[Flap harvest training on a new ultrarealistic simulation model: In-training operator feedback about a pulsating reperfused and reventilated cadaver Simlife®]. / Prélèvement des lambeaux sur sujet anatomique et nouveau modèle de simulation ultra-réaliste : retour d'expérience d'un opérateur en formation sur corps reperfusé pulsatile et reventilé Simlife®.

INTRODUCTION: The anatomical subject is still a key element to learn complex procedures in plastic surgery. We present here the evaluation of an in-training operator on a SIMLIFE® model, hyper realistic model consisting in human bodies donated to science equipped with pulsating recirculation and reventilation device. MATERIAL AND METHODS: From February 2019 to October 2019, 8 forearm flaps with radial proximal pedicle were harvested by the learner on a SIMLIFE® model. Conditions were as close as possible to the operating room : asepsy, sterile draping, assistant and instrumentation including electrocoagulation. RESULTS: The procedure was decomposed in 13 distinct steps. Mean total surgery time was 90,5±11,62minutes. There was only one case of arterial pedicle lesion resulting in major blood leak. Bleeding was measured by fake blood loss from the SIMLIFE® console. Mean intraoperatoy bleeding was 171±108 milliliters. We review pros and cons of this new technology particulary suited for complex plastic and reconstructive surgery training. CONCLUSION: Using SIMLIFE® technology we have a new mean to train for complex procedures in plastic and reconstructive surgery. This new technology could be applied to numerous other surgical procedures. Broader applications are still limited by cost and cadaver use legislation.

Benzodiazepine long-term administration is associated with impaired attention/working memory in schizophrenia: results from the national multicentre FACE-SZ data set.

OBJECTIVE: The effect of benzodiazepine long-term administration (BLTA) in cognitive functioning of subjects with schizophrenia (SZ) has been partially explored to date. The objective was to assess BLTA-associated cognitive impairment with a comprehensive cognitive battery in a non-selected multicentric/national community-dwelling sample of stabilized SZ subjects. METHOD: 407 community-dwelling stabilized SZ subjects were consecutively included in the FondaMental Academic Centers of Expertise for Schizophrenia Cohort (FACE-SZ). Patients taking daily benzodiazepine were defined as BLTA+ as all patients examined by the Expert Center were clinically stabilized and under stable dose of treatment for at least 3 months. Each patient has been administered a 1-day long comprehensive cognitive battery (including The National Adult Reading Test, the Wechsler Adult Intelligence Scale, the Trail Making Test, the California Verbal Learning Test, the Doors test, and The Continuous Performance Test-Identical Pairs). RESULTS: In the multivariate analyses, results showed that BLTA was associated with impaired attention/working memory (OR 0.60, 95% confidence interval 0.42-0.86; p = 0.005) independently of socio-demographic variables and illness characteristics. Verbal and performance current IQ-[respectively, OR 0.98, 95% CI (0.96;0.99), p = 0.016 and 0.98, 95% CI(0.97;0.99), p = 0.034] but not premorbid IQ-(p > 0.05) have been associated with BLTA in a multivariate model including the same confounding variables. CONCLUSION: BLTA is associated with impaired attention/working memory in schizophrenia. The BLTA benefit/risk ratio should be regularly reevaluated. Alternative pharmacological and non-pharmacological strategies for comorbid anxiety disorders and sleep disorders should be preferred when possible. It seems reasonable to withdraw BLTA before the start of cognitive remediation therapy, as soon as possible, to improve the effectiveness of this therapy. Limits: the delay between the last benzodiazepine intake and testing, as well as the specific class of benzodiazepines (long half-life vs. short half-life), and the number of benzodiazepine daily intakes have not been recorded in the present study. The precise motive for BLTA prescription and sleep disturbances have not been reported, which is a limit for the interpretation of the present results.

SIM Life: a new surgical simulation device using a human perfused cadaver.

