Clinical predictors of surgical intervention for gastrointestinal magnetic foreign bodies in children

Seventy-two children admitted to our hospital between January 2019 and June 2022 due to the accidental ingestion of magnetic foreign bodies were chosen as the research subjects. It was reviewed and approved by the Children’s Hospital Affiliated with Soochow University’s Ethics Committee (NO.2022CS153). According to the treatment method, all children were divided into surgery group (laparoscopic, Laparotomy) and non-surgery groups (conservative, gastroscopic removal) and the admission situation of the two groups was analyzed. The relevant data were analyzed and presented. The study was approved by the institutional review board of Children’s Hospital of Soochow University. The authors have identified the institutional and/or licensing committee approving the experiments, including any relevant details; confirming that all experiments were performed in accordance with following relevant guidelines and regulations. Informed consent was waived by the institutional board of Children’s Hospital of Soochow University as a retrospective study is performed.

Inclusion criteria: there must be a clear history of ingestion of magnetic foreign bodies, or endoscopy, imaging, and surgery must indicate the presence of magnetic foreign bodies.

Exclusion criteria: the foreign body in the digestive tract is non-magnetic, and the patient cannot cooperate due to other issues.

The relevant clinical data of all children who accidentally ingested magnetic foreign bodies include age, gender, time from onset to consultation, primary symptoms, type of accidental ingestion, number of accidental ingestions, supplementary examination, treatment method, complications, and prognosis.

By examining the inpatient medical records, a database was established. Excel was utilized to establish a database. Two individuals entered data, which a third person reviewed. The statistical analysis was conducted with SPSS 17.0. Various statistical methods were used to analyze the data. Normally distributed data in measurement data were expressed as mean ± standard deviation (x ± s), and comparisons between groups were made using an independent samples t-test. Skewed distribution data were expressed as median numbers and interquartile ranges, and comparisons between groups were made using the Mann-Whitney U test. Enumeration data were expressed as n (%), and χ2 test or Fisher’s test was utilized for group comparison. All statistical tests were two-sided, and P values < 0.05 were considered statistically significant. Among the relevant risk factors compiled are univariate logistic regression analysis. To exclude confounders and include all relevant risk factors, all factors with P < 0.1 were included in multiple logistic regression analysis. This study’s final statistically significant (P < 0.05) factor was an independent risk factor.

The collected case information was categorized and summarized according to admission years and treatment methods. See Table 1 for details. In our hospital, the incidence and cost of gastrointestinal foreign bodies in hospitalized children ranged from 54 to 88 cases per year. In the first half of 2022, there were 54 cases of foreign bodies in the digestive tract, of which 11 (20.4%) were magnetic foreign bodies. The specific data are depicted in Fig. 1.

In the cases, vomiting, persistent abdominal pain, diarrhea, and parental findings or self-reported ingestion of magnetic beads were the most common reasons for medical treatment; the most common clinical manifestations were nausea and vomiting (42.62%), persistent abdominal pain (57.38%), abdominal muscle tension (13.11%), local mass (3.28%), local tenderness (27.87%), and poor spirit (3.28%). Refer to Fig. 2. To further confirm the diagnosis, the upright abdominal X-ray is frequently utilized in the clinic as the preferred supplementary examination. This study’s abdominal X-ray examination can detect foreign bodies in the gastrointestinal tract. Figure 3 demonstrates the typical X-ray findings.

Of the 72 children in this study, 9 (12.5%) were under 1 year old, 26 (36.11%) were between1 to 3 years, and 55 (76.4%) were between 3 to 6 years, with a gender ratio of 3.69:1 (Male:Female). The number of accidental ingestions ranged from 2 to 95, with the most extended duration exceeding 1 month. In the cases included in this article, magnetic foreign bodies in the digestive tract are primarily treated with observation, gastroscope removal, and surgery. There were 37 surgical intervention cases (51.39%) and 35 non-surgical intervention cases (48.61%). Age, gender, ingested number by mistake, local tenderness on physical examination, and mass did not differ between the two groups. As for statistical significance, on the contrary, there were statistically significant differences between the groups regarding the time of ingesting by mistake, clinical manifestations (e.g., nausea, vomiting, persistent abdominal pain, abdominal muscle tension) and 24-h radiograph movement (P < 0.05). The information is presented in Table 2.

