Anastomotic leaks and the relationship with anastomotic strictures after esophageal atresia surgery; effects of patient characteristics.

BACKGROUND: This study aimed to evaluate the link between anastomotic leaks (AL) and anastomotic strictures (AS) after esophageal atresia surgery and the influence of patient demographics. MATERIALS AND METHODS: The clinical data of neonates who underwent surgical repair for esophageal atresia were retrospectively reviewed. The results of AL treatment and the relationship with AS, also the effects of patient characteristics were examined with logistic regression analysis. RESULTS: Primary repair was performed on 122 of 125 patients who underwent surgery for esophageal atresia. AL occurred in 25 patients and 21 were treated non-operatively. While 4 patients were re-operated, AL recurred in 3 and led to the death of one. There was no correlation between the development of AL and sex or the presence of additional anomalies. The gestational age and birth weight of patients with AL were significantly higher than those of patients without. AS developed in 45 patients. The mean gestational age was significantly higher in patients who developed AS (p < .001). While the development of AS was significantly higher in patients with AL (p = .001), the number of dilatation sessions needed was also significantly higher in these patients (p = .026). Complications related to anastomosis were less common in patients whose gestational age was ≤33 weeks. CONCLUSION: Non-operative treatment remains effective for AL after esophageal atresia surgery. AL increases the risk of developing AS and significantly increases the number of dilatation sessions needed. Anastomotic complications are less common in patients with lower gestational age.NOVEL ASPECTSGestational age and birth weight were found to be significantly higher in patients with anastomotic leaks than in those without and fewer anastomotic complications were encountered in patients whose gestational age was ≤ 33 weeks.Anastomotic stricture development was significantly higher in patients with anastomotic leaks and the number of dilatation sessions needed for treatment was also significantly higher in these patients.

Single port laparoscopic and open surgical accesses of chronic peritoneal dialysis in children: A single center experience over 12 years.

INTRODUCTION: The aim of this study was to evaluate patients with end stage renal failure (ESRD) who underwent chronic peritoneal dialysis (CPD). The clinical outcomes of laparoscopic and open placements of catheters were compared. MATERIALS AND METHODS: We reviewed 49 (18 male and 31 female) children with CPD according to age, sex, cause of ESRD, catheter insertion method, kt/V rate, complications, presence of peritonitis, catheter survival rate between January 2002 and February 2014. RESULTS: Thirty-three patients were with open placement and 16 patients were with laparoscopic placement. The rate of the peritonitis is significantly less in patients with laparoscopic access than open access (n = 4 vs n = 25) (P <0.01). Patients with peritonitis were younger than those who had no attack of peritonitis (10.95 ± 0.8 years vs 13.4 ± 0.85 years). According to the development of complications, significant difference has not been found between the open (n = 9) and laparoscopic (n = 3) approaches except the peritonitis. Catheter survival rate for the first year was 95%, and for five years was 87.5%. There was no difference between open and laparoscopic group according to catheter survival rate. The mean kt/V which indicates the effectiveness of peritoneal dialysis was mean 2.26 ± 0.08. No difference was found between laparoscopic and open methods according to kt/V. CONCLUSION: Laparoscopic placement of CPD results in lower peritonitis rate. Catheter survival rate was excellent in both groups. Single port laparoscopic access for CPD catheter insertion is an effective and safe method.

Laparoscopic repair in children with traumatic bladder perforation.

Here, we report two patients with a traumatic intraperitoneal bladder dome rupture repaired by laparoscopic intracorporeal sutures. The first patient was a 3-year old boy was admitted with a history of road accident. He had a traumatic lesion on his lower abdomen and a pelvic fracture. Computed tomography (CT) scan revealed free intraabdominal fluid. The urethragram showed spreading contrast material into the abdominal cavity. Laparoscopic exploration revealed a 3-cm-length perforation at the top of the bladder. The injury was repaired in a two fold fashion. Post-operative follow-up was uneventful. The second case was a 3-year-old boy fell from the second floor of his house on the ground. He had traumatic lesion on his lower abdomen and a pelvic fracture. Due to bloody urine drainage, a cystography was performed and an extravasation from the dome of the bladder into the peritoneum was detected. On laparoscopy, a 3-cm long vertical perforation at the dome of the bladder was found. The perforation was repaired in two layers with intracorporeal suture technique. The post-operative course was uneventful. Laparoscopic repair of traumatic perforation of the bladder dome is a safe, effective and minimally invasive method. The cosmetic outcome is superior.