PURPOSE: In primary and continuing medical education, simulation is becoming a mandatory technique. In surgery, simulation spreading is slowed down by the distance which exists between the devices currently available on the market and the reality, in particular anatomical, of an operating room. We propose a new model for surgical simulation with the use of cadavers in a circulation model mimicking pulse and artificial respiration available for both open and laparoscopic surgery. METHODS: The model was a task trainer designed by four experts in our simulation laboratory combining plastic, electronic, and biologic material. The cost of supplies needed for the construction was evaluated. The model was used and tested over 24 months on 35 participants, of whom 20 were surveyed regarding the realism of the model. RESULTS: The model involved a cadaver, connected to a specific device that permits beating circulation and artificial respiration. The demonstration contributed to teaching small groups of up to four participants and was reproducible over 24 months of courses. Anatomic correlation, realism, and learning experience were highly rated by users CONCLUSION: This model for surgical simulation in both open and laparoscopic surgery was found to be realistic, available to assessed objectively performance in a pedagogic program.

[Autobiographical memory and self-disorders in schizophrenia]. / Les troubles de la mémoire autobiographique et du self dans la schizophrénie.

OBJECTIVES: Disorders of self in schizophrenia have been considered as the core feature of the illness since its early clinical description. However, until recently, the understanding of these disorders referred mostly to philosophical considerations. The aim of this work is to examine how the various aspects of autobiographical memory deficits may be considered as possible cognitive mechanisms accounting for self-disorders in patients. METHODS: We performed a theoretical review of the literature on autobiographical memory studies in schizophrenia. Our approach of cognitive psychopathology was grounded in the model of the Self-Memory System put forward by Conway (2005), which posits reciprocal relationships between autobiographical memory and the self. This model stresses the distinction between the working-self and the autobiographical memory knowledge base. The latter contains all autobiographical information stored in our life and is organized according to the specificity of this information. The role of the working-self is to maintain the coherence of the self and to control the access to autobiographical memories and corresponding memory details. The working-self supports an experiential or phenomenological dimension of the self, especially when a highly detailed autobiographical memory is retrieved, and a past event is re-experienced by the rememberer. The working-self also entails a conceptual part, the conceptual self, which contains self-knowledge and self-images. RESULTS: Our review showed that autobiographical memories of patients with schizophrenia are less specific and contain fewer phenomenological details than those of healthy participants. Patients also have difficulty assessing the subjective temporal distance of past events, and their ability to re-experience unique past personal events is affected as shown by a reduced conscious recollection and a smaller frequency of Field visual perspective during recall of autobiographical memories. This global alteration of all phenomenological characteristics of autobiographical memories strongly suggests an alteration of the phenomenological dimension of the self in schizophrenia. Since some of these alterations are also found in patients when they plan for future personal events, the ability to mentally travel in time is reduced in patients and reflects an impaired sense of self across time. The literature also shows that self-images are more passive, less coherent and less stable in time in patients compared to healthy participants. These results point to an alteration of the conceptual dimension of the self in schizophrenia. This may be partly explained by a weaker connection between the self and autobiographical memory and by other alterations of autobiographical memories closely linked to the self. In fact, the reminiscence bump is disorganized in patients and comprises poorly detailed memories. Memories grounding self-images are less organized and weakly connected to self-images. Finally, patients have an impaired ability to give a meaning to or to draw lessons from self-defining memories of their life. CONCLUSION: Based on these results, we discuss current and future therapeutic interventions including both cognitive remediation methods and cognitive psychotherapy applied to autobiographical memory. These methods appear relevant to help patients improve both the sense of self associatied with their autobiographical memory retrieval and the coherence and stability of the self.

Self-continuity across time in schizophrenia: An exploration of phenomenological and narrative continuity in the past and future.

BACKGROUND: Disorders of the self, such as a reduced sense of personal continuity in time, are a core symptom of schizophrenia, but one that is still poorly understood. In the present study, we investigated two complementary aspects of self-continuity, namely phenomenological and narrative continuity, in 27 patients with schizophrenia, and compared them with 27 control participants. METHODS: Participants were asked to identify important past events and to narrate a story from their life that included these events. They were also asked to imagine important events that might happen in their personal future and to build a narrative of their future life. The vividness of these important life events and the proportion of self-event connections in the narratives were used as a measure of phenomenological and narrative continuity, respectively. RESULTS: Our study showed patients with schizophrenia experienced less vivid representations of personally significant events (p = .02) for both temporal directions (past and future) (p < .001). In addition, their ability to make explicit connections between personal events and self-attributes in life narratives was also impaired (p = .03), but only in the case of past narratives (p < .001). CONCLUSIONS: These results shed new light on the cognitive mechanisms underlying self-disorders in schizophrenia. The clinical and therapeutic implications of these findings are discussed.

