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 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. 2

 PHASE I RECOGNITION AND STABILISATION  PHASE II ANATOMICAL DEFINITION AND DECISION  PHASE III DEFINITE OPERATION 3

 As soon as enteric fistula is recognised 4 life threatening concerns are : 1) FLUID AND ELECTOLYTE IMBALANCE  2) SEPSIS  3) NUTRITION  4) SKIN CARE 4

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 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 6

 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. 7

 RESECTING AN ECF AND RE-ESTABLISHING CONTINUITY OF GI TRACT IS A COMPLEX OPERATION THAT REQUIRES CAREFUL PLANNING 8

 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 9

 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 10

 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. 11