Laparoscopic Band Removal is Indicated
This patient requires urgent laparoscopic band removal within 12-24 hours due to gastric band erosion with sepsis, as evidenced by hemodynamic instability (hypotension, tachycardia), systemic infection (leukocytosis, port site redness), and gastric erosion on endoscopy. 1
Rationale for Urgent Surgical Intervention
The clinical presentation clearly indicates sepsis from gastric band erosion with hemodynamic compromise:
Hypotension in this context represents hemodynamic instability that precludes conservative or endoscopic management alone. 1 While endoscopy has an 88-94% success rate for stable patients with band obstruction 2, this patient's hypotension and septic picture moves them beyond the stable category.
Surgery is mandatory within 12-24 hours in patients with acute abdominal symptoms and hemodynamic compromise to decrease morbidity and mortality. 1 The combination of severe pain, vomiting, tachycardia, leukocytosis, hypotension, and confirmed gastric erosion meets these criteria.
Laparoscopic band removal is safe and feasible even in infected cases and is preferred over laparotomy when skills are available and the patient is not in extremis requiring damage control. 1 This patient, while unstable, can be resuscitated for laparoscopic approach rather than requiring immediate damage control laparotomy.
Why Not Other Options
Non-operative management (Option D) is contraindicated because hemodynamic instability indicates the patient is not stable for conservative approaches. 1 NPO, IVF, and antibiotics alone are insufficient when sepsis with band erosion is present.
Endoscopic management alone (Option A) is inadequate because while endoscopy successfully diagnosed the erosion, the patient's hemodynamic instability and sepsis require definitive source control through band removal. 1 Endoscopic retrieval techniques exist for stable patients 3, but this patient requires surgical intervention.
Laparotomy (Option C) is reserved for more extreme scenarios: hemodynamic instability unresponsive to resuscitation, diffuse peritonitis with incomplete source control, or failed laparoscopic approach. 1 This patient should first undergo attempted laparoscopic removal with concurrent aggressive resuscitation.
Perioperative Management
Concurrent aggressive resuscitation with IV fluids and antibiotics during surgical preparation is essential. 1 The patient should be optimized as much as possible while preparing for urgent surgery.
Correct electrolyte abnormalities, particularly potassium and thiamine deficiency, given the persistent vomiting. 1
Band removal prevents progression to more serious complications including chronic infection, delayed perforation, and abscess formation (including rare complications like splenic abscess). 4
Clinical Pitfalls to Avoid
Do not delay surgery for prolonged conservative management when sepsis with hemodynamic compromise is present—this increases morbidity and mortality. 1
Do not proceed directly to laparotomy without considering laparoscopic approach first, as laparoscopic removal is safe even in infected cases and reduces postoperative complications. 1, 5
Recognize that band erosion can present with nonspecific symptoms, but this patient has clear signs of sepsis requiring urgent intervention. 4
Answer: B. Laparoscopic band removal 1