Temporary peritoneal dialysis in newborns and children: a single-center experience over five years.

AIM: To evaluate the indications, complications, and outcomes of temporary peritoneal dialysis (TPD) in children with acute renal failure (ARF). PATIENTS AND METHODS: All patients undergoing TPD between February 2006 and January 2011 in a children's hospital were included in the study. Patient characteristics, indications, complications, and duration of TPD (DPD), requirement of re-operation, length of stay, presence of sepsis, and outcome were recorded. RESULTS: There were 21 newborns (14 prematures), 9 infants, and 9 children. The main nephrotoxic agents were gentamicin (n = 7), netilmisin (n = 5), vancomycin (n = 3), and ibuprophen (n = 3). Patients with multiorgan failure (n = 9) had significantly higher blood urea nitrogen (BUN) and creatinine levels than those without multiorgan failure (n = 30) [BUN: 94 ± 27.3 vs. 34.3 ± 4.9) and creatinine: 4.1 ± 0.8 vs. 1.9 ± 0.2)]. The mean DPD was longer in mature patients than in prematures (newborn: 3.7; children: 7.1). Nine complications were observed (23%) (leakage in three and poor drainage in six patients). Twenty-five patients (64.1%) responded to TPD treatment and were discharged, and 14 patients (10 newborns and 7 of them were premature) died (35.9%). Mortality rate was higher in prematures (n = 7) and patients with a history of nephrotoxic agent (n = 10). CONCLUSION: TPD is effective especially in neonates with ARF and it is a reliable alternative to the hemodialysis or other continuous renal replacement therapies but it is not free of complications. It has limited effects, particularly in patients with multiorgan failure.

Pyloric atresia associated with epidermolysis bullosa: report of two cases and review of the literature.

The coexistence of pyloric atresia (PA) and epidermolysis bullosa (EB) is a rare but well-known surgical emergency in neonates. PA/EB is described by the association of atresia of the pylorus and bullous lesions on the skin. Ninety one cases have been reported in the literature to date. We present two new cases and evaluate the association of PA/ EB, its etiopathogenesis and the clinical properties. Case 1: A three-day-old female presented with nonbilious vomiting and bullous lesions 2-3 cm in diameter on the extremities. Abdominal X-ray showed a single air-fluid level in the left upper quadrant. At laparotomy, we found PA and performed a pyloro-pylorostomy. The patient died due to sepsis complication of EB two months after surgery. Case 2: A two-day-old male presented with severe dermal bullous lesions on the trunk, neck and extremities. His stomach was dilated and there was no gas distally. We found PA and performed gastroduodenostomy. Initially, he tolerated the feeding well, but he died due to severe sepsis on the postoperative 23rd day. Almost all neonates born with the PA/EB result in a fatal outcome in the first few years. The complications related to EB are usually the cause of death. Even after successful repair of PA, skin lesions lead to death due to infection.

A rare cause of chronic rectal bleeding in children; solitary rectal ulcer: case report.

Solitary rectal ulcer causing lower gastrointestinal bleeding is extremely rare in children. Rare presentation, non-specific symptoms, insufficient experience, and characteristics mimicking other rectal diseases may cause misdiagnosis or delay of diagnosis in some pediatric patients. Here, we report a 10-year-old boy with solitary rectal ulcer diagnosed two years after onset of the symptoms who responded well to the conservative therapy, including high-fiber diet, laxatives, defecation training, and sucralfate enema.

Minimally invasive management of children with caustic ingestion: less pain for patients.