Grasping the mechanisms of narratives' incoherence in schizophrenia: an analysis of the temporal structure of patients' life story.

OBJECTIVE: Life narratives of patients with schizophrenia are characterized by impaired coherence so that the listener has often difficulties to grasp the life trajectory of the patients. In order to better understand what causes this reduced temporal coherence, we investigated the temporal structure of patients' life narratives through different temporal narrative elements (elaboration of beginnings and endings, local temporal indicators and temporal deviations from a linear order), across two complementary studies. METHODS: Life narratives were collected by means of two different methods; a free recall in study 1 and a more structured protocol, aiming at reducing the cognitive task demands in study 2. All narratives from the two studies were analyzed using the same validated method. RESULTS: Both studies showed that global temporal coherence is significantly reduced in patients with schizophrenia (ps.02). This is mainly due to their stronger tendency to temporally deviate from a linear temporal order without marking the deviation as such. We also observed significant correlations in the patient groups between global temporal coherence and executive dysfunction (p=.008) or their higher tendency to temporally deviate from a linear temporal order in their life narratives (p<.001). CONCLUSIONS: These results shed light on narrative correlates of temporal narrative incoherence in schizophrenia and highlight the central role of executive dysfunction in this incoherence.

[Theoretical reflection on the place of memory and temporal cognitive mechanisms in addictive disorders]. / Réflexion théorique sur la place des mécanismes cognitifs mnésiques et temporels dans l'addiction.

INTRODUCTION: Addictions can be regarded as cognitive disorders related to neurobiological impairments. On the one hand, some cognitive impairments occur as a result of substance intake and withdrawal upon stopping intake, while, on the other hand, cognitive mechanisms are responsible for initiating and maintaining addiction. In this review, we detail the memory and temporal mechanisms involved in this pathology. METHODOLOGY: We reviewed the literature dedicated to the mechanisms of conditioning association between a substance and a context, and the memory and temporal mechanisms involved in the maintenance of addiction. Cognitive impairments in this context are accompanied by both short-term and long-term neurobiological disorders. RESULTS: Drug-context conditioning is dependent on learning abilities in rats and humans, and it is the first step towards the development of an addiction. In fact, with the beginning of an addiction, it is the context associated with the substance intake, which determines the reinforcing factors (such as pleasure in the case of drug consumption) for the development of an addiction. Maintenance of addiction is related to the persistence of this association between context and substance. Furthermore, the impulsiveness of patients renders them unable to delay their gratification. Consequently, even if delayed gratifications are more valuable, patients prefer immediate gratification such as substance use. DISCUSSION: The memory and temporal mechanisms of addiction are central to the initiation and maintenance of drug addiction. They also affect patients' ability to develop projects for the future. The salience of the memory association between drug and context is accompanied by a decline in autobiographical memories, which become poor and lacking in detail. It is probably these impairments which are responsible for the difficulty that the patients have while investigating their story during psychotherapy. On the other hand, given that even though delayed gratification is greater patients prefer immediate gratification, they have difficulty making plans for the future and constructing their own personality. These cognitive impairments are sustained by neurobiological correlates such as dopamine dysregulation in the short-term and changes in neural plasticity in the cortico-meso-limbic system in the long term. CONCLUSION: We reviewed full arguments which highlight that addiction is mediated by cognitive mechanisms which are related on the one hand to clinical symptoms and, on the other hand, to neurobiological alterations. According to the literature, memory and time mechanisms seem to be central to the initiation and maintenance of addictive behaviours. More research is needed to improve our knowledge of the cognitive mechanisms of addiction and to develop new tools for treating patients.

From anatomy to laparoscopic surgery, or how to reconcile surgeons to embryology.

PURPOSE: With the development of laparoscopy, new surgical techniques for colon resection were required. New anatomic plans of dissection were described for laparoscopic technique (medial to lateral approach) and the surgeons had to learn a complete different anatomy known as "laparoscopic anatomy". To help the surgeon through the milestones of laparoscopic colon resection, we propose an embryological and anatomical analysis of the changes of the colon and peritoneum during the foetal period to highlight the laparoscopic approach and surgical landmarks. METHODS: Seventeen human foetuses, age ranged from 7½ to 33 weeks were studied by dissections and histology. Three adult cadavers underwent laparoscopic colon surgery. RESULTS: Photographic representations of surgical views are displayed, and detailed descriptions applicable to anatomical structures are presented. CONCLUSION: Understanding the changes in the colon and peritoneum morphology leads to a clarification of the surgical technique for laparoscopic colon surgery.

