Management of multiple magnetic foreign body ingestion in pediatric patients

Multiple magnetic foreign body (MMFB) ingestion in children has increased rapidly in recent years [1]. Unlike other ingested foreign bodies, MMFB can cause serious consequences such as intestinal necrosis, ileus, and perforation by being able to connect to one another across the loops of the bowel [2]. Thus, it is very important for pediatricians to understand the harm of the MMFB and know how to deal with this situation. In the present study, a retrospective analysis was performed on 91 patients who ingested MMFB, and the management of this disease was summarized to provide information for other clinicians.

A total of 22 patients (14 males and 8 females) received conservative treatment. The median age of the patients was 61 months (IQR: 40.75–93 months) with a median weight of 18.75 kg (IQR: 14.75–25.63 kg). All patients were asymptomatic and the abdominal x-ray showed a meaningful change in the position of the foreign body, among them, 13 patients (59%) could tell the doctor with great certainty that the foreign bodies were swallowed at one time. The foreign bodies were discharged through the anus without medical intervention.

A total of 69 patients consisting of 52 males and 17 females received surgical treatment. The median age of those patients was 43 months (IQR: 21–67 months) with a median weight of 15.5 kg (IQR: 12.25–20 kg). The most common symptom was abdominal pain and vomiting. Thirty-eight cases underwent laparotomy and 31 cases underwent laparoscopy, with 18 cases converted to laparotomy. The small intestine was the most frequent site for magnet adsorption, the main surgical approach was perforation repair. If the perforation could not be repaired, intestinal resection and anastomosis were performed. For the laparoscopic surgery group, the diseased bowel was exteriorized through an enlarged umbilical incision, followed by foreign body removal and repair, so the patients suffered less trauma and had a quicker recovery compared to the laparotomy group. The conversion of 18 children from laparoscopy to laparotomy was due to obvious abdominal distension or difficulty in exteriorizing the diseased bowel through the umbilicus incision (Table 1).

The foreign bodies of 13 cases were partially removed by gastroscope and the remaining foreign bodies were excreted without further medical interventions in three cases, removed by laparoscopic surgery in six cases, including three cases converted from laparoscopy to laparotomy, and removed by laparotomy in four cases (Table 2).

All patients were examined by x-ray to confirmed that there was no foreign body residue in the body.

Multiple magnetic foreign body (MMFB) ingestion in children has gradually become a global problem nowadays [1, 3]and require special attention. When multiple magnetic foreign bodies are ingested, they can attract each other across the bowel walls, leading to acute complications, including intestinal obstruction, perforation and peritonitis or death [4].

For the management of this disease, several algorithms have been published [5], but due to the complexity of the situation, there is currently no clear consensus, especially for the timing of endoscopy and the treatment of post-pyloric magnets [6, 7]. If the foreign bodies are in the esophagus or stomach, there is a clear consensus that gastroscope is the best method of removal [8], but if an x-ray shows that foreign bodies are located in the middle or lower abdomen (beyond the stomach), some researchers recommend surgical management [9], while the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) recommends endoscopy if patients are asymptomatic [7]. In addition, NASPGHAN recommends that clinicians consult pediatric surgeons prior to endoscopic removal if ingestion is greater than 12 h prior to the time of procedure as ulceration and indentation of the mucosa may occur in less than eight hours [10]. However, the exact time of ingestion is often unknown.

This study showed that the patient’s medical history is very important, especially for elder children. If the patient is asymptomatic and informed the doctor that the multiple foreign bodies were swallowed at the same time, the patient can receive conservative treatment with hospital admission for further monitoring and serial x-rays; most such foreign bodies will pass through the digestive tract without medical intervention (Fig. 1). However, if the magnetic foreign bodies remain in the same position on sequential abdominal x-rays, surgical treatment should be considered even if the patient has no symptoms, because for such patients, intestinal fistula may have been formed [11].

Gastroscope is really important for the treatment of this disease, no matter when the patient swallowed the foreign bodies. If the multiple magnetic foreign bodies are clearly diagnosed by plain abdominal x-ray, and their location is not in the pelvic cavity, gastroscopy should be considered first, because magnetic foreign bodies can attract each other, x-ray could not accurately show whether the foreign bodies are in the stomach (Fig. 2); if the magnetic foreign bodies are identified by gastroscope whether they are in the stomach, surgeons would know which kind of incision they can choose, this would not only facilitate the surgeon’s operation, but also reduce the length of the incision and the trauma to the patient; in addition, if the magnetic foreign bodies in the stomach are removed by gastroscope, and there is no sign of pneumoperitoneum or peritonitis for the patient, removal of the remaining foreign bodies can be delayed to observe if passage will occur via the anus without medical intervention (Fig. 3).

If the patient still has symptoms such as vomiting, abdominal pain, or the remaining magnetic foreign bodies remain in the same position on sequential abdominal x-rays, surgical intervention is required (Fig. 4). The two types of surgical methods used are laparotomy and laparoscopy, some researchers recommended laparoscopic removal [4, 12], while some researchers believed that open surgery is the first choice [13], in our opinion, considering the minimally invasive of laparoscopic surgery, laparoscopy should be attempted first; when laparoscopic exploration find that only the small intestine is adsorbed by foreign bodies, the operator can expand the umbilical incision, pull the intestinal tube out of body, remove the foreign bodies and repair the intestine; in addition, if only a few intestinal tubes are sucked by foreign bodies, and there is no obvious intestinal necrosis and adhesion, surgeons can operate in the abdominal cavity to remove foreign bodies and repair intestinal tubes, when the situation is not suitable for laparoscopic operation, surgeons need to convert it to open surgery to avoid further complications. In the present study, there were 31 patients in the laparoscopic group, of which 18 (58%) were converted to open surgery. The reason for the high conversion rate was that magnetic foreign bodies often attracted each other across multiple digestive tracts. When magnets were partially located in the duodenum, colon, et. al, it was difficult to exteriorize the diseased bowel through the umbilicus incision. If magnets were forcibly removed by laparoscopy, celiac pollution and residual magnet beads may happen, also tiny perforations may be overlooked, resulting in serious postoperative complications.

The limitations of this study were that it is retrospective, descriptive, and had a small sample size of cases from a single pediatric surgery center. Future studies should be more extensive to produce more reliable results and produce reliable advice.

Multiple magnetic foreign bodies can cause serious injuries to children, we call upon governments to introduce policies to ban the sale of such magnetic toys, or at least establish effective warning labels to keep children away from such toys, we also need to strengthen publicity to make the parents aware of the harm of magnetic toys. Gastroscope is important for the treatment of this disease, and when surgery is needed, considering laparoscopic exploration first but also preparing to switched to open surgery.