PURPOSE: Management of caustic ingestion in children is still controversial. In this study, we evaluate a minimally invasive management consisting of flexible endoscopy, balloon dilatation and intralesional steroid injection in children, with a history of caustic ingestion. METHODS: Between April 2002 and January 2009, 350 (206 males and 144 females) children with a history of caustic ingestion were admitted. Enteral feeding was discontinued for 24 h. Parenteral feeding was started in patients with inadequate oral intake. No patient underwent an early esophagoscopy or gastrostomy. A contrast study of upper gastrointestinal tract was performed in all patients with persistent dysphagia within 3 weeks after injury. In case of an esophageal stricture, a dilatation program was initiated. For this purpose, a flexible esophagoscopy was performed. A guidewire was placed through the narrowed segment into the stomach and a balloon dilatator was inserted with the assistance of the guidewire. Balloon dilatations were performed every 1-3 weeks. In intractable strictures, triamcinolone acetonide (TAC) was injected into the narrowed segment via flexible endoscopy. RESULTS: Seventeen patients (8 males, 9 females, median 3 years old) required esophageal dilatation. All of the patients completed dilatation program with complete relief of symptoms. None of the patients required any stent application nor esophageal replacement or gastrostomy. Ten patients underwent intralesional TAC injection. No patient had an esophageal perforation or any other complication related to dilatation. In all patients, the symptoms have been alleviated completely and no further dilatation was necessary after a median of five dilatation sessions (1-19 dilatations). CONCLUSION: Minimally invasive management of caustic ingestion consisting of flexible endoscopy, guidewire-assisted esophageal balloon dilatation and intralesional TAC injection without any gastrostomy or esophageal stent/placement is effective and leads to relief of dysphagia in almost all patients. This method of dilatation is also safe and iatrogenic esophageal perforation is very unlikely.

Coin ingestion in children: which size is more risky?

AIM: Because of economic inflation, different-sized coins are in circulation in our country. The coin ingestion and retention in the esophagus are common problems in childhood. We evaluated the patients with coins retained in the esophagus and the impact of the size of the coins on lodgment. PATIENTS AND METHODS: Sixty-two children with a history of coin ingestion and a chest X-ray with retained coin in the esophagus were evaluated. Patients' age, sex, type of the ingested coin, and localization of coin were recorded. The size of all coins was measured. All coins were removed either directly with a Magill forceps or with the aid of an esophagoscope from the esophagus under general anaesthesia. RESULTS: There were 27 male and 35 female patients with coin lodgment (median age, 4 years; range, 1-13). Forty-five patients (73%) ingested a coin with a diameter between 23.45 and 26.00 mm. In the remaining 17 patients (27%), the coins had a diameter between 17.00 and 20.90 mm or between 26.85 and 28.00 mm. Fifty coins were at the upper esophagus, eight coins were in the middle esophagus, and 4 patients had a coin in the distal esophagus. There was a positive correlation between the diameter of coin and age of the patient (r = 0.415 and P < 0.001). CONCLUSIONS: Coin ingestion is rather common among childhood and its treatment may require an endoscopic approach. Most retained coins had a diameter between 23.45 and 26.00 mm. We think we could redesign our coins so that they would either be too big to ingest or so small they would always pass spontaneously.

The right-sided aortic arch in children with esophageal atresia and tracheo-esophageal fistula: a repair through the right thoracotomy.

PURPOSE: The management of the esophageal atresia and tracheo-esophageal fistula (EA/TEF) with right-sided aortic arch (RAA) is controversial. The preoperative diagnostic techniques may fail to show RAA associated with EA/TEF. Surgeon may need to make a decision to change the side of thoracotomy. The aim of the current study was to evaluate the possibility of preoperative diagnosis of RAA and the primary anastomosis through right chest. METHODS: A retrospective review was performed in EA/TEF patients between February 2001 and 2008. A total of 79 patients (35 female, 44 male) with EA/TEF were reviewed. Eleven (13%) patients (5 female, 6 male) had an RAA. Echocardiography was performed in 10 of 11 patients with RAA. The chest was accessed through the right side in all patients. RESULTS: The incidence of RAA was found to be higher in our study than previous studies (13%). Right thoracotomy was performed successfully in all patients. Three patients died due to multiple congenital anomalies and 1 patient due to bleeding postoperatively. Five of 10 had normal echocardiography findings. Only one patient with RAA has been successfully diagnosed by preoperative echocardiographic examination. Seven patients had no complication after operation. Their follow-up was uneventful. CONCLUSION: Preoperative recognition of RAA with echocardiography is unlikely in patients with EA/TEF but the presence of RAA does not decrease the success rate of EA/TEF repair through the right thoracotomy.

Plummer-Vinson syndrome in a 15-year-old boy.

Plummer-Vinson syndrome presents as a classical triad of dysphagia, iron deficiency anemia and upper esophageal web(s). The syndrome usually occurs in adults, and is rare in childhood. We report a case of this syndrome occurring in a 15-year-old boy. He presented with dysphagia and anemia. Radiological examination showed the presence of webs at the cervical esophagus. The boy was treated with endoscopic balloon dilation and iron supplementation and remains in good general condition six months after the treatment.

