KEYWORDS:
Buckyballs
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endoscopy
-
foreign body
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fullerenes
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magnet
INTRODUCTION
Foreign body ingestion is a common presentation for pediatric emergency rooms, often
requiring gastroenterology or surgical involvement for removal. Although magnets constitute
a low number of these ingestions, they have a significantly higher rate of morbidity
and mortality.[1 ] The children's toy known as “Buckyballs” is spherical fullerene molecules with C
60 formula made of 20 hexagons and 12 pentagons with a carbon atom at each vertex.[2 ] These and similar rare earth metals are have been made into magnetic children's
toys and are 5–10 times stronger than traditional magnets.[2 ] Ingestion of these toy magnetic balls has been associated with serious gastrointestinal
(GI) injuries requiring emergent surgical interventions such as laparoscopy or laparotomy,
GI perforation, fistula formation, and death in some cases.[1 ],[2 ],[3 ],[4 ] Reviews of studies that discuss multiple magnet ingestions have reported successful
endoscopic removal of up to ingestion of 27 magnets. Here, we describe successful
endoscopic removal following ingestion of 42 magnets, avoiding hospitalization and
the morbidity associated with surgical intervention.
CASE REPORT
A 3-year-old male patient presented to our Emergency Department within 1 h following
concern for ingestion of magnetic balls. Although the ingestion was not witnessed,
the mother observed him playing with the toy and that multiple magnets were missing.
On arrival to the emergency department, he was asymptomatic by history and clinical
examination. Abdominal radiographic imaging showed 42 linked magnetic balls initiating
in the stomach and terminating in the fourth portion of the duodenum [Figure 1 ]. The appearance was concerning for the final magnetic ball in the duodenum being
magnetically attracted to a magnet that was located in the stomach, potentially compromising
the blood supply in these areas. After discussion with the surgical team, it was decided
to initially attempt endoscopic removal but to switch to a surgical intervention if
unsuccessful or if concerns for acute abdomen noted during the procedure. We performed
an emergent endoscopy 2.9 h after initial presentation to our facility with the pediatric
surgery on standby under general anesthesia with cuffed endotracheal intubation. Upper
endoscopy (Olympus GIF-H190 9.2 mm) was performed to visualize any mucosal injury
in the esophagus, stomach, and duodenum, and also to appreciate the chain of ingested
magnetic balls [Figure 2 ]. Subsequently, rat tooth alligator forceps (Olympus FG-44NR-1) were used to successfully
detach the attracted magnets in the stomach from the magnets in the duodenum, and
pull a continuous chain of magnets free from the upper GI tract without any mucosal
injury in the duodenum, stomach, and esophagus. The magnets located in the stomach
provided a magnetic attraction to the material comprising the forceps materials. The
magnetism allowed enough of a firm grasp on the circular object to disrupt the gastric-duodenal
magnetic attraction. Intraoperative radiological imaging confirmed that all magnets
were successfully removed with no evidence of abdominal free air to suggest perforation.
The patient awoke from anesthesia with no complications and was discharged home after
2 h of observation following appropriate safety counseling. The patient's mother canceled
a 4-week follow-up clinical appointment as the patient recovered well and remained
asymptomatic.
Figure 1: Abdominal x-ray imaging showing 42 metallic rounded magnets in the distal stomach
extending to the 4th segment of the duodenum
Figure 2: Intra-operative endoscopic imaging showing chain of magnetic balls in the stomach,
extending out of the pylorus and into the duodenum
DISCUSSION
Despite being recalled and banned from the market in 2014 by The United States Consumer
and Product Safety Commission,[5 ] Buckyballs and similar products continue to pose a danger through households that
had purchased the toy before withdrawal from retail stores or online sales. Pediatric
emergency departments, jointly with surgical and gastroenterology teams, would benefit
from having a protocol in place to rapidly triage these patients, allowing them to
be directed to procedural intervention as quickly as possible. Several factors served
in the success of this patient's outcome and avoidance of surgical intervention. These
included early awareness of possible ingestion and presentation to the emergency department
by the patient's family, presence of the magnets in the stomach, and quick turnaround
time from diagnosis by radiographic imaging to beginning endoscopic procedure. We
feel that in the setting of gastric containing magnetic foreign bodies known to be
acutely ingested, attempting endoscopic removal in an operating room with surgical
team on standby is indicated to avoid morbidity and mortality associated with surgery.
However, given the high risk of perforation and fistula formation following multiple
magnet ingestions, this is a decision that must be made jointly and with the awareness
of the surgical team based on the patient's clinical presentation.
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