Initially, univariate analysis was performed. Magnetic foreign bodies in the digestive tract are associated with accidental eating time, clinical manifestations (nausea, vomiting, persistent abdominal pain, abdominal muscle tension), and movement trajectory by every 24-h radiograph related to surgical procedures. Therefore, significant univariate factors were included in the multivariate logistic regression analysis, excluding confounding variables. In children with magnetic foreign bodies in the digestive tract, abdominal muscle tension and intermittent abdominal pain are independent risk factors for surgical intervention. See Table 3 for details.

For 26 (42.6%) of the 72 children with magnetic foreign bodies in the gastrointestinal tract, gastrointestinal perforation and the formation of an internal fistula were present. Most perforations occur in the ileum, colon, or stomach. The information is provided in the table below. Among the 39 children with magnetic foreign bodies treated by surgery, 26 cases showed gastrointestinal perforation (66.7%), including magnetic beads (22, 84.62%) and other magnetic bodies (4, 15.38%). The numbers of perforation ranged from one to four sites, and there was only one perforation in most cases (14, 53.85%) (Table 4). The perforation sites were very diverse and unexpected, including jejunum or ileum (15,57.69%), stomach—jejunum/ileum (3,11.54%), stomach—colon (1,3.85%), jejunum/ileum—colon (6,23.08%) and others (1,3.85%).

Magnetic foreign bodies in the digestive tract of children are a relatively common and highly unique category of foreign bodies in the digestive tract that are primarily determined by their physical characteristics. Accidental ingestion of a single magnetic foreign body typically results in few clinical manifestations, and most are excreted naturally. However, it dramatically increases the likelihood that the gastrointestinal tract, mesentery, and other tissues will be compressed. Prolonged ischemia will cause necrosis, perforation, and fistulas in the gastrointestinal tract. In this group of children with magnetic foreign bodies in the digestive tract, the number of accidental ingestions ranged from 2 to 95, with the most extended duration exceeding 1 month. Consequently, the severity of the clinical manifestations varies. Common symptoms include intermittent abdominal pain, nausea and vomiting, abdominal distension, and diarrhea. Severe cases can rapidly develop life-threatening intestinal obstruction, peritonitis, and shock.

Previous research has demonstrated that magnetic beads attract one another and rarely cause abdominal leakage. The primary cause of the symptoms is intestinal obstruction. These children develop internal fistulas because of long-term perforation. Compression of the intestinal tube leads to intestinal root obstruction in a closed intestinal loop. Intestinal obstruction caused by magnetic foreign bodies is mainly manifested as vomiting, abdominal pain, abdominal distension and gastrointestinal type visible in the abdomen, whereas abdominal pain is mostly concentrated around the umbilicus or upper abdomen, and it is manifested as high obstruction on X-ray (Fig. 3b). The results of this study suggest that nausea, vomiting, abdominal pain, tenderness or rebound tenderness are closely related to surgical treatment. Therefore, it is suggested that once magnets in digestive tract is clinically diagnosed with the previous symptoms, emergency surgery should be considered, the more severe of obstruction, the higher priority of operation.

The most common clinical imaging examination is a thoraco-abdominal X-ray, which frequently reveals multiple high-density shadows distributed in a beaded or clumpy pattern. Multi-angle abdominal X-ray photography and CT scan can be used when the number of magnets are uncertain (Fig. 3a). Dynamic abdominal X-ray monitoring is an important indication of operation. Unfortunately, abdominal B-ultrasound is not specific for diagnosing magnetic foreign bodies in the digestive tract, resulting in a high rate of missed diagnoses. The type of perforation caused by magnetic foreign bodies in the digestive tract is uncommon, and it typically has a small diameter and is predominantly an internal fistula. Therefore, abdominal X-rays reveal less free gas under the diaphragm [8]. There were only 2 cases appeared subphrenic free gas (Fig. 3c).

A complete and comprehensive medical history is essential for diagnosing and treating this type of illness. Children who ingest magnetic foreign bodies inadvertently typically have a clear history of exposure to magnetic foreign bodies. Unfortunately, time is not adequately described. Consequently, the diagnosis of accidental ingestion of magnetic foreign bodies in the digestive tract is frequently based on clinical manifestations combined with imaging examinations, with abdominal X-ray being the most important (frontal and lateral view). It is intuitively reflected and provides practical assistance in selecting follow-up treatment options.

Presently, the most frequently used clinical treatments for magnetic foreign bodies in the digestive tract are the self-discharge of foreign bodies, gastroscopy, and laparoscopic foreign body removal. Dynamic abdominal X-ray monitoring is the current “gold standard” for clinical guidance [8], which is consistent with our research. If the patient is not in critical condition, and the magnets are persistently moving appeared in X ray, conservative treatments are considered preferentially (Fig. 4a), most of these magntic beads can be discharged within 3–5 days. If the magnetic beads continuously move to the ileocecal valve and then are fixed, we could still observe another 3–5 dayss as well as laxative therapy. However, if the magnatic beads in the children’s radiographs are fixed combine with clinical manifestations, surgical treatment should be performed to avoid serious complications.