Removal of open safety pins in infants by flexible endoscopy is effective and safe.

PURPOSE: In our country, safety pin ingestion by infants is commonplace. When swallowed, open safety pins are mostly found within the esophagus or stomach, and they cannot be easily removed by rigid esophagogastroscopy. Our aim was to evaluate the removal of safety pins using flexible endoscopy in infants. MATERIALS AND METHODS: We evaluated the cases of 7 infants who had ingested open safety pins between 2001 and 2004. In all the patients, the primary diagnostic tool was a direct x-ray of the neck, chest, and abdomen. In all cases, the safety pins were removed by flexible esophagogastroduo-denoscopy. Clinical records for the cases were reviewed. RESULTS: Four of the open safety pins were lodged in the esophagus, two in the stomach, and one in the duodenum. One infant had a safety pin lodged in the esophagus with the pin's open end pointed caudally; the pin was held with the endoscopic forceps by its tail end and removed. Three safety pins in the esophagus had their open ends pointing cephalad; these were held by their tail ends using the endoscopic forceps and pushed into the stomach. Then they were rotated in the stomach and removed tail end first. The safety pins located in the stomach or duodenum were also removed similarly. All safety pins were successfully removed, and there were no operative complications. CONCLUSION: Open surgery or other invasive removal methods are not necessary in infants with open safety pin ingestions. In our opinion, the best way to extract an open safety pin from the esophagus, stomach, or duodenum is by using a flexible endoscopic device.

Balloon-assisted single-port thoracoscopic debridement in children with thoracic empyema.

PURPOSE: In this study, we evaluated the results of a balloon-aided single-port thoracoscopic debridement of late-stage thoracic empyema in children. PATIENTS AND METHODS: We retrospectively reviewed age, gender, duration of prehospital illness, physical findings, surgical interventions, and the morbidity in 12 children with late-stage parapneumonic empyema. The diagnosis of pleural effusion was confirmed by a thoracocentesis before thoracoscopy. A balloon connected to a 12 F feeding tube was inserted into the thoracic cavity and inflated with air before the enterance of the thoracoscope. By this maneuver, a cavity was formed just under the enterance point. Thereafter, a routine debridement and chest irrigation was performed by thoracoscopy. Only one port was inserted in all but 1 patient, and the telescope was used as a dissecting tool. A thorax tube was inserted through the port site at the end of the procedure and left for the drainage. RESULTS: The main symptoms of the patients were dyspnea, cough, and fever. The empyema was located on the right hemithorax in 5 patients and on the left side in 7 patients. A second port was necessary to enhance the dissection in 1 case. The chest tube was removed within 3-30 days (median, 11 days) after the surgical approach. No complication directly related to the procedure was seen. The only problems postoperatively were a self-limited and spontaneously resolved bronchopleural fistula in 4 patients, and we had to perform an additional thoracoscopy to resolve the remaining intrapleural adhesions in 1 child. CONCLUSIONS: Thoracoscopic debridement in patients with late-stage thoracic empyema may be very beneficial, and this treatment method may provide any further thoracotomy. A balloon inflated in the thoracic cavity may achieve a wider field of vision for thorascopic surgery, and single-port thoracoscopy is sufficient and safe for the dissection.

Ultrasound guided reduction of intussusception with saline and comparison with operative treatment.

BACKGROUND: Reduction of intussusception under ultrasound guidance by saline has become popular in recent years. However, methods, duration of the procedure and causes of failure are not defined. In this study, we reviewed the patients who underwent ultrasound (US) guided saline reduction and compared them with those who were previously managed by operative intervention. METHODS: Patients with severe peritonitis or perforation, those over 3 years or younger than 1 month were excluded. Saline was applied by anus. Entry of saline into the ileum was the main indicator for successful reduction. Dramatic improvement in the clinical findings was considered as an additional sign of successful reduction. No limit was imposed on duration of the procedure. RESULTS: Hydrostatic reduction was successful in 41 out of 51 patients with intussusception. In three patients with partial resolution, hydrostatic reduction was attempted later and total reduction was achieved. No perforation or other complications were seen. In ten cases with reduction failure, one had an ileal lymphoma and another one had a duplication cyst as lead points. CONCLUSION: US guided hydrostatic reduction for childhood ileocolic intussusception is safe and, painless, has a high success rate and avoids radiation exposure risk. Presence of ultrasonographic and clinical changes is the best indicator of a successful reduction. In some cases, a second attempt may be necessary for reduction.

