Multiple Intestinal Perforation and Necrosis due to Magnet Ingestion

Surgical management of pediatric multiple magnet ingestions in the past two decades of minimal access surgery- systematic review of operative approaches

BACKGROUND

Multiple magnet ingestion is increasingly reported in paediatrics and can cause significant morbidity. Various surgical approaches exist, though minimal literature compares outcomes between techniques. This review evaluates laparoscopic, laparoscopic-assisted, and open surgery with regard to outcomes.

METHOD

Systematic review across MEDLINE, Embase, Scopus, and Web of Science identified reports of paediatric multiple magnet ingestion managed surgically between 2002 and 2022.

RESULTS

Ninety-nine studies were included, reporting data from 136 cases. Of these, 82 (60%) underwent laparotomy, 43 (32%) laparoscopic surgery, and 11 (8%) laparoscopic-assisted procedures. Sixteen laparoscopic cases were converted to open, often due to intraoperative findings including necrosis/perforation, or grossly dilated bowel. Bowel perforation occurred in 108 (79%); 47 (35%) required bowel resection, and 3 had temporary stoma formation. Postoperative recovery was uneventful in 118 (86%). Complications were reported following 15 (18%) open and 3 (7%) laparoscopic surgeries. No complications occurred following laparoscopic-assisted surgery. All post-laparoscopic complications were Clavien-Dindo (CD) Grade I. Following open surgery, 5 complications were CD grade I, 6 were CD grade II, and 4 were CD grade IIIb, requiring re-laparotomy. Median length of stay for open and laparoscopic-assisted procedures was 7 days, and for laparoscopic was 5 days (p < 0.001).

CONCLUSION

Surgical management of multiple magnet ingestion often achieved uncomplicated recovery and no long-term sequelae. Whilst open laparotomy was the more common approach, laparoscopic surgery was associated with reduced length of stay and postoperative complications. Therefore, in experienced hands, laparoscopic surgery should be considered first-line, with the possibility of conversion to open if required.

Application of high-frequency ultrasound in the diagnosis of gastrointestinal magnet ingestion in children

BACKGROUND

The incidence of magnet ingestion by children has recently increased in China. Magnet ingestion is associated with an extremely high risk of gastrointestinal damage because loops of bowel can become trapped and squeezed between multiple magnets in different locations. However, the lack of imaging sensitivity makes clinical decision-making difficult.

OBJECTIVE

This study was conducted to investigate the performance of ultrasound in diagnosing gastrointestinal magnet ingestion in children.

METHODS

From April 2017 to February 2021, all children with a history of magnet ingestion or a diagnosis of gastrointestinal magnet as shown by x-ray or ultrasound in our hospital were included as study candidates. Patients who were lost to follow-up or had known malformations of the gastrointestinal tract were excluded. Eligible patients were those with surgical or endoscopic confirmation of gastrointestinal magnet, those who passed the magnet out of the alimentary tract without assistance, and those with confirmed absence of the magnet on abdominal x-ray examination after 1 month of conservative treatment. All eligible patients' ultrasound and x-ray examination data were evaluated. The sensitivity, specificity, and area under the curve (AUC) of ultrasound was calculated for diagnosing magnet ingestion, locating the magnet (stomach, small intestine, or colon), and confirming the phenomenon of wall entrapment.

RESULTS

Of 112 patients, 107 had a magnetic foreign body and 5 did not. Magnets were correctly detected by ultrasound in 97 patients, with an observed sensitivity of 90.65% and specificity of 100%. Satisfactory sensitivity was obtained for ultrasound localization of gastric magnets (96.30%) and small intestinal magnets (100.00%), but sensitivity for ultrasound localization of colonic magnets was relatively poor (73.33%). The discrimination of wall entrapment by ultrasound was good (AUC = 0.93), with an observed sensitivity and specificity of 92.00% and 93.62%, respectively.

CONCLUSIONS

Ultrasound can be used to locate gastrointestinal magnets (in the stomach, small intestine, or colon) with good clinical efficacy in identifying wall entrapment.

Magnet ingestion in children and its implications: tertiary centre experience

BACKGROUND

Swallowing multiple magnets or a magnet and second metallic object can carry risks of intestinal obstruction, fistula and perforation because they can attach to each other with loop of bowel in between. An updated management plan and reviewing our experience are warranted because of increased incidence of magnets ingestion among children.

METHODS

All the patients who had a history of single, multiple magnet or single magnet and second metallic object ingestion in Bristol Royal Hospital for children during the period from January 2014 till November 2020 were included in our study.