Extrusion and meniscal mobility evaluation in case of ramp lesion injury: a biomechanical feasibility study by 7T magnetic resonance imaging and digital volume correlation.

Introduction: The existing body of literature on the biomechanical implications of ramp lesions is limited, leaving a significant gap in our understanding of how these lesions impact joint kinematics and loading in the medial compartment. This cadaveric biomechanical study aims to address this gap by employing an innovative Digital Volume Correlation (DVC) method, utilizing 7 Tesla Magnetic Resonance Imaging (MRI) images under various loading conditions. The primary objective is to conduct a comprehensive comparison of medial meniscal mobility between native knees and knees affected by grade 4 ramp lesions. By focusing on the intricate dynamics of meniscal mobility and extrusion, this work seeks to contribute valuable insights into the biomechanical consequences of medial meniscus ramp lesions. Materials and methods: An initial set of 7T MRI imaging sessions was conducted on two intact native knees, applying load values up to 1500N. Subsequently, a second series of images was captured on these identical knees, with the same loads applied, following the creation through arthroscopy of medial meniscus ramp lesions. The application of DVC enabled the precise determination of the three components of displacement and spatial variations in the medial menisci, both with and without ramp lesions. Results: The measured directional displacements between native knees and injured knees indicate that, following the application of axial compression load, menisci exhibit increased extrusion and posterior mobility as observed through DVC. Discussion: Injuries associated with Subtype 4 medial meniscus ramp lesions appear to elevate meniscal extrusion and posterior mobility during axial compression in the anterior cruciate ligament of intact knees. Following these preliminary results, we plan to expand our experimental approach to encompass individuals undergoing weight-bearing MRI. This expansion aims to identify meniscocapsular and/or meniscotibial insufficiency or rupture in patients, enabling us to proactively reduce the risk of osteoarthritic progression.

SimLife model: introducing a new teaching device in endocrine surgery simulation.

To evaluate the validity and reliability of an innovative training model for endocrine surgical procedures. A simulator training model for endocrine procedures (SimLife) was developed at an academic center. The model consisted of a realistic operating environment with a coherent simulated patient dynamized by pulsatile vascularization with simulated blood warmed to 37 °C, and ventilation. Training sessions were designed for adrenal and thyroid surgery, as well as neck dissection. The primary outcome of interest was to evaluate learners' performance and satisfaction. Learners' performance was evaluated based on a scoring scale that followed the Downing method for the assessment of competency. While learners' satisfaction was evaluated using a Likert scale of 1 to 10 on four items (ease of learning, anatomic correspondence of landmarks, realism, and overall satisfaction). Participants were engaged in 32 training sessions. These included 24 adrenalectomies (conventional and laparoscopic both transabdominal and posterior), and 4 thyroid lobectomies with concomitant functional lateral compartment neck dissection. competency scores were procedure-specific addressing specific core components of a given procedure. Learners' performance scored above average in all procedures evaluated. Satisfaction scores for the specified four items ranged between 8.43 (SD 0.87) and 8.89 (SD 0.96). No major events were reported for the adrenalectomies, while only one jugular vein injury occurred during neck dissection. SimLife is a hyper-realistic training model that allows for satisfactory acquisition of skills and the evaluation of performance progression. It has the potential to become a cornerstone in specialized surgical training.

Bariatric Surgical Simulation: Evaluation in a Pilot Study of SimLife, a New Dynamic Simulated Body Model.

BACKGROUND: The demand for bariatric surgery is high and so is the need for training future bariatric surgeons. Bariatric surgery, as a technically demanding surgery, imposes a learning curve that may initially induce higher morbidity. In order to limit the clinical impact of this learning curve, a simulation preclinical training can be offered. The aim of the work was to assess the realism of a new cadaveric model for simulated bariatric surgery (sleeve and Roux in Y gastric bypass). AIM: A face validation study of SimLife, a new dynamic cadaveric model of simulated body for acquiring operative skills by simulation. The objectives of this study are first of all to measure the realism of this model, the satisfaction of learners, and finally the ability of this model to facilitate a learning process. METHODS: SimLife technology is based on a fresh body (frozen/thawed) given to science associated to a patented technical module, which can provide pulsatile vascularization with simulated blood heated to 37 °C and ventilation. RESULTS: Twenty-four residents and chief residents from 3 French University Digestive Surgery Departments were enrolled in this study. Based on their evaluation, the overall satisfaction of the cadaveric model was rated as 8.52, realism as 8.91, anatomic correspondence as 8.64, and the model's ability to be learning tool as 8.78. CONCLUSION: The use of the SimLife model allows proposing a very realistic surgical simulation model to realistically train and objectively evaluate the performance of young surgeons.

