Management of Gastric Band Complication with Sepsis
This patient requires urgent laparoscopic band removal (Option B) given the constellation of hemodynamic instability (hypotension, tachycardia), systemic infection (leukocytosis, fever implied by septic presentation), gastric erosion, and port site infection. 1, 2
Clinical Reasoning
This presentation represents band erosion with systemic sepsis, not simple obstruction. The key distinguishing features are:
- Hemodynamic instability (hypotension) - This patient is NOT stable for conservative or endoscopic approaches 1
- Systemic inflammatory response (leukocytosis, tachycardia) with port site infection indicates established sepsis from band erosion 2
- Gastric erosion on endoscopy - Confirms band migration into gastric lumen, a surgical emergency requiring removal 3, 4
Why Laparoscopic Band Removal is Indicated
Band erosion with sepsis mandates immediate band removal to achieve source control. 2, 4 The World Journal of Emergency Surgery guidelines emphasize that surgery is mandatory within 12-24 hours in patients with acute abdominal symptoms and hemodynamic compromise to decrease morbidity and mortality. 1
Key Evidence Supporting Urgent Surgical Removal:
- Band erosion leads to chronic infection, abscess formation, and septic shock if not promptly removed 2
- Laparoscopic removal is safe and feasible even in infected cases, with successful outcomes when performed urgently 4, 5
- Hypotension in this context represents septic shock requiring source control, not just resuscitation 1, 2
Why Other Options Are Inappropriate
Option D (Non-operative Management) is CONTRAINDICATED:
- Hemodynamic instability (hypotension) precludes conservative management 1
- Band erosion with systemic infection requires removal for source control - antibiotics alone will fail 2, 4
- The World Journal of Emergency Surgery explicitly states that surgery should not be delayed in patients with hemodynamic compromise 1
Option A (Endoscopic Management):
- While endoscopic band removal can be effective for stable, asymptomatic patients with erosion 5, this patient's hypotension and sepsis make her unsuitable
- Endoscopic removal is reserved for hemodynamically stable patients without peritonitis 6, 5
Option C (Laparotomy):
- Laparoscopy is preferred over laparotomy when skills are available and the patient is not in extremis requiring damage control 1
- Laparotomy is reserved for: (1) hemodynamic instability unresponsive to resuscitation requiring damage control, (2) diffuse peritonitis with incomplete source control, or (3) failed laparoscopic approach 1
- This patient, while hypotensive, can likely be stabilized for laparoscopic approach with concurrent resuscitation
Surgical Approach
Laparoscopic band removal with gastric wall repair should be performed urgently: 4, 5
- Remove the eroded band completely 3, 4
- Repair the gastric wall defect with sutures 4
- Drain any associated abscess if present 2
- Do NOT replace the band in the setting of active infection 2, 4
Perioperative Management:
- Concurrent aggressive resuscitation with IV fluids and antibiotics during surgical preparation 1
- Broad-spectrum IV antibiotics for polymicrobial infection 2
- Correct electrolyte abnormalities, particularly potassium and thiamine deficiency given persistent vomiting 1
Critical Pitfall to Avoid
The most dangerous error would be attempting non-operative management (Option D) in a hemodynamically unstable patient with an infected foreign body. 1, 2 Band erosion with sepsis requires source control through band removal - antibiotics and supportive care alone will result in progressive septic shock, multi-organ failure, and death. 2
The threshold to operate should be lower, not higher, in bariatric patients presenting with acute symptoms and tachycardia, even if imaging is inconclusive. 1 This patient has already progressed to hypotension, making surgical intervention mandatory.