Visual abstract

A recently published case report described the laparoscopic removal of a metallic foreign fragment from the head of the pancreas which was believed to be part of a broken acupuncture needle left behind from a prior treatment [1]. This startling scenario highlights a rare complication of acupuncture and raises broader questions about: (1) foreign body migration to retroperitoneal organs; (2) the clinical plausibility of such events, and (3) the best practice in reporting device- or procedure-related injuries in case reports. In this editorial, historical cases of foreign bodies migrating to the pancreas are reviewed, the mechanisms and risks are discussed, the standards for assessing causality are examined, and clinical and ethical guidelines for reporting such cases are considered.

Historical Cases of Foreign Body Migration to the Pancreas

Well-documented cases of foreign objects being found in the pancreas or similar retroperitoneal sites are exceedingly rare, but a number of case reports and consequently reviews, illustrate that it can happen under specific circumstances. The most common scenarios involve sharp ingested objects that perforate the gastrointestinal tract and move into adjacent organs. Notably, fish bones, and sewing needles are the typical culprits amongst the many intrapancreatic foreign bodies which have been reported. In a recent systematic review of foreign objects found in the pleura and pancreas, there were 41 non-glass objects reported, of which 46% were fish bones and 34% were sewing needles [2]. Accidental ingestion with subsequent transgastric or transduodenal perforation of the pancreas was common [2]. These penetrating objects often go unrecognized at the time of ingestion and patients may not recall swallowing anything unusual. It may become apparent when they are asked during presentation with abdominal symptoms, or the objects may be discovered incidentally.

A variety of intra-abdominal complications may arise from fish bones which have caused perforation, e.g., reported cases of fish bones traveling from the duodenum into the pancreatic head and masquerading as other conditions [3]. One study reported that a patient was initially misdiagnosed with chronic pancreatitis [3]. Similarly, ingested bones have been found embedded in the liver, spleen, and bile duct where they can cause abscesses, or mimic tumors or gallstones on imaging. In a systematic review of foreign bodies in the pleura and pancreas some studies reported that needles had been found in the pancreas, remained clinically silent, and so were managed conservatively [2]. However, cases of acupuncture needles moving from the skin into the pancreas were previously virtually unheard of. While acupuncture-related organ injuries have been described (e.g. needles causing pneumothorax or cardiac tamponade), Kim et al [1] published the first report of a broken acupuncture needle found lodged in the pancreatic head. Indeed, the authors of the case noted that no previous study had identified this phenomenon before. This makes the case unique in medical literature, even against the backdrop of other foreign body migration phenomena.

Causality Assessment in Case Reports of Procedure-Related Injuries

Attributing causality from a single-case report such as claiming a needle fragment in the pancreas was attributable to an acupuncture session, is inherently challenging. The authors built a strong circumstantial argument by excluding other possibilities (normal endoscopy of the duodenum made an ingested fish bone less likely, and the imaging of the fragment was characteristic of metal) and by the patient’s disclosure of a recent acupuncture treatment session [1]. The removed fragment was compared with an intact acupuncture needle for identification purposes. Causality between the foreign object and acupuncture treatment was not proven. Temporal association alone does not prove causation. It is crucial to consider alternative explanations, and gather as much evidence as possible. Reviews of similar case reports of acupuncture-related adverse events found that authors often do not rigorously assess causality. A recent systematic review of acupuncture injury cases in Korea reported that only about 11% of studies could be rated “certain” in causality, while 43% were essentially impossible to assess due to incomplete information [4]. Frequently, key details are missing, e.g., documentation of the needling site relative to the injured organ, and consideration of other risk factors that might have caused the injury. Formal causality assessment frameworks exist [the World Health Organization-Uppsala Monitoring Centre (WHO-UMC) criteria, or the Naranjo algorithm in pharmacovigilance] to grade the likelihood of an adverse event being caused by a particular intervention. However, these tools are mostly used for drug reactions and are not routinely applied to acupuncture or device-related cases. Nonetheless, the principles are applicable: a “certain” causality rating would require clear evidence linking the procedure to the outcome (such as direct observation or undeniable forensic evidence), whereas “possible” or “probable” causality might be decided if the timing fits and other causes are reasonably excluded.

In case reports, authors should avoid overstatements. Case reports serve a vital role in alerting the medical community to unexpected presentations and management challenges [5,6]. Yet their value depends on rigorous methodology, balanced interpretation, and transparent illustration. Misleading statements or unwitting exaggeration of the risks of an intervention may misinform readers. In the case of a metal fragment lodged in the pancreas, without metallurgical analysis or other definitive means to prove its origin, the evidence strongly indicates the acupuncture needle was the source. However, wording such as “consistent with an acupuncture needle fragment” would be more appropriate rather than an absolute declaration. Due to the nature of a case report, this distinction is fundamental in upholding scientific rigor, and avoids unscientific assumptions about a therapeutic modality until there is enough evidence.