SimLife® technology in surgical training - a dynamic simulation model.

In initial surgical formation and continuing surgical education, simulation has become a compulsory technique. Just as becoming an airplane pilot requires skills, the acquisition of technical skills is essential to becoming a surgeon. The old apprenticeship model "I see, I do, and I teach" is no longer entirely compatible with the socio-economic constraints of the operating room, demands for guaranteeing patient safety, and the compulsory reduction in resident working hours. We propose a new surgical simulation model, using cadavers donated to science that are rendered dynamic with pulsatile vascularization and ventilation. Such models are available for simulation of both open surgery and laparoscopy. Surgery on a human body donated to science makes it possible to accurately reproduce the hand gestures characteristic of surgical procedures. Learning in an appropriate and realistic simulation context increases the level of skills acquired by residents and reduces stress and anxiety when they come to perform real procedures.

Sleeve Gastrectomy: You Might Lose your Liver!

Sleeve gastrectomy (SG) is currently the most popular bariatric procedure. Portomesenteric venous thrombosis (PVT) is a feared and increasingly reported complication. Herein, we describe the history of a patient who developed a post-operative PVT after SG, aggravated with refractory ascites, and finally required orthotopic liver transplantation (LT). Acquired thrombophilia-anti-cardiolipin syndrome was present. As SG expands worldwide, this first case of LT for PVT following SG may warrant a systematic screening for prothrombotic condition and information on the possible consequences of PVT prior to bariatric surgery.

[Functioning of memory in subjects with autism]. / Fonctionnement de la mémoire chez les sujets avec autisme.

INTRODUCTION: Autism is an early developmental disorder with cognitive impairments that leads to learning and social integration disabilities. The characterization of memory functions in individuals with autism has been the subject of numerous investigations, with widely varying conclusions. The notable differences between these studies can be attributed to variations in the age, intelligence and level of severity of the participants with autism. LITERATURE FINDINGS: The purpose of our review of the recent literature is to describe the memory function of individuals with autism. Some of the different memory subtypes are intact, others are impaired. Short-term memory (digit span) is not impaired while working memory is impaired in some of its components, but the findings are inconsistent. More recent studies demonstrate reduced spatial working memory abilities in autism and extend previous findings by demonstrating that these deficits are significant when tasks impose heavier demands on working memory. Episodic long-term memory, as measured by free recall, cued recall or recognition tasks, is intact, but participants with autism perform significantly less well than controls as the complexity of the verbal or visual material to be recalled increases. Source or contextual memory involves a variety of characteristics specifying the conditions under which specific items or facts are acquired: it has been investigated in individuals with autism with different methods. Deficits in source memory for temporal information have been found, but there were no reality monitoring deficits. Recent findings indicate that the nature of source memory confusion in autism does not appear to reflect a generalized deficit in attaching context to memories, but rather is dependant on the specific to-be-remembered information that involves social aspects of context. The self-reference effect is missing, with individuals with autism recalling events performed by themselves less well than the events performed by a peer, suggesting they have difficulties in relation to processes involving the self. Studies involving assessment of subjective states of awareness during recognition show less conscious recollection and more feelings of familiarity. Recent investigations are consistent in demonstrating memory impairments related to the failure of subjects with autism to use organizing strategies or meaning to support memory, an effect which grows with the increasing complexity of the material. Memory deficits in autism may be related more to retrieval and less to encoding, as deficit in source memory in participants with autism is largely eliminated when source was supported at test. DISCUSSION: The neuroanatomical basis of the specificities of memory impairment in autism is still uncertain, but it is suggested that autism involves an impairment in the conversion of limbic inputs into medial prefrontal outputs. Memory deficits found in individuals with autism may explain some of the clinical symptoms. Failure to encode all the information, especially its social aspects, may therefore contribute to dysfunction in the social, communication, and reasoning domains. Abnormal memory functioning in autism is also related to more general cognitive impairments, including executive function deficits and central coherence weakness. Evidence of the normality of certain memory capacities, at least in individuals with moderate autistic symptomatology, is encouraging for adaptive improvements in cognitive functioning.

