Is surgery always necessary for multiple magnet ingestion in children?-evidence for an endoscopy-first approach.

Background: Multiple magnet ingestion in children can lead to severe complications, including obstruction, fistula, and perforation. Although surgery has traditionally been the preferred treatment, recent evidence suggests that endoscopy may be safe and effective in selected patients. We compared the clinical characteristics and outcomes of pediatric patients with multiple magnet ingestion treated by endoscopic versus surgical removal, and aimed to clarify which patients should be prioritized for an endoscopy-first approach. Methods: A retrospective review of patients aged <18 years who ingested multiple magnets between May 2016 and August 2025 at two tertiary centers was conducted. The clinical data, imaging findings, treatment modalities, and outcomes were compared between the endoscopic and surgical groups. Results: Thirty-one patients (mean age 4.39±3.46 years; 61.3% boys) were included. Ten patients underwent endoscopic removal (six by duodenofibroscopy and four by ileocolonoscopy), and 21 underwent surgery. Surgery was more common in symptomatic patients who presented late and in those with magnets located beyond endoscopic reach. In selected, early-presenting, asymptomatic patients, endoscopic removal was associated with shorter hospital stay, shorter fasting time, less antibiotic use, and lower rates of severe complications. All endoscopic procedures were performed under moderate sedation, whereas all surgical procedures required general anesthesia. Conclusions: Endoscopy-first approach may be a safe and effective initial option for selected, early-presenting, hemodynamically stable children with endoscopically accessible magnets and no signs of high-grade obstruction or perforation, potentially avoiding unnecessary general anesthesia and surgery.