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INTRODUCTION

ACCIDENTAL INGESTION OF OBJECTS by infants andsmall children is very common.1 Although the vast

majority of these objects can pass through the whole gas-trointestinal (GI) tract without any harm, objects withsharp edges or sharp points may get lodged anywhere inthe GI tract. These can cause complications such as per-forations, fistulas, or bleeding, necessitating surgical in-tervention.1–3

In our country, infants can easily get hold of safetypins.3 If they remain closed, they can easily pass throughthe GI tract, but open safety pins are potentially danger-ous and may lead to serious complications. They shouldbe removed either endoscopically or surgically.1–3 Opensafety pins located in the esophagus can be removed byrigid endoscopy if their sharp points are pointed towardsthe stomach. However, if the open end is pointed towardthe hypopharynx, or if the safety pin is in the stomach orduodenum, it cannot be removed by rigid endoscopy.

JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUESVolume 17, Number 2, 2007© Mary Ann Liebert, Inc.DOI: 10.1089/lap.2006.0060

Removal of Open Safety Pins in Infants by FlexibleEndoscopy Is Effective and Safe

AYHAN KALAYCI, MD,1 BURAK TANDER, MD,2 SULE KOCAK, MD,1RIZA RIZALAR, MD,2 and FERIT BERNAY, MD2

ABSTRACT

Purpose: In our country, safety pin ingestion by infants is commonplace. When swallowed, opensafety pins are mostly found within the esophagus or stomach, and they cannot be easily removedby rigid esophagogastroscopy. Our aim was to evaluate the removal of safety pins using flexible en-doscopy in infants.

Materials and Methods: We evaluated the cases of 7 infants who had ingested open safety pins be-tween 2001 and 2004. In all the patients, the primary diagnostic tool was a direct x-ray of the neck,chest, and abdomen. In all cases, the safety pins were removed by flexible esophagogastroduo-denoscopy. Clinical records for the cases were reviewed.

Results: Four of the open safety pins were lodged in the esophagus, two in the stomach, and onein the duodenum. One infant had a safety pin lodged in the esophagus with the pin’s open endpointed caudally; the pin was held with the endoscopic forceps by its tail end and removed. Threesafety pins in the esophagus had their open ends pointing cephalad; these were held by their tailends using the endoscopic forceps and pushed into the stomach. Then they were rotated in the stom-ach and removed tail end first. The safety pins located in the stomach or duodenum were also re-moved similarly. All safety pins were successfully removed, and there were no operative complica-tions.

Conclusion: Open surgery or other invasive removal methods are not necessary in infants withopen safety pin ingestions. In our opinion, the best way to extract an open safety pin from the esoph-agus, stomach, or duodenum is by using a flexible endoscopic device.

Departments of 1Pediatric Gastroenterology and 2Pediatric Surgery, Ondokuz Mayis University, Samsun, Turkey.

FLEXIBLE ENDOSCOPY FOR REMOVAL OF OPEN SAFETY PINS 243

Although the removal of open safety pins by fiberop-tic flexible gastroscopy in adults has been reported,4 thereare fewer reports of such a procedure performed in in-fants.2

MATERIALS AND METHODS

Between 2001 and 2004, all infants who were seen toswallow, or were suspected of swallowing, a safety pinwere evaluated. All of these patients had thoracoabdom-inal x-rays including the neck. If the safety pin was closedand located anywhere in the GI tract, the infant was dis-charged and followed-up on to make sure the safety pinwas safely excreted.

For the 7 infants with swallowed open safety pins, werecorded their age, sex, and the location of the open safetypin. All the patients with open safety pins located in theesophagus, stomach, or duodenum underwent flexible en-doscopy. All procedures were performed under generalanesthesia. In all cases, we removed the safety pin witha forceps passed through the instrument channel of theflexible gastroduodenoscope. In the patients in whom theopen end of the safety pin was pointed cephalad and lo-cated in the esophagus, we pushed the safety pin into thestomach, rotated it, and pulled it out by the tail end ofthe pin. If the safety pin was located in the stomach orduodenum, or in the esophagus with the open end pointedcaudally, the pin was removed by pulling from the tailend of the pin.

RESULTS

There were 7 patients with ingested open safety pins(Table 1). Four of the safety pins were in the esophagus,two in the stomach, and one in the duodenum (Fig. 1).Three of the esophageal safety pins had their open endspointing cephalad.

One of the patients had mental retardation and a ven-triculoperitoneal shunt for hydrocephalus. Each patienthad vomiting, dispnea, and coughing as their initial symp-toms prior to admission. One patient swallowed the safetypin more than 24 hours prior to admission. In two cases,the ingestion of the safety pin was not witnessed by par-ents or anyone else. In two patients, the sharp end of thesafety pin was embedded in the stomach mucosa (Fig. 2).In two of the patients, the initial x-ray examination re-vealed a safety pin in the middle esophagus yet, at en-doscopic examination, the safety pin was found to be inthe stomach. In one patient, the safety pin appeared to bein the stomach, but in fact it was in the second portion

TABLE 1. PATIENT CHARACTERISTICS

Direction Lodgedof the Rotation in the

N Age Sex Location of the safety pin open end required mucosa

1 6.5 months F Lower esophagus Cephalad Yes No2 3.5 years F Duodenum, second part Caudal No Yes3 8 months M Initially middle esophagus, Caudal No Yes

then stomach/antrum andpylorus

4 9 months F Upper esophagus Cephalad Yes No5 8 months M Upper esophagus Cephalad Yes No6 6 months M Initially middle esophagus, Cephalad Yes No

then fundus of stomach7 12 months F Upper esophagus Caudal No No

FIG. 1. A swallowed safety pin located in the middle esoph-agus.

