DISPOSABLE OVERTUBE

K040836 · United States Endoscopy Group, Inc. · FED · Jun 10, 2004 · Gastroenterology, Urology

Device Facts

• Record ID: K040836
• Device Name: DISPOSABLE OVERTUBE
• Applicant: United States Endoscopy Group, Inc.
• Product Code: FED · Gastroenterology, Urology
• Decision Date: Jun 10, 2004
• Decision: SESE
• Submission Type: Traditional
• Regulation: 21 CFR 876.1500
• Device Class: Class 2

Intended Use

The disposable Overtube is a device used in conjunction with a flexible endoscope for foreign body or tissue retrieval and/or for endoscopic endoscope intubations.

Device Story

Disposable Overtube functions as accessory to flexible endoscopes; facilitates passage of endoscope into gastrointestinal tract; aids in foreign body or tissue retrieval. Device used in clinical settings by physicians; provides protective conduit for endoscope insertion; reduces mucosal trauma during repeated intubations or instrument exchanges. Benefits include improved procedural efficiency and patient safety during endoscopic interventions.

Clinical Evidence

No clinical data provided; bench testing only.

Technological Characteristics

Disposable overtube; flexible polymer construction; designed for use with standard flexible endoscopes; non-powered; single-use.

Indications for Use

Indicated for use with flexible endoscopes to facilitate foreign body or tissue retrieval and/or endoscopic intubations.

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.

Submission Summary (Full Text)

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Food and Drug Administration 9200 Corporate Boulevard Rockville MD 20850

JUN 1 0 2004

Ms. Gretchen Y. Cohen Executive Vice President US Endoscopy 5976 Heisley Road MENTOR OH 44060

Re: K040836

Trade/Device Name: Disposable Overtube Regulation Number: 21 CFR §876.1500 Regulation Name: Endoscope and accessories Regulatory Class: II Product Code: 78 KOG Dated: May 24, 2004 Received: May 25, 2004

Dear Ms. Cohen:

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 for use bated in to May 28, 1976, the enactment date of the Medical Device Amendments, or to conniner or proc to rial 20, 20, 2017 11:11 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 r ou may, aterere, misions 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 I Tease be actived that I Drimination that your device complies with other requirements of the Act that I Driviso mas and regulations administered by other Federal agencies. You must or uny Federal barates in requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); good manufacturing practice requirements as set (21 CFR Part 807), accemis (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) This letter will allow you to ocgin marketing your antial equivalence of your device to a legally premarket nothication. The PDA inding of backlania equivalians 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 If you desire specific advice for your device on our lief to good 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 Additionally, Tor questions on the promotion and the regulation entitled, "Misbranding
Office of Compliance at [phone]. Also, possessed on Main - Other agences Othice of Compliance at [phone]. Fast, production of Soltan. Other general by reference to premarked nonitation (21 Or Fer and on 17) in the Division of Small information on your responsionalites and consumer Assistance at its toll-free number [phone] or
Manufacturers, International and Consumer Assistance at its toll-democr Manufacturers, International and Collisation Fibroads.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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## Indications for Use

510(k) Number (if known): K040836

Device Name: Disposable Overtube

Indications for Use:

The disposable Overtube is a device used in conjunction with a The disposable Overtube is a device dood in terrjans.
flexible endoscope for foreign body or tissue retrieval and/or for endoscopic nextble endoscope for relige endoscope intubations.

| Prescription Use | <div style="text-align: left;">✓</div> |
|-----------------------------|----------------------------------------|
| (Part 21 CFR 801 Subpart D) | |
| | AND/OR |
| | Over-The-Counter Use |
| | (21 CFR 807 Subpart C) |

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

Concurrence of CDRH, Office of Device Evaluation (ODE)

David M. Chapman

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

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