Different techniques for biliary diversion in progressive familial intrahepatic cholestasis.

BACKGROUND: Progressive familial intrahepatic cholestasis (PFIC) is a cholestatic liver disease of childhood. Pruritus resulting from increased bile salts in serum might not respond to medical treatment, and internal or external biliary drainage methods have been described. In this study, we aimed to evaluate different internal drainage techniques in patients with PFIC. PATIENTS AND METHODS: Between 2009 and 2014, seven children (4 male, 3 female, 3months-5years old), (median 2years of age) with PFIC were evaluated. The patients were reviewed according to age, gender, complaints, surgical technique, laboratory findings and outcome. In each two patients, cholecystoileocolonic anastomosis, cholecystojejunocolonic anastomosis and cholecystocolostomy were performed. Cholecysto-appendico-colonic anastomosis was the technique used in one patient. RESULTS: Jaundice and excessive pruritus were the main complaints. One of the patients with cholecystoileocolonic anastomosis died of comorbid pathologies (cirrhosis, adhesive obstruction and severe sepsis). Temporary rectal bleeding was observed in all the patients postoperatively. Regardless of the surgical technique, pruritus was dramatically decreased in all the patients in the postoperative period. CONCLUSION: Regardless of the technique, internal biliary diversion methods are beneficial for the relief of pruritus in PFIC patients. Selection of the surgical method might vary depending on the surgeon's preference and the surgical anatomy of the gastrointestinal system of the patient.

Bladder exstrophy: effects on bone age, bone mineral density, growth, and metabolism.

Bladder exstrophy patients with or without augmentation have not been investigated according to metabolic bone problems, bone ages and growth, and development in details yet. We studied alterations in growth, bone ages, biochemistry of bone, bone mineral densities (BMD) of the forearm, neck of femur and lumbar vertebrae, blood gases, glomerular filtration rates (GFR), and electrolytes of 15 bladder exstrophy patients with augmentation and in those who had no augmentation. In six patients, a sigmoid colon was used for bladder augmentation and one patient underwent a ureterosigmoidostomy. Growth charts of all children were analyzed for determination of the percentiles. The parameters were compared with normal children and a comparison between augmented and nonaugmented patients were made. Growth retardation and decreased bone age were detected in all of the children. Ten patients with bladder exstrophy were below the 10th percentile for height. The mean age/bone age ratio of the patients was 1.59. The mean lumbar and femoral Z scores of the patients were -1.00 and -0.49, respectively. Mean BMD for distal radius was 0.239 g/cm2. Seven patients had a marked BMD decrease, their femoral and/or lumbar Z scores were below -1. Four cases had a pH lower than 7.35. In five patients, a HCO3 level less than 19 mmol/l was detected, four of them had an augmentation. Chloride measurements were slightly increased in six patients and alkaline phosphatase levels in five cases. Reduced GFR values were detected in two patients. There were no significant difference in laboratory values, in percentile height, and weights, in BMDs of femur, vertebra, forearm nor were any differences noted in age/bone age ratios in patients with augmentation when compared with those who had no augmentation. We found varying alteration in bone mineral density and HCO3 levels in patients with bladder exstrophy. Patients with bladder exstrophy, with or without augmentation, may develop serious growth retardation. As much as 45% of them, regardless of presence of augmentation, have an osteopenia or osteoporosis. We found a considerable difference in percentiles of heights as well as bone ages in bladder exstrophy patients when compared with normal population. We recommend close follow up of children with bladder exstrophy for linear growth, development of osteopenia, and bone ages.

Traumatic diaphragmatic rupture in children.

BACKGROUND: We aimed to emphasize the importance of early diagnosis and treatment of traumatic diaphragmatic (TDR) rupture which is an uncommon but potentially life-threatening problem with a high incidence of associated injuries. METHODS: We presented 8 children with traumatic diaphragmatic ruptures who were admitted to our department within a 13 year period after the incident. Relevant information about clinical and radiological findings herniated organs into the thorax, type of injury and applied surgical intervention and outcome of patients were evaluated so as to draw important clues leading to early diagnosis and treatment of this potentially life threatening condition with associated morbidities. RESULTS: In five patients, TDR occurred after a blunt trauma. Five patients underwent laparotomy while 3 of them were managed with thoracotomy. The surgical interventions were performed successfully and only one patient failed to survive. One patient died of associated severe head injury. CONCLUSIONS: The TDR in children could be promptly identified and easily diagnosed, only if this pathology is highly suspected. Since, TDR must be ruled out in all severe cases of trauma, information related to the experiences of various centers must be considered as important clues which might lead to earlier diagnosis and prompt treatment.

