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Background: Accidental ingestion of foreign bodies is a common problem in children. Fortunately the gastrointestinal tract is quiet resilient to foreign bodies. On the other hand the ingestion of magnets can result in enormous morbidity. Because of their natural tendency to firmly adhere they can cause intestinal obstruction, pressure necrosis, fistula formation or perforation. With this case report we aim to raise the awareness of the risks that these magnets pose to children. Methods: We describe a case of intestinal perforation caused by the separate ingestion of multiple magnets from a children’s toy (bucky balls, Neodymium spheres) by a two-year-old boy. A search in the Pubmed database showed some publications and varied management guidelines. Results: The boy was treated with an exploratory laparoscopy converted to mini- laparotomy. We removed the four magnets through separate enterotomies. Postoperative recovery was uneventful. The boy was discharged on postoperative day five and had no complications at three months follow-up. Conclusion: Accidental ingestion of multiple magnets is rare but can create a life threatening situation in children. If the magnets are still in the stomach, endoscopic retrieval is needed. If they are beyond the stomach, in asymptomatic cases close clinical and radiographic vigilance is mandatory. When symptomatic we advise urgent removal. If treated on time, surgical outcome is good and fast recovery is expected.
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