Foreign bodies can be removed under a gastroscope from children who have swallowed them by accident or if the foreign body is in the duodenum or above within 24 h. If the gastroscope cannot be removed entirely, the foreign body’s dynamic changes should be closely monitored, and surgery should be performed if it remains for an extended period [9]. As depicted in Fig. 4b, Continuous radiographs showed all the foreign bodies were located in stomach, we removed them successfully by gastroscopy. In this study, a gastroscopy was performed on 16 children, and the success rate was 68.75%, which has the benefits of a high success rate, minimal damage, and low cost.

Gastroscopy combined with laparoscopy has great advantages for complicated magnetic bead cases, and this not only reduces risks for repeated anesthesia, but also accidentally finds out the foreign remaining in the esophagus. Immediate surgical treatment should be administered to patients who did not respond to gastroscopy removal, those with obvious signs of peritoneal irritation, and those with confirmed gastrointestinal magnetic foreign bodies and unstable vital signs. Some scholars believe that laparotomy should be the first choice for surgical intervention [10]. We agree that laparoscopic exploration should be the first choice for surgical intervention, primarily because it is not only a surgical method but also a visual inspection. Laparoscopic exploration can assist in diagnosing patients who cannot identify the location of the foreign body on an abdominal X-ray and who are unable to judge the necrosis and perforation [11] (Fig. 5a, b, c). In comparison to traditional laparotomy, laparoscopic surgery causes less damage. Simultaneously, it is possible to enlarge the umbilical incision and remove the free intestinal tube that is absorbed only by foreign bodies. The intestinal canal of an internal fistula can also be used to locate the abdominal wall incision more precisely, thereby preventing blind expansion of the incision. When there is apparent necrosis and perforation, or the endoscopic procedure is complex, it should be converted to laparotomy in time to ensure a smooth and smooth operation of the digestive tract (stomach to rectum) to prevent missed perforation sites (Fig. 5d, e, f). In this study, 21 instances of laparoscopic surgery were converted to open surgery, accounting for 65.6% of all surgical procedures. La laparoscopic exploration frequently reveals necrosis, perforation, or the formation of an internal fistula due to the absence of a clear opportunity for surgical intervention, which is the primary cause of its high incidence [11].

Complications caused by magnetic foreign bodies in the digestive tract of children frequently have a direct bearing on their treatment, hospital stay, hospital costs, and prognosis [12]. The principal complications include mucosal edema, erosion, intestinal necrosis, perforation, bleeding, and intestinal obstruction, with gastrointestinal perforation being the most prevalent. Digestive tract perforation accounted for in this study accounts for more than 70% of surgical treatment cases. Among them, patient No. 19 was found to have Meckel’s diverticulum during the operation. Upon perforation, he underwent “Meckel’s diverticulum excision, gastrointestinal foreign body removal, intestinal adhesion release, enteroenteric anastomosis, and abdominal drainage,” and the postoperative recovery was acceptable (Fig. 4c). Patient No.9 showed another complicated perforation locations, the magnetic beads penetrated through the descending duodenum as well as ascending colon mesentery and located around appendix. We then performed “digestive tract foreign body removal and intestinal perforation repair” subsequently. Patient No. 23 ingested magnetic beads and button batteries by accident. Due to the high corrosiveness of button batteries, the degree of intestinal adhesion during the operation was severe, and most of the intestinal tubes were necroticwe immediately resected the necrotic intestine and performed adhesive tape loosening and intestinal anastomosis. The child developed intestinal obstruction after the surgery but gradually improved with conservative treatment. According to the prognosis survey of all children in this study, most children have been completely cured, and there were two cases of postoperative intestinal obstruction [13, 14].

In conclusion, the damage caused by magnetic foreign bodies in children’s digestive tracts is highly severe, so prevention is frequently preferable to treatment. Therefore, we should urge the social level to actively promote education, discourage the use of magnetic toys, and remind relevant manufacturers to create visible signs. Awaken all parents and safeguard children from contact. Medical personnel must actively adopt a treatment plan for children who have ingested by accident, prioritizing the use of gastroscope removal or gastroscope combined with laparoscopy to improve the foreign body removal rate, reduce the incidence of complications, and ensure the safety of children’s lives [15, 16].