Risk factors associated with PIGE may have a synergistic effect. Bacterial plaque, however, appears the most important determinant of PIGE severity. This latter finding emphasises the importance of instituting a preventive plaque-control programme, particularly in young patients on phenytoin therapy.

Introduction Penetrating injury due to gunshot wounds is a common problem seen in trauma centres around South Africa. Gunshot wounds can injure organs directly or may cause indirect injury. The temporary cavity is responsible for injury to organs distant to the wound tract. Organs with higher density such as bone or liver are more prone to injury due to the temporary cavity. Presentation of case A 25 year old male patient sustained a gunshot wound to the right lower chest from a handgun. He was haemodynamically and metabolically stable with no evidence of peritonitis. CT scan of the abdomen revealed a Grade 2 injury of the liver. There was subcutaneous emphysema along the tract of the bullet. No injury to the lung or pleura was reported. The patient was explored laparoscopically to rule out diaphragmatic injury. At exploration the peritoneum was not breeched but the liver had a grade two laceration caused by an indirect ballistic injury Discussion Penetrating trauma to the right lower chest can potentially injure multiple organs. CT scan can reliably diagnose the bullet tract as well as solid organ injuries. In this case the diaphragm was contused and the liver was lacerated by energy created by the temporary cavity. The difference in severity of the injury of these organs is related to the pliability of the tissue. Conclusion Gunshot wounds can injure organs directly as well as those located close to the bullet tract. These injuries may be found in adjacent cavities not traversed by the bullet. A high index of suspicion, as well as imaging, is important to diagnose and grade these injuries. The possibility of indirect ballistic injury should always be kept in mind when managing patients with gunshot wound even in the lower velocity handgun injuries. Highlights

Background. Diverticular disease was previously thought to be non-existent in the black African population. Studies over the past four decades, however, have shown a steady increase in the prevalence of the disease. Objective. To report on the profile and current prevalence of diverticular disease in the black South African (SA) population at Dr George Mukhari Academic Hospital, Pretoria, SA. Methods. A retrospective descriptive study was performed in black SA patients who were diagnosed with diverticular disease by colonoscopy between 1 January and 31 December 2015.Results. Of 348 patients who had undergone colonoscopies and who were eligible for inclusion in this study, 47 were diagnosed with diverticular disease -a prevalence of 13.50% (95% confidence interval 10.30 -17.50). The greatest number of patients diagnosed were in their 7th and 8th decades, with an age range of 46 -86 (mean 67) years. There was a female predominance of 57.45%. Lower gastrointestinal bleeding was the most common (65.96%) indication for colonoscopy. The left colon was most commonly involved (72.34%), followed by the right colon (55.31%). A substantial number of patients had pancolonic involvement (27.65%). Conclusion. This retrospective study suggests that there has been a considerable increase in the prevalence of diverticular disease among black South Africans, possibly owing to changes in dietary habits and socioeconomic status.

Methods: Surgical treatment performed at 17 patients with Mirizzi symdrome in period of five years. Mean age of 62.9 years(40 to 83 years) Main parameters(clinical changes, lab results,sonography) were evaluated. Results: According to the Csendes classification : type I-7 patients-(41.0%)type II-2 (11.8%)type III-6(35.4%)type IV-2(11.8%).Laparoscopy as a first step of surgical treatment was performed at 5 patients with Mirizzi syndrome type I-II. At 8 patients open cholecystectomy was performed. At 6 patients-cholecystectomy with drainage of bile ducts, and at 3 patients-cholecystectomy and hepaticojejunostomy(all with type 3 Mirizzy. In cases with significant defect of common bile duct we performed reconstruction or partial(2 cases) cholecystectomy.Concomitant and related surgical pathology (at 8 cases gangrenous cholecystitis with local peritonitis, 1 case-liver abscess, 1 case-multiple liver abscesses, 1 case of combination of cholecystocholedocheal and cholecysto-duodenal fistula) provide significant impact on type of treatment and process of recovery. Leukocytic index of intoxication by Kalf-Kalif(LII) measured at all patients, RR-0.51-2.1. At admission mean level of LII were 3.82 (from11.2 to 0.47) At 5e7 day after the surgical treatment LII normalized (mean 1.0)All patients recovered well and were discharged from hospital in satisfactory conditions. Conclusions: Preoperetive diagnosis of Myrizzi syndrome is difficult task. Combination of anamnesis of current disease, length of cholecystitis, and results of ultrasonography(size of gallbladder, presence of gallstones in neck area) reflects high possibility of significant changes in Calot triangle. Open approach safe and effective especially for patients with type 3-4 Mirizzy. We recommend length of postsurgical in-hospital stay at 5e7 days, as the time for normalization of basic parameters.

pancreaticoduodenctomy(PD) and distal pancreatectomy(DP). We aimed to investigate the difference of fistula rates after pancreatectomies between the different techniques Methods: We collected the datas of 500 patients that were operated between 2009e2014 at Ege University. Duct to mucosa pancreaticojejunostomy(PJ) anastomosis was performed after all PDs. The pancreatic parenchyma stump closure was achieved either with a stappler or hand sewn. Fistula was defined according to the definition of International Study Group on Pancreatic Fistula (ISGPF) (Grade A,B,C). Fisher exact test was used to determine the difference of the fistula rates between the stappled and hand sewn distal pancreatectomies. Chi-square test was used for determining the difference between the presence of the stent in the fistula rates after pancreaticoduodenectomies. Results: 247 of the patients were male and 253 of them were female with the average age of 60,3 years. Of the 500 patients, 311 were performed PD, 153 were performed DP, 32 were performed enucleation and 4 were performed duodenum preserved total pancreatectomy. Stent was used in 68 of the 311 PD's. Pancreatic parenchyma stump closure was achieved by using stappler in 7 of the 153 DP's. Fistula was determined in 14 of 68 patients that stent was placed in PJ where in 9 of 243 that stent was not used in PJ (p < 0,01). Fistula was determined in 4 of 7 patients whose stump closure was achieved by using stappler where 6 of 146 patients with hand sewn stump after DP (p < 0,01). Conclusions: We determined that using intraductal pancreatic stent while performig PJ anastomosis raises POPF rate. Hand sewn closure of pancreatic stump after DP has lower rates of POPF than stapled closure of the parenchyma.