GASTROINTESTINAL VIDEOSCOPE XGIF-Q14OM, XGIF-2T140M COLONOVIDEOSCOPE XCF-Q14ML/I, XPCF-160AML/I

K032177 · Olympus Opto-Electronics Co., Ltd. · FDS · Oct 2, 2003 · Gastroenterology, Urology

Device Facts

• Record ID: K032177
• Device Name: GASTROINTESTINAL VIDEOSCOPE XGIF-Q14OM, XGIF-2T140M COLONOVIDEOSCOPE XCF-Q14ML/I, XPCF-160AML/I
• Applicant: Olympus Opto-Electronics Co., Ltd.
• Product Code: FDS · Gastroenterology, Urology
• Decision Date: Oct 2, 2003
• Decision: SESE
• Submission Type: Traditional
• Regulation: 21 CFR 876.1500
• Device Class: Class 2
• Attributes: Therapeutic

Intended Use

GASTROINTESTINAL VIDEOSCOPE XGIF-Q140M, XGIE-2T140M This instrument has been designed to be used with the OLYMPUS Video System Center, Light Source, Documentation Equipment, Video Monitor, Electrosurgical unit, Endo-Therapy Accessories 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). COLONOVIDEOSCOPE XCF-Q140ML/L XPCF-160AML/I This instrument has been designed to be used with the OLYMPUS Video System Center, Light Source, Documentation Eguipment, Video Monitor, Electrosurgical unit, Endo-Therapy Accessories such as a Biopsy Forceps and other ancillary equipment for endoscopy and endoscopic surgery within the lower digestive tract (including the anus, rectum, and sigmoid colon, colon, and ileocecal valve).

Device Story

Flexible endoscopes (gastroscopes and colonoscopes) used for visualization and surgical intervention in the GI tract. Devices connect to Olympus video systems, light sources, and monitors. Features include multi-bending sections for improved lesion access and variable stiffness (XPCF-160AML/I only) to assist insertion. Operated by physicians in clinical settings. Input is optical/visual data from the distal tip; output is real-time video displayed to the clinician to guide diagnostic or therapeutic procedures (e.g., biopsy). Benefits include enhanced maneuverability and visualization compared to conventional scopes, facilitating easier lesion approach.

Clinical Evidence

Bench testing only. No clinical data provided. Performance evaluated via comparison of approach performance against predicate devices using a colon model.

Technological Characteristics

Flexible endoscopes with multi-bending distal sections and variable stiffness mechanisms. Materials are biocompatible per ISO 10993-1. Compliant with IEC 60601-1, IEC 60601-1-1, and IEC 60601-2-18. System is networked via connection to Olympus Video System Center and ancillary equipment.

Indications for Use

Indicated for endoscopic visualization, diagnosis, and surgery within the upper digestive tract (esophagus, stomach, duodenum) and lower digestive tract (anus, rectum, sigmoid colon, colon, ileocecal valve) in patients requiring gastrointestinal endoscopy.

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.

Predicate Devices

• GIF-Q140 EVIS-140 Series Scopes (K954451)
• GIF-2T140 EVIS-140 Series Scopes (K954451)
• CF-Q140L/I EVIS-140 Series Scopes (K954451)
• PCF-140L/I EVIS-140 Series Scopes (K954451)
• EVIS EXERA Colonovideoendoscopes (K001241)

Submission Summary (Full Text)

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K 032177

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# SMDA 510(k) SUMMARY

This summary of 510(k) safety and effectiveness information is being submitted in accordance with the requirements of SMDA 1990 and 21CFR, Part 807, Subpart E, Section 807.92.

## A. GENERAL INFORMATION

| 1. Applicant: | OLYMPUS OPT-ELECTRONICS CO., LTD. (New Company Name: AIZU OLYMPUS CO., LTD) |
|---------------------------------|--------------------------------------------------------------------------------------------|
| Address: | 500 Aza Muranishi Ooaza Niidera, Monden-machi Aizuwakamatsu-shi Fukushima, Japan, 965-8520 |
| Establishment Registration No.: | 9610595 |
| 2. Submission Correspondent: | Tina Steffanie-Oak |
| Title: | Senior Regulatory Affairs Analyst OLYMPUS AMERICA INC. |
| Address: | Two Corporate Center Drive, Melville, NY 11747-3157 |
| Telephone: | 631-844-5477 |
| Facsimile: | 631-844-5416 |
| E-mail address: | [e-mail] |
| Establishment Registration No.: | 2429304 |