244 KALAYCI ET AL.

of the duodenum. In all the patients, we successfully re-moved the safety pin by flexible endoscope. There wasno postoperative morbidity or mortality. All patients weredischarged one day after surgery.

DISCUSSION

In the pediatric age group, accidental ingestion of for-eign bodies is common. In the vast majority of cases theingested foreign body passes through the alimentary tractwith no harm.1 Sometimes it can lodge in the esophagusand is easily removed by esophagoscopy.2,3 However,when objects with sharp edges are ingested, there is arisk of complications such as perforation, erosion, andfistula.1–3 Like other sharp objects, open safety pins havea tendency to lodge in the esophagus, stomach, or any-where in the alimentary tract.5

In our country, people believe that an evil eye bead at-tached to the clothes of newborns and small babies mayprotect them from harm. This blue bead is almost alwaysattached by a safety pin.3 Furthermore, jewelry is alsotraditionally attached to the clothes of infants and chil-dren with a safety pin.3 Therefore, many infants and chil-dren can easily get hold of a safety pin. As a result, safetypin ingestion is quite common. Infants and children withmental or emotional disturbances have a greater tendencyto swallow foreign objects.5,6

Although the removal of open safety pins in adults byfiberoptic flexible gastroscopy has been reported,4 thereare few studies in infants.2 To the best of our knowledge,our study is the first in which open safety pins were ex-tracted from the GI tracts of infants using flexible en-doscopy.

It has been reported that only a small percentage ofopen safety pins swallowed by adults necessitate a la-parotomy for removal. More than 80% of open safety

pins may pass through the GI tract.4,7 However in caseof signs of perforation or failure of the foreign body toprogress, a laparatomy should be performed.4

If the open safety pin is lodged anywhere in the stom-ach or duodenum, it is relatively easy to hold the pin fromthe tail end and extract it; but if the safety pin is in theesophagus with its open end pointed cephalad, the pinshould be pushed into the stomach first, rotated, and thenpulled out by its tail end by the forceps of the endoscope.

The Foley catheter technique for removal has a greatrisk of esophageal perforation.5 In a study by Gün andcolleagues, 7 of 49 infants required open surgery for theremoval of an open safety pin.3 Several reports have sug-gested that removal of an open safety pin in the stomachor the duodenum should be done by open surgery if thesafety pin does not pass spontaneously.3,5 In our opinion,however, this approach is too invasive. In the era of flex-ible endoscopy, open safety pins may be removed suc-cessfully and safely by endoscopic intervention. In caseswhere endoscopic removal attempts are unsuccessful,open surgery will be the solution.8 In this study wedemonstrated with 7 patients that flexible endoscopy isa very useful tool for the extraction of open safety pinsfrom the esophagus, stomach, and duodenum.

The safety pin may be lodged at the level of the up-per, lower, or middle esophageal sphincter. In some pa-tients, as in one of our cases, muscle relaxation after in-duction of anesthesia may result in spontaneous passageof the foreign body from the esophagus into the stom-ach.1 In one of our cases, the safety pin was located inthe stomach on initial x-ray examination but, at en-doscopy, it was found in the duodenum. Arana reportedthree sharp metal objects located and trapped in the duo-denum, which were removed by flexible duodenoscopy.1

Likewise, the safety pin in the duodenum of our patientwas successfully removed by flexible endoscopy.

Published success rates for endoscopic removal of for-eign bodies in adult patients vary from 64% to 99%.1,9,10

In our series, all the safety pins were successfully re-moved by flexible endoscopy with no complications. Al-though the removal of an open safety pin using a flexi-ble endoscope may sometimes be very difficult, it shouldbe the method of choice, especially in experienced hands.

REFERENCES

1. Arana A, Hauser B, Hachimi-Idrissi S, Vandenplas Y.Management of ingested foreign bodies in childhood andreview of the literature. Eur J Pediatr 2001;160:468–472.

2. Bizakis JG, Prokopakis EP, Papadakis CE, Skoulakis CE,Velegrakis GA, Helidonis ES. The challenge ofesophagoscopy in infants with open safety pin in the esoph-agus: report of two cases. Am J Otolaryngol 2000;21:255–258.

FIG. 2. Endoscopic image showing an embedded safety pinin the prepyloric region.

FLEXIBLE ENDOSCOPY FOR REMOVAL OF OPEN SAFETY PINS 245

3. Gun F, Salman T, Abbasoglu L, Celik R, Celik A. Safety-pin ingestion in children: a cultural fact. Pediatr Surg Int2003;19:482–484.

4. Marsh BR. The problem of the open safety pin. Ann OtolRhinol Laryngol 1975;84:624–626.

5. Sarihan H, Kaklikkaya I, Ozcan F. Pediatric safety pin in-gestion. J Cardiovasc Surg 1998;39:515–518.

6. Kalayci AG, Baysal K, Uysal S, Sarac A, Bernay F, Gebe-soglu F. Hemopericardium caused by ingested safety pin.Endoscopy 2002;34:93.

7. Spitz L. Management of ingested foreign bodies in child-hood. Br Med J 1971;4:469–472.

8. Barber GB, Peppercorn MA, Ehrlich C, Thurer R.Esophageal foreign body perforation: report of an unusualcase and review of the literature. Am J Gastroenterol1984;79:509–511.

9. Kim JK, Kim SS, Kim JI, et al. Management of foreignbodies in the gastrointestinal tract: an analysis of 104 casesin children. Endoscopy 1999;31:302–304.

10. Olives JP. Ingested foreign bodies. J Pediatr GastroenterolNutr 2000;31(Suppl 2):S188.

Address reprint requests to:Burak Tander, MD

Department of Pediatric SurgeryOndokuz Mayis University

KurupelitSamsun 55139, Turkey

E-mail: btander@omu.edu.tr