SYSTEM 83 PLUS

K122172 · Custom Ultrasonics · FEB · Jan 25, 2013 · Gastroenterology, Urology

Device Facts

• Record ID: K122172
• Device Name: SYSTEM 83 PLUS
• Applicant: Custom Ultrasonics
• Product Code: FEB · Gastroenterology, Urology
• Decision Date: Jan 25, 2013
• Decision: SESE
• Submission Type: Special
• Regulation: 21 CFR 876.1500
• Device Class: Class 2

Intended Use

System 83 Plus Endoscope Washer/Disinfector is designed for the simultaneous reprocessing of up to two flexible submentible endoscopes that are used in the gastrointestinal and/or pulmonary tracts. Flexible scopes that are submention oneoooped to the washing/disinfection cycle of the System 83 Plus may be high level disinfected predicalled and the ruspood to the labeled contact conditions for the germicide as in the predicated device. Note: System 83 Plus device includes two models. Note. System 83 Plus 2 is a device with one processing chamber which can process 1 to 2 flexible endoscopes at a time. The System 83 Plus 9 is two 'System 83 Plus 2' units put together. It has two processing chambers which can process 1 to 2 flexible endoscopes in each independently operated processing chamber.

Device Story

System 83 Plus is an automated endoscope reprocessor (AER) designed for high-level disinfection of flexible gastrointestinal and pulmonary endoscopes. The device operates by subjecting endoscopes to a washing and disinfection cycle using a germicide. It is available in two configurations: System 83 Plus 2 (single chamber, processes 1-2 scopes) and System 83 Plus 9 (dual chamber, two independently operated chambers, each processing 1-2 scopes). The device is intended for use in clinical settings to ensure endoscopes are reprocessed according to labeled germicide contact conditions. It automates the cleaning and disinfection workflow, reducing manual labor and ensuring consistent exposure to disinfecting agents, thereby minimizing the risk of cross-contamination between patient procedures.

Clinical Evidence

No clinical data provided; substantial equivalence is based on technological characteristics and intended use.

Technological Characteristics

Automated endoscope washer/disinfector; dual-chamber (System 83 Plus 9) or single-chamber (System 83 Plus 2) configurations; supports simultaneous reprocessing of multiple flexible endoscopes; utilizes chemical germicide for high-level disinfection.

Indications for Use

Indicated for high-level disinfection of flexible endoscopes used in gastrointestinal and/or pulmonary tracts. Supports simultaneous reprocessing of up to two flexible submersible endoscopes.

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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Image /page/0/Picture/0 description: The image shows the logo for the U.S. Department of Health & Human Services. The logo is a circular seal with the words "DEPARTMENT OF HEALTH & HUMAN SERVICES • USA" arranged around the perimeter. Inside the circle is an abstract symbol that resembles an eagle or a stylized human figure.

### DEPARTMENT OF HEALTH & HUMAN SERVICES

## January 25, 2013

Mr. Frank J. Weber President Custom Ultrasonics, Incorporated 144 Railroad Drive IVYLAND PA 18974

Re: K122172

Trade/Device Name: System 83 Plus Regulation Number: 21 CFR 876.1500 Regulation Name: Endoscope and Accessories Regulatory Class: II Product Code: FEB Dated: January 3, 2013 Received: January 8, 2013

Dear Mr. Weber:

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. 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.

Public Health Service

Food and Drug Administration 10903 New Hampshire Avenue Document Control Center - WO66-G609 Silver Spring, MD 20993-0002

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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); medical device reporting (reporting of medical devicerelated adverse events) (21 CFR 803); 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.

If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please go to http://www.fda.gov/AboutFDA/CentersOffices/CDRH/CDRHOffices/ucm115809.htm for the Center for Devices and Radiological Health's (CDRH's) Office of Compliance. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to

http://www.fda.gov/MedicalDevices/Safety/ReportaProblem/default.htm for the CDRH's Office of Surveillance and Biometrics/Division of Postmarket Surveillance.

You may obtain other general information on your responsibilities under the Act 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/MedicalDevices/ResourcesforYou/Industry/default.htm.

Sincerely yours,

Anthony Lo m

Anthony D. Watson, B.S., M.S., M.B.A. Director Division of Anesthesiology, General Hospital, Respiratory, Infection Control and Dental Devices Office of Device Evaluation Center for Devices and Radiological Health

#### Enclosure

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# Indications for Use

#### 510(k) Number (if known): K122172

Device Name: System 83 Plus

Indications For Use:

System 83 Plus Endoscope Washer/Disinfector is designed for the simultaneous reprocessing of up to two flexible submentible endoscopes that are used in the gastrointestinal and/or pulmonary tracts. Flexible scopes that are submention oneoooped to the washing/disinfection cycle of the System 83 Plus may be high level disinfected predicalled and the ruspood to the labeled contact conditions for the germicide as in the predicated device. Note: System 83 Plus device includes two models.

Note. System 83 Plus 2 is a device with one processing chamber which can process 1 to 2 flexible endoscopes at a time. The System 83 Plus 9 is two 'System 83 Plus 2' units put together. It has two processing chambers which can process 1 to 2 flexible endoscopes in each independently operated processing chamber.

Prescription Use (Part 21 CFR 801 Subpart D) AND/OR

Over-The-Counter Use _ ਮ (21 CFR 801 Subpart C)

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

Concurrence of CDRH, Office of Device Evaluation (ODE)

Sheila A. Murphey

| | <p>Digitally signed by Sheila A. Murphey<br/> DN: c=US, o=U.S. Government, ou=HHS,<br/> ou=FDA, ou=People, cn=Sheila A. Murphey,<br/> 0.9.2342.19200300.100.1.1=1300369048<br/> Date: 2013.01.25 14:10:31 -05'00'</p> |
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(Division Sign-Off)

Division of Anesthesiology, General Hospital

Infection Control, Dental Devices

| 510(k) Number: | K122172 |
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