG Family) (K131902). The predicate device is identical to the device subject to this 510(k); the only change relates to the manual pre-cleaning and cleaning portions of the reprocessing instructions to streamline the instructions and improve clarity. No changes are being made to the high-level disinfection or any other portion of the instructions for use. {4}------------------------------------------------ #### IV. REFERENCE DEVICES The PENTAX Video Colonoscopes (EC Family) K181084 have recently obtained clearance for the similarly revised reprocessing instructions which include the optimized manual pre-cleaning and cleaning instructions for the PENTAX Medical Video Colonoscopes (EC Family), its components, and its accessories. Because of the similarities in design and reprocessing instructions between the cleared EC family (K181084) and the subject EG family of scopes, and the fact that EC master scopes as well as accessories apply to EG reprocessing validation process, the former will be used as the reference device for the EG family of scopes with revised reprocessing instructions. The rationale for the selection of master scopes is documented in the Reprocessing validation plan for 90i/90K/i10 series EG family (EX-062-0139). #### V. DEVICE DESCRIPTION The subject device is identical to the predicate device. There are no changes to the design, specifications, or technological characteristics of the PENTAX Medical Video Upper GI Scopes as described in K131902. The associated model numbers for the PENTAX Medical Video Upper Gl Scopes are provided in Table 5.2. | PENTAX Video Upper G.I. scopes (EG Family) | | | | | |--------------------------------------------|----------|----------|-----------|----------| | EG-2990i | EG-1690K | EG-2790K | EG-3490K | EG27-i10 | | EG-2790i | EG-2490K | EG-2990K | EG-3890TK | EG29-i10 | Table 5.2: Model Numbers Associated with the PENTAX Medical Video Upper GI Scopes The PENTAX Medical Video Upper G.I. scopes (EG Family) are used with Video Processors. They are composed of three main components: Insertion Portion, Control Body and PVE Connector. The Insertion Portion is inserted into the body cavity of patient. The Insertion includes the Distal End and Bending Section. The Objective Lens, Light Guide, and Instrument Channel are located on the Distal End of the Insertion Portion. The Distal End also contains an Air/Water Nozzle and Water Jet Nozzle. This Air/Water Feeding System is used to deliver the air and water to the Objective Lens. The Control Body is held by the user's hand. The Control Body includes the Angulation Control lever used to operate the endoscope angulation; Suction Cylinder and Suction Nipple for suctioning fluid and air in the body cavity; Remote Button used to operate the function of video processor; and Instrument Channel Inlet used to insert endotherapy devices, such as biopsy forceps, into the body cavity. The GI Family of scopes also contains a Magnification Control Lever used to magnify the image on the video monitor, as necessary. As this magnification is performed electrically, focus and depth of field are not changed. {5}------------------------------------------------ # PENTAX Medical Video Upper G.I. (EG Family) Optimized IFU Traditional 510(k) Submission The PVE Connector is connected to the Video Processor via an Electrical Contacts. The PVE Connector includes the Electrical Contacts and Light Guide Plug. The Light Guide Plug is connected to the Light Source inside the Video Processor. The Light Guide of the Distal End is used to illuminate the body cavity by light that is carried through the Light Carrying Bundle. The Light Carrying Bundle guides the light from Light Guide Plug that is connected to the Light Source. The CCD built into the Distal End receives reflected light (image data) from the body cavity, and sends the image data to the Video Processor through the video cable. The image data are converted into the image signal by the Video Processor, and the image inside the body cavity is displayed on the Monitor. The PENTAX Medical Video Upper G.I. scopes are reusable semi-critical devices. Since they are packaged non-sterile, they must be high-level disinfected or sterilized before initial use. Prior to each subsequent procedure, they must be subjected to an appropriate cleaning and either highlevel disinfection or sterilization processes. ### VI. INDICATIONS FOR USE There are no changes to the Indications for Use for the subject device. The sole purpose of this 510(k) is to modify the manual pre-cleaning and cleaning portions of the instructions to streamline them and improve clarity. No changes are being made to the high-level disinfection instructions. This instrument is intended to be used with a PENTAX video processor (including light source), documentation equipment, monitor, Endotherapy Device such as a Biopsy Forceps, and other ancillary equipment for endoscopy and endoscopic surgery within the upper digestive tract including the esophagus, stomach, and duodenum. ### VII. COMPARISON OF TECHNOLOGY CHARACTERISTICS WITH THE PREDICATE The subject device is identical to the predicate device. The subject device has the same fundamental technology and operating principles of the predicate device, including the same intended use and design technological characteristics, such as Insertion Portion, Control Body and fiberoptic illumination. There are no differences in specifications, including, but not limited to, the depth of field, distal end width, insertion tube width, instrument channel width, and total length. The sole difference between the subject and predicate device is that the reprocessing instructions have been modified. This modification does not impact the intended use and does not raise different questions of safety and effectiveness. #### VIII. PERFORMANCE DATA The optimization of the reprocessing instructions for the PENTAX Medical Video Upper GI scopes do not affect the biocompatibility, electromagnetic compatibility, P E N T A X M e d i c a l C o n f i d e n t i d e n t i d e n t i a l {6}------------------------------------------------ # PENTAX Medical Video Upper G.I. (EG Family) Optimized IFU Traditional 510(k) Submission software verification and validation, or performance testing for the scopes. Reprocessing validation data is provided to support the equivalence of the subject and predicate devices, including soil accumulation and cleaning efficiency studies. #### VIII. CONCLUSION The subject device is identical to the predicate device. The subject device has the same intended use and technological characteristics as the predicate device. There are no changes to the design of the subject device. The data submitted support the optimization of reprocessing instructions for the PENTAX Medical Video Upper G.I. scopes demonstrate that the scopes can be reprocessed in a safe and effective manner. The data provided in this 510(k) Premarket Notification support the equivalence of the subject and predicate devices.
Innolitics

Panel 1

/
Ready

Predicate graph will load when search results are available.

Embedding visualization will load when search results are available.

PDF viewer will load when search results are available.

Loading panels...

Select an item from Submissions

Click any panel, subpart, regulation, product code, or device to see details here.

Section Matches

Results will appear here.

Product Code Matches

Results will appear here.

Special Control Matches

Results will appear here.

Loading collections...