Pulmonary hypoplasia presenting with recurrent wheezing in an infant.

Pulmonary hypoplasia is characterized by decrease in the number and size of pulmonary airways, alveoli and vessels. In autopsy, pulmonary hypoplasia is a major cause of death in neonates and infants. The disease is usually diagnosed in childhood period. Although it mimics lung parenchymal disease and other vascular abnormalities radiologically, it is easily recognized with computed tomography angiography and magnetic resonance angiography examinations. In 50% of patients, concomitant cardiovascular, neuromuscular, gastrointestinal tract, and urogenital anomalies are also available. There are two types of pulmonary hypoplasia: primary and secondary. Primary unilateral pulmonary hypoplasia may be asymptomatic and the tendency for bronchopulmonary infections is often increased in children. In this case report, a 22-month-old male patient characterized by recurrent infections and recurrent wheezes in infantile period, whose episodes of wheezing regressed after the pulmonectomy, was presented.

The role of nitric oxide in an experimental necrotising enterocolitis model.

BACKGROUND: Necrotising enterocolitis (NEC) causes a significant life-threatening gastrointestinal system (GIS) disease with severe mortality and morbidity, particularly in premature infants. Nitric oxide (NO) has many functions in the GIS. Therefore, in the present study, we evaluated the effects of NO in experimentally induced NEC of newborn 1-day-old rats following hypoxia/reoxygenation (HR). MATERIALS AND METHODS: Thirty Wistar albino rats (weight, 5-8 g) were randomly divided into three groups: group 1 (HR), group 2 (HR + nitroglycerine), and group 3 (control). HR was achieved by placing the rat in carbon dioxide (CO2) for five minutes at 22°C, which was followed by five minutes of 100% oxygen. After HR, nitroglycerine was administered for three days at 50 µg/Kg/day. On day 4, the rats were decapitated and the intestines between the duodenum and sigmoid colon were resected and histopathologically examined. RESULTS: The histopathological findings of groups 1 and 2 were characteristic of NEC. Intestinal injury in group 1 was significantly more prevalent than that in group 2 (χ2 = 21.55, P = 0.000). The intestinal injury score in group 3 was significantly lower than that in the other groups (P < 0.05). CONCLUSIONS: NO treatment was effective for treating experimentally induced NEC.

The comparison of the intestinal adaptation effects of subcutaneous and oral insulin in a rats with short bowel syndrome.

AIM: Insulin has been reported to have positive effects on intestinal adaptation after short bowel syndrome when applicated oral or subcutaneously. The purpose of this study is to compare the intestinal adaptation effects of subcutaneous and oral routes of insulin in rats with short bowel syndrome. MATERIALS AND METHODS: The short bowel syndrome (SBS) was performed through 70-75% of small intestinal resection and an end-to-end anastomosis. The control group rats underwent SBS only. In the second group, oral insulin (1 U/ml) was administrated twice-daily. In the last group, the insulin was administrated subcutaneously (1 U/kg) as in the control group. All rats were killed on day 15. Outcome parameters were weight of small intestine, the crypt length, villous depth, the blood levels of vascular endothelial growth factor (VEGF), and granolocyt-monocyst colony-stimulating factor (GMCSF). RESULTS: Intestinal weight was significantly more in oral insulin group and subcutaneous insulin group than in the control group (72.6 ± 4.3, 78.6 ± 4.8 and 59.7 ± 4.8) (P < 0.05). There was no difference between the groups according to villus length, crypt depth, and villous/crypt ratio both in proximal and distal parts of the resected bowel (P > 0.05). VEGF values were not statistically significant between the groups (200.3 ± 41.6, 178.9 ± 30.7 and 184.3 ± 52.2) (P > 0.05). GMCSF was statistically higher in the control group than in other groups (3.34 ± 1.34, 1.56 ± 0.44 and 1.56 ± 0.44) (P < 0.05). CONCLUSION: Insulin has positive effects on intestinal adaptation in short bowel syndrome. Subcutaneous administration is slightly more effective than the oral route.