SimLife a new model of simulation using a pulsated revascularized and reventilated cadaver for surgical education.

INTRODUCTION: Alike becoming a pilot requires competences, acquisition of technical skills is essential to become a surgeon. Halsted's theory on surgical education "See one, do one, and teach one" is not currently compatible with the reality of socio-economic constraints of the operating room, the patient's safety demand and the reduction of residents' work hours. MATERIEL AND METHODS: In all countries, this brings mandatory to simulation education for surgery resident's training. Many models are available: video trainers or pelvi-trainers, computed simulator, animal models or human cadaver… Human cadaveric dissection has long been used to teach surgical anatomy. RESULTS: Surgery on human cadaveric model brings greatest accuracy to the haptic characteristics of surgical procedures. Learning in an appropriate and realistic simulation context increases the level of acquisition of the residents' skills and reduces stress and anxiety when performing real procedures. CONCLUSION: We present a technique of perfusion and ventilation of a fresh human cadaver that restores pulsatile circulation and respiratory movements of the model.

Functional mechanisms underlying impaired recognition memory and conscious awareness in patients with schizophrenia.

BACKGROUND: Schizophrenia impairs episodic memory in its critical feature, autonoetic awareness, i.e., the type of awareness that is characterized by mentally reliving events from one's personal past. It spares noetic awareness, another form of awareness based on feelings of familiarity. We investigated the hypothesis that the impairment of autonoetic awareness is related to defective information that binds together separate aspects of events. METHODS: An experiential approach to recognition memory was used. Twenty-five patients with schizophrenia and 25 normal subjects performed or watched actions consisting of pairing objects. Then, they had to recognize pairs of objects and who paired them (source recognition). Subjects were also asked to provide a "remember" (autonoetic awareness) or a "know" (noetic awareness) response according to their subjective state at the time they recognized each pair of objects and each source. RESULTS: Patients exhibited an impaired recognition memory. When actions were observed, recognition of pairs of objects, but not of source, was no better than chance. There was a reduction in frequency of autonoetic awareness, its consistency throughout recognition of objects and source, and its relationship to source discrimination accuracy. Recognition was based largely on noetic awareness. CONCLUSIONS: Patients with schizophrenia are unable to link the separate aspects of events into a cohesive, memorable, and distinctive whole. The corollary of this defective relational binding is a quantitative and qualitative impairment of autonoetic awareness.

Explicit memory and repetition priming in depression. Preliminary findings.

Explicit memory and repetition priming, a form of implicit memory, were examined in depressed patients and controls. Explicit memory of depressed patients was severely impaired, whereas repetition priming was intact. These results are consistent with the hypothesis that the impairment of memory in depression is linked to a failure of effort-demanding cognitive processes. Repetition priming might be useful in differentiating between depression and dementia.

Primary versus secondary delayed gastric emptying (DGE) grades B and C of the International Study Group of Pancreatic Surgery after pancreatoduodenectomy: a retrospective analysis on a group of 132 patients.

Delayed gastric emptying (DGE) is a common complication after pancreaticoduodenectomy (PDD) significantly contributing to post-operative morbidity. Clinical risk factors for DGE occurrence after PDD remain controversial. From January 2004 to December 2011, a total of 132 patients underwent PDD for either malignancies (73.5%) or benign diseases (26.5%) in one single universitary center. Post-operative mortality and morbidity were, respectively, 3 and 44.7%. DGE has been defined in accordance with the International Study Group of Pancreatic Surgery (ISGPS) classification. DGE was distinguished in primary or secondary. Factors associated with grades B and C of DGE, based on severity and clinical impact, were assessed by means of univariate and multivariate analysis. Thirty-eight patients (28.8%) had clinical DGE grade B or C. Post-operative complications (pancreatic fistula and/or hemorrhage or anastomotic leak) were reported in 25 out of the 38 patients (65.8%, secondary DGE), while in 13 patients it was not associated to any other complication (34.2%, primary DGE). Post-operative complications (pancreatic fistula and hemorrhage) appeared to be the most important predictive factor for Grade B or C DGE.