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2.  Mr.Mohammed AL-Odaini 35 years old yemeni male got admitted under
the care of Dr.Fahad Bamehriz on 23/10/11 with morbid obesity with
height 180 cm ,weight 181kg and bmi 155.2kg.He was medically free
complaining of increased body weight since childhood. Upon admission
rotine bloodworks, chest xray,ECG done.prepared for surgery as per unit
protocol with NPO,IV FLUIS ,PROPHYLACTIC ANTIBIOTICS AND
DVT MEASURES.He underwent laproscopic sleeve gasterectomy on
24/10/2011 and recovered well without any complications.He got
discharged on 27/10/2011 with panteprazole and analgesics.He was
tolerating well with clear fluids on 27/11/2012.He got re-admitted on
29/11/2011 in the emergency department with colicky abdominal pain
and vomitting diagnosed with bowel ischaemia.He underwent bowel
resection and anastomosis and complicated with enterocutaneous
fistula.Then He was NPO for 3months and was with TPN AND IV
FLUIDS AS PART OF HYDRATION.Fistula site attached with stoma bag
to prevent skin irritation due to leak.He underwent resection of
enterocutaneous fistula and adhesolysis on 26/3/12 after which he
recoverd slowly.The fistula was closed and no more leakage from the
site.HE was started on clear flids and he tolerated well without further
leak and pain and got discharged on 7/5/12 in stable condition.
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3.  PHASE I RECOGNITION AND
STABILISATION
 PHASE II ANATOMICAL
DEFINITION AND DECISION
 PHASE III DEFINITE
OPERATION
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4.  As soon as enteric fistula is
recognised 4 life threatening
concerns are : 1) FLUID AND
ELECTOLYTE IMBALANCE
 2) SEPSIS
 3) NUTRITION
 4) SKIN CARE
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6.  FIRST 4 HOURS AGGRESSIVE RESTORATION
AND CORRECTION OF ELECTROLYTE
IMBALANCE INCLUDING HYPOKALEMIA
 LOSSES FROM HIGH OUTPUT FISTULAS
SHOULD BE REPLACED EVERY 4 HOURS
 FISTULA OUTPUT FROM UPPER GI TRACT IS
TYPICALLY REPLACED WITH NORMAL
SALINE AND POTASSIUM
SUPPLEMENTATION
 DUODENAL AND PANCREATIC FISTULAS
REQUIRE HCO3 SUPPLEMENTATION
 SKIN PROTECTION FROM CORROSIVE
EFFECTS OF ENTERIC CONTENT THEREFORE
FREQUENT WOUND DRESSING
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7.  FISTULA OUTPUT CAN BE REDUCED BY
SOMATOSTATIN AND OCTREOTIDE
 NUTITIONAL REQUIREMENTS TO BE MET
BY BASELINE REQ OF 20KCAL/KG/D
CARBOHYDRATE AND 0.8/KG/D OF
PROTEIN
 TPN HAS SHOWN TO IMPROVE
SPONTANEOUS CLOSURE RATES OF
ENTERIC FISTULAS.
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8. RESECTING AN ECF AND
RE-ESTABLISHING
CONTINUITY OF GI
TRACT IS A COMPLEX
OPERATION THAT
REQUIRES CAREFUL
PLANNING
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9.  ALTERED NUTRITIONAL STATUS
RELATED TO HIGHOUTPUT
FISTULAS
 ALTERED SKIN STATUS RELTED TO
CORROSIVE SECRETIONS FROM
FISTULAS
 FLUID AND ELECTOLYTE
IMBALANCE RELATED TO FLUID
LOSSES FROM FISTULAS
 HIGH RISK FOR SEPSIS
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10.  PROVIDE IV FLUIDS AS PER REQUIREMENT
 POTASSIUM LOSSES TO BE REPLACED
WITH IV FLUIDS CONTAINING
POTASSIUM
 FREQUENT CHANGE OF DRESSINGS AS
PER REQUIREMENT
 TPN AS PER REQUIREMENT
 IV ANTIBIOTICS TO PREVENT INFECTION
 SKIN CARE
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11.  THE AIM IS TO DEVELOP ENOUGH IMAGING
INFORMATION TO ASSESS LIKELIHOOD OF SPONTANEOUS
CLOSURE
 CT SCAN DEMONSTRATES ANATOMY OF TACT,FISTULA
AND ITS ORIGIN WITH ASSOCIATED PRESENCE OF INTRA-
ABDOMINAL ABSCESSES;CT SCAN-CONTRAST HELPS IN
MORE DEFINITE STUDY OF FISTULA
 SPONTANEUS CLOSURE OF FISTULAS VARY FROM 37%TO
46.2% AS PER RECENT STUDIES
 RECONSTRUCTIVE OPERATIONS SHOULD BE DELAYED IF
FISTULA OUTPUT IS GRADUALLY DECREASING AND
WOUND SHOWS SIGNS OF HEALING
 THERE ARE CHANCES OF ASSOCIATED OBLITERATIVE
PERITONITIS;IF SO THE INTA-ABDOMINAL
INFLAMMATORY RESPONSE LEADS TO DENSE VASCULAR
ADHESIONS THAT PRECLUDE SURGICAL INTERVENTION.
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