Causation Versus Coincidence

The authors reported that the foreign body originated from an acupuncture treatment performed 3 months earlier [1]. However, temporal proximity between the events alone does not establish causality. No direct evidence such as practitioner documentation of a missing part of the needle upon removal and immediate patient discomfort post-procedure was reported, nor was metallurgical matching performed to link the fragment found in the pancreas to the needles used by the practitioner. Alternative explanations, including examples of inadvertent ingestion of a sharp object that moved through the ampulla of Vater [7–9], were not explored. If a systematic differential diagnosis is absent the conclusions from the study risk confirmation bias.

Biomechanical Plausibility

For an intact standard acupuncture needle inserted posteriorly could have traversed the skin, paraspinal musculature, retroperitoneum, and major vascular structures without acute symptoms, and then lodge in the pancreatic head. A credible mechanism of acupuncture needle fracture would be where the sharp tip disappears while the blunt end remains intact in situ maybe, this should have been discussed. The fragment length and expected tissue disruption along such a trajectory were also not discussed.

Radiological and Intra-operative Evidence

There is limited imaging evidence to suggest that there is a correlation between the fragment that had penetrated the retroperitoneal organs and delayed inflammatory signs, and the expected microscopic hemorrhage. None of these expected signs are commented upon. The authors juxtaposed a pristine acupuncture needle, used as a visual aid, with the extracted fragment. This presentation inadvertently invites readers to equate the objects, reinforcing an unproven link.

It is imperative that case reports maintain high scientific standards to avoid misrepresentation and ensure the reliability of medical literature. The following are the brief recommendations for stronger reporting (Table 1): (1) compre-hensive differential diagnosis (outline all plausible sources and migration pathways for the foreign body, supported by imaging and literature); (2) mechanistic justification (provide anatomical measurements and biomechanical reasoning for any proposed trans-paraspinal route); (3) transparent visual documentation (display the retrieved object in multiple orientations, separate from illustrative comparators, with scale bars and material analysis if available; and (4) a balanced interpretation (phrase conclusions conditionally, emphasizing hypothesis over certainty when direct proof is lacking).

Conclusion

Unusual discoveries such as metallic fragments in the pancreas unquestionably warrant publication, but scrupulous attention to evidentiary standards is necessary. By critically appraising alternative etiologies and presenting unequivocal data, authors can turn intriguing observations into robust contributions that advance knowledge rather than propagate speculation. By following the simple recommendations suggested in this editorial, we hope to promote better reporting in similar case studies of device- or procedure-related injuries that are potentially related to adverse events.

Article information

Author Contributions

Writing – original draft: YSL and THK. Writing – review and editing: YSL and THK.

Conflicts of Interest

The authors have no conflicts of interest to declare.

Author Use of AI Tools Statement

No AI tools were used.

Funding

None.

Ethical Statement

This study does not include any data requiring individual patient information or informed consent.

References

• [1] Kim KH, Jo S, Song S. Laparoscopic removal of a broken acupuncture needle in pancreatic head: a case report. J Surg Case Rep 2024;2024(11):rjae714. ArticlePubMedPMCPDF
• [2] Ehrsam JP, Meier Adamenko O, Schlumpf RB, Schöb OM. Foreign glass bodies in pleura and pancreas: systematic review for entry hypotheses and treatment options in an unresolved case. Surg Laparosc Endosc Percutan Tech 2024;34(2):206−21.ArticlePubMedPMC
• [3] Li D, Zeng W, Chen J. Fish bone migration: complications, diagnostic challenges, and treatment strategies. World J Emerg Surg 2025;20(1):35. ArticlePubMedPMCPDF
• [4] Kim SA, Lee JS, Kim TH, Lee S, Lee JD, Kang JW. The reporting quality of acupuncture-related traumatic adverse events: a systematic review of case studies in Korea. BMC Complement Med Ther 2024;24(1):120. ArticlePubMedPMCPDF
• [5] Kim T-H, Kang JW. Appropriate reporting of acupuncture-related adverse events should be promoted in case reports. Perspect Integr Med 2025;4(1):65−6.ArticlePDF
• [6] Graca S, Allen SJ, Lansdown H, Schnyer RN, Lumiere K. Empowering acupuncture students through an education in research: using case reports to enhance learning and clinical practice. Perspect Integr Med 2025;4(1):1−5.ArticlePDF
• [7] Islam SR, Islam EA, Hodges D, Nugent K, Parupudi S. Endoscopic removal of multiple duodenum foreign bodies: an unusual occurrence. World J Gastrointest Endosc 2010;2(5):186−9.ArticlePubMedPMC
• [8] Yi L, Cheng Z, Zhou Y, Wang Q, Liu Y, Liu K, et al. Fishbone foreign body ingestion in duodenal papilla: a cause of abdominal pain resembling gastric ulcer. BMC Gastroenterol 2020;20(1):323. ArticlePubMedPMCPDF
• [9] Soga M, Tanaka T, Ueda T, Kirihataya Y, Yamaguchi Y, Okura Y, et al. Accidental duodenal foreign body of toothbrush removed laparoscopically: a case report. Surg Case Rep 2022;8(1):141. ArticlePubMedPMCPDF

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