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A 50-year-old male presented with a T4 N0 squamous cell carcinoma of the floor of the mouth and alveolus. Treatment included a partial mandibulectomy with a free osteocutaneous fibula flap reconstruction. He made a good postoperative recovery and was given adjuvant radiotherapy. No problems were reported with the donor site or ankle. Five months after harvesting the flap the patient sustained a fracture of the medial malleolus having jumped over a ditch playing golf. This was treated successfully with a below knee plaster of Paris cast. The interosseous membrane was not ruptured in the accident indicating that the distal fibula left in situ was adequate to maintain the integrity of the mortice. A degree of ankle instability may be present after fibula flap harvest which is only revealed by athletic activity.

A 50-year-old male presented with a T4 N0 squamous cell carcinoma of the floor of the mouth and alveolus. Treatment included a partial mandibulectomy with a free osseocutaneous fibula flap reconstruction. He made a good postoperative recovery and was given adjuvant radiotherapy. No problems were reported with the donor site or ankle. Five months after harvesting the flap the patient sustained a fracture of the medial malleolus having jumped over a ditch playing golf. This was treated successfully with a below knee plaster of Paris cast. The interosseous membrane was not ruptured in the accident indicating that the distal fibula left in situ was adequate to maintain the integrity of the mortice. A degree of ankle instability may be present after fibula flap harvest which is only revealed by athletic activity. (c) 2000 Harcourt Publishers Ltd Copyright 2000 The British Association of Plastic Surgeons DOI: 10.1054/bjps.1999.3227.

Forty-two patients with biliary obstruction caused by a stricture had a diagnostic ERCP with subsequent