#### 3. Initial Impoter: Olympus America Inc. Two Corporate Center Drive, Melville, NY 11747-3157 Address: Establishment Registration No .: 2429304

### B. DEVICE IDENTIFICATION

### 1. Common/Usual Name

GASTROINTESTINALVIDEOSCOPE / COLONOVIDEOSCOPE

#### 2. Device Name

GASTROINTESTINALVIDEOSCOPE XGIF-Q140M, XGIF-2T140M COLONOVIDEOSCOPE XCF-Q140ML/I, XPCF-160AML/I

#### 3. Classification Name

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|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------|
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# C. IDENTIFICATION OF LEGALLY MARKETED DEVICES WHICH WE CLAIM SUBSTANTIAL EQUIVALENCE

The following listed devices are considered as predicate devices in consideration of their characteristics, and the following table shows their regulatory histories.

| Model | 510(k)# | Manufacturer | Class | Product<br>Code |
|--------------------------------------|----------|---------------------------|-------|-----------------|
| GIF-Q140<br>EVIS-140 Series Scopes | #K954451 | Olympus Optical Co., Ltd. | II | 78-FDS |
| GIF-2T140<br>EVIS-140 Series Scopes | #K954451 | Olympus Optical Co., Ltd. | II | 78-FDS |
| CF-Q140L/I<br>EVIS-140 Series Scopes | #K954451 | Olympus Optical Co., Ltd. | II | 78-FDS |
| PCF-140L/I<br>EVIS-140 Series Scopes | #K954451 | Olympus Optical Co., Ltd. | II | 78-FDS |
| EVIS EXERA<br>Colonovideoendoscopes | #K001241 | Olympus Optical Co., Ltd. | II | 78FDF |

#### D. DEVICE DESCRIPTION

#### 1. Summary

The subject devices. XGIF-Q140M. XGIF-2T140M. XCF-Q140ML/I. XPCF-160AML/I are basically identical to the predicate devices, GIF-Q140, GIF-2T140, CF-Q140L/I, PCF-140L/I except that the mechanical structure of variable stiffness* and Multi-bending function has been added.

*This feature has been added to XPCF-160AML/I only.

While XPCF-160AML/I has the mechanical structure of variable stiffness (Refer to Attachment 2. "Flexibility Adiustment Function") this feature is identical to those of another predicate device, the EVIS EXERA Colonovideoendoscopes (#K001241). The addition of the variable stiffness function does not require any new insertion method or technique.

The Multi-bending function has two independent bending sections in the insertion portion of the scope. This new function provides an easier approach in reaching the lesion and also a better view of the lesion from the front. Some lesions in the upper digestive tract were difficult to perform a perfect biopsy and endoscopy with the conventional forward-viewing gastroscope. (Refer to Appendix-3, "Clinical Literature"). The subject devices improve the approach to the lesion in the lower digestive tract compared with the predicate devices. We have evaluated the approach performance of the XPCF-160AMI compared to the predicate device using a colon model. (Refer to Attachment 1, "Comparison between approach performance of Predicate and Subject Device using a colon model").

In conclusion, the subject device is substantially equivalent to the predicate devices. A comparison table of the subject device and predicate devices is found in Attachment 1.

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#### 2. Design

XGIF-Q140M, XGIF-2T140M, XCF-Q140MLII, XPCF-160AMLII has been designed, manufactured and tested in compliance with voluntary safety standards. It meets the requirement of IEC60601-1, IEC60601-1-1and IEC60601-2-18.

#### 3. Materials

All the patient contacting materials used in this endoscope and ancillary equipment are identical materials that have been cleared in the past 510(k) submissions. And all materials have been confirmed with ISO 10993-1.

#### 4. Intended Use of the device

GASTROINTESTINALVIDEOSCOPE XGIF-Q140M, XGIF-2T140M

This instrument has been designed to be used with the OLYMPUS Video System Center, Light Source, Documentation Equipment, Video Monitor, Electrosurgical unit, Endo-Therapy Accessories 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).

#### COLONOVIDEOSCOPE XCF-Q140ML/I, XPCF-160AML/I

This instrument has been designed to be used with the OLYMPUS Video System Center, Light Source, Documentation Equipment, Video Monitor, Electrosurgical unit, Endo-Therapy Accessories such as a Biopsy Forceps and other ancillary equipment for endoscopy and endoscopic surgery within the lower digestive tract (including the anus, rectum, and sigmoid colon, colon, and ileocecal valve).

