Foreign body ingestion in children is a common public health problem worldwide. In the United States of America, foreign body ingestions cause approximately 1,500 deaths per year [1]. Of the 23,087 cases of foreign body ingestion reported by the American Association of Poison Control Centers in 2015, 64% involve children aged ≤5 years [2]. Although >80% of the gastrointestinal foreign bodies can be spontaneously excreted, some lead to severe morbidity and mortality [3].

Safety pin ingestion has been reported in 1% of children with foreign body ingestions, but it is more common in some regions of the world [4]. In our country, ingested safety pins constitute 7.8–38.6% of all ingested foreign bodies in children [56]. The high frequency of safety pin ingestion is somehow our country's cultural phenomenon. Safety pins are mostly used to attach blue beads and other amulets believed to protect the baby against the evil eye or to attach gold jewellery gifts. Babies may usually pull and open these attachments and then swallow the open safety pin.

In the present study, children who had ingested safety pins and underwent endoscopic procedures were evaluated. The aim was to present some practical approaches for ingested safety pins. An algorithmic proposal of endoscopic removal for ingested safety pins was presented for the first time in the literature to the best of our knowledge.

The median age of patients was 9.5 months (interquartile range, 6.3–14 months), and 70% were girls. Table 1 presents details regarding age, sex, localizations of the ingested safety pins during endoscopy, and results of the endoscopic interventions. All patients were admitted to the hospital with foreign body ingestion complaints. All foreign body ingestions were accidental. All patients ingested the safety pins themselves, and the reason why the parents brought the infants to the hospital was that the safety pins were lost. All suspicions were verified on X-ray images.

Eighteen of the 20 cases of safety pin ingestion involved patients aged <2 years, and the youngest patient was 3.5 months old. The largest safety pin removed in our case series was approximately 6-cm long. The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) suggests the removal of sharp foreign bodies (i) immediately if they are in the esophagus, (ii) immediately if they are in the stomach and intestines and are symptomatic, (iii) within 24 hours if they are in the stomach and intestines and are asymptomatic via endoscopy first, and (iv) by surgical intervention if endoscopy is not successful and no spontaneous clearance is achieved 3 days after ingestion [7]. The European Society of Gastrointestinal Endoscopy (ESGE) and European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) recommend that if sharp-pointed objects are located in the esophagus, stomach, or proximal duodenum, the removal procedure must be performed within <2 hours, even in asymptomatic children [8]. As suggested by the NASPGHAN and ESGE/ESPGHAN, safety pins, as well as other sharp-pointed objects, should be removed as soon as possible.

Sarihan et al. [9] reported that they performed right esophagoscopy in 15 children who had ingested safety pins; nine safety pins were removed, five passed out with spontaneous clearance, and one open safety pin lodged at the duodenum required laparotomy. Kalayci et al. [10] reported seven cases of ingested open safety pins. They reported that all safety pins, including four lodged in the esophagus, two in the stomach, and one in the duodenum, were successfully removed.

In a series of 49 cases reported by pediatric surgeons [11], 5 of the 18 safety pins in the esophagus could not be removed using endoscopy; eighteen safety pins in the stomach were left for spontaneous passage, and 7 of these 18 safety pins required surgical intervention; five safety pins below the stomach were spontaneously excreted; and surgical intervention was required for 7 safety pins in the intestines and the last one in the colon. Both in the present study and in other studies, safety pins passing through the duodenum could be excreted spontaneously. However, Gün et al. [11] reported that they had operated on a patient with a safety pin in the colon. In the present study, all cases wherein safety pins were not observed or removed using endoscopy involved spontaneous clearance.

Rupture of the carotid artery [12], hemopericardium and cardiac tamponade [13], duodenocolic fistulas [14], and incarcerated umbilical hernia [15] have also been reported as serious complications. For this reason, endoscopic removal of an ingested safety pin should be immediately arranged following an NPO status. In the current case series, safety pins in the esophagus and stomach were removed easily, while in one case, wherein the safety pin was lodged in the second part of the duodenum, it could not be removed easily. Thus, the best option is to remove the safety pin using endoscopy while it is still in the esophagus and stomach.

An algorithmic proposal for the technique of endoscopic removal for ingested safety pins is presented in Fig. 2. This algorithm presents some suggestions on how to remove safety pins with different localizations.

In conclusion, safety pins are easily removed endoscopically. For this reason, endoscopic procedures should be performed as soon as possible in children who have ingested safety pins. To the best of our knowledge, an algorithmic proposal of endoscopic removal for ingested safety pins has not been presented in the literature. A limitation of the study is that this was a single-center study. Therefore, there is a need for multicenter studies to evaluate these presented proposals.