RESULTS

A total of 46 patients were referred to our hospital with a history of magnet ingestion. The number of magnets ingested ranged between one and twenty one magnets. All patients had abdominal x-ray undertaken either Antero-posterior alone (AP) (n = 32) or both AP and lateral (n = 14). Surgical intervention was performed in 18 patients; Oesophago-gastro-duodenoscopy (n = 8), laparotomy/laparoscpy (n = 10) to retrieve the magnets or deal with the complications.

CONCLUSIONS

Magnets ingestion in children can be tricky when it comes to management. Complications can happen quite often and carry severe risks on children. An updated structured algorithm is proposed to manage children with magnet ingestion.

Multiple magnetic foreign body ingestion in pediatric patients: a single-center retrospective review

OBJECTIVE

Foreign body (FB) ingestion is increasingly common in children, and ingestion of multiple magnetic FBs can cause serious injuries. This study aimed to identify the clinical features and management options of such cases.

METHODS

A retrospective review was conducted of 35 pediatric patients diagnosed as having ingested multiple magnetic FBs.

RESULTS

The main clinical manifestations were abdominal pain, vomiting, and fever. Of the 35 patients, 6 (17.1%) were conservatively treated and the remaining 29 (82.9%) were surgically treated. Of those who were surgically treated, 26 underwent exploratory laparotomy and 3 underwent laparoscopic surgery that was switched to open surgery. Intestinal structure and function were restored without complications in patients who underwent successful perforation repair following removal of multiple magnetic FBs.

CONCLUSIONS

Ingestion of multiple magnetic FBs can lead to intestinal perforations, bowel strangulation, and necrosis. Accordingly, timely diagnosis and effective management of multiple magnetic FB ingestions in pediatric patients are of paramount importance to reduce further complications.

A nationwide questionnaire survey on accidental magnet ingestion in children in Japan

AIM

The aim is to investigate the actual situation of accidental ingestion of magnets in children in Japan and the clinical features of the resulting gastrointestinal damage.

METHODS

We developed a questionnaire and sent it to 496 board-certified training hospitals nationwide. Information was collected on the number of children with accidental magnet intake from 2015 to 2017, witnesses of magnet intake, number and type of magnets, presence or absence of gastrointestinal injury, treatment, etc RESULTS: The number of cases of accidental ingestion of magnets within the study period was 104, with a median age of 2 years. About half of the incidents were unwitnessed. There were 33 cases of accidental ingestion of multiple magnets. Among them, oesophagogastroduodenoscopy was performed in 4 children and surgery in 10, and significantly invasive treatment was required in comparison with single-magnet ingestion. Gastrointestinal injury was observed in 11 cases, 10 of which were caused by multiple-magnet ingestion. All 10 of these patients underwent surgical treatment. There was no mortality.

CONCLUSION

The incidence of accidental magnet ingestion in Japan is estimated to be 50-70 per year. Unwitnessed cases are not uncommon. Multiple magnet ingestion often causes gastrointestinal injury. Many cases of gastrointestinal injury are caused by ingestion of magnetic toys.

After the Recall: Reexamining Multiple Magnet Ingestion at a Large Pediatric Hospital

OBJECTIVES

To evaluate the effectiveness of a mandatory product recall on the frequency of multiple mini-magnet ingestion at a large tertiary pediatric hospital, and to examine the morbidity and mortality associated with these ingestions.

STUDY DESIGN

In this retrospective chart review, we searched our institution's electronic patient record for patients aged <18 years who had been diagnosed with ingested magnetic foreign bodies between 2002 and 2015, a period that included the mandatory product recall. We compared the frequency and character of ingestions before and after the recall.

RESULTS

Comparing the postrecall years (January 1, 2014, to December 31, 2015) with the 2 years immediately preceding the recall year (January 1, 2011, to December 31, 2012) yields an incidence rate ratio of 0.34 (95% CI, 0.18-0.64) for all magnet ingestions and 0.20 (95% CI, 0.08-0.53) for ingestion of multiple magnets. Based on the Fisher exact test, the incidence of both magnet ingestion (P < .001) and multiple magnet ingestion (P < .001) decreased, and the morbidity associated with magnet ingestion decreased. There were no deaths in either study period.

CONCLUSION

There was a significant decrease in multiple mini-magnet ingestion following a mandatory product recall. This study supports the effectiveness of the recall, which should bolster efforts to keep it in place in jurisdictions where it is being appealed. More broadly, the result provides general evidence of a recall helping decrease further harm from a product that carries a potential hazard.