#### 5. Summary including conclusion drawn form Non-clinical Tests

When compared to the preamendment/predicate devices, XGIF-Q140M. XGIF-2T140M. XCF-Q140ML/I, XPCF-160AML/I does not incorporate any significant changes in the intended use, method of operation, material, or design that could affect the safety and effectiveness. Therefore clinical data is not necessary for its evaluation of safety and efficacy.

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DEPARTMENT OF HEALTH & HUMAN SERVICES

Public Health Service

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# OCT - 2 2003

Food and Drug Administration 9200 Corporate Boulevard Rockville MD 20850

OL YMPUS OPT-ELECTRONICS CO., LTD./AIZU OLYMPUS CO., LTD. c/o Ms. Tina Steffanie-Oak Senior Regulatory Affairs Analyst Olympus America Inc. Two Corporate Center Drive MELVILLE NY 11747-3157

Re: K032177

Trade/Device Name: Gastrointestinal Videoscope, XGIF-Q140M, XGIF-2T140M and Colonovideoscope, XCF-Q140ML/I, XPCF-160AML/I Regulation Number: 21 CFR §876.1500 Regulation Name: Endoscope and accessories Regulatory Class: II Product Code: 78 FDS and FDF Dated: July 11, 2003 Received: July 16, 2003

Dear Ms. Steffanie-Oak:

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. 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.

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 801); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820); and if applicable, the electronic product radiation control provisions (sections 531-542 of the Act); 21 CFR 1000-1050.

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This letter will allow you to begin marketing your device as described in your Section 510(k) premarket notification. The FDA finding of substantial equivalence of your device to a legally marketed predicate device results in a classification for your device and thus, permits your device to proceed to the market.

If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please contact the Office of Compliance at one of the following numbers, based on the regulation number at the top of the letter:

| 8xx.1xxx | [phone] |
|----------------------------------|----------------|
| 876.2xxx, 3xxx, 4xxx, 5xxx | [phone] |
| 884.2xxx, 3xxx, 4xxx, 5xxx, 6xxx | [phone] |
| 892.2xxx, 3xxx, 4xxx, 5xxx | [phone] |
| Other | [phone] |

Additionally, for questions on the promotion and advertising of your device, please contact the Office of Compliance at [phone]. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21CFR Part 807.97) you may obtain. Other general information on your responsibilities under the Act may be obtained from the Division of Small Manufacturers, International and Consumer Assistance at its toll-free number [phone] or [phone] or at its Internet address http://www.fda.gov/cdrh/dsma/dsmamain.html.

Sincerely yours,

Nancy C. Brogdon

Nancy C. Brogdon Director, Division of Reproductive, Abdominal and Radiological Devices Office of Device Evaluation Center for Devices and Radiological Health

Enclosure

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K 032/77

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510(k) Number(if known): GASTROINTESTINALVIDEOSCOPE XGIF-Q140M, XGIE-2T140M Device Name: COLONOVIDEOSCORE XCF-Q140ML/L XPCF-160AML/I

Indications for Use:

#### GASTROINTESTINAL VIDEOSCOPE XGIF-Q140M, XGIE-2T140M

This instrument has been designed to be used with the OLYMPUS Video System Center, Light Source, Documentation Equipment, Video Monitor, Electrosurgical unit, Endo-Therapy Accessories 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).

#### COLONOVIDEOSCOPE XCF-Q140ML/L XPCF-160AML/I

This instrument has been designed to be used with the OLYMPUS Video System Center, Light Source, Documentation Eguipment, Video Monitor, Electrosurgical unit, Endo-Therapy Accessories such as a Biopsy Forceps and other ancillary equipment for endoscopy and endoscopic surgery within the lower digestive tract (including the anus, rectum, and sigmoid colon, colon, and ileocecal valve).

# (PLEASE DO NOT WRITE BELOW THIS LINE - CONTINUE ON ANOTHER PAGE IF NEEDED)

Concurrence of CDRH, Office of Device Evaluation (ODE)

Prescription Use

OR

Over-The-Counter Use

(Per 21 CFR 801.109)

(Optional Format 1-2-96)

Gabriel A. Segarra

(Division Sign-Off) Division of Reproductive, Abdominal, and Radiological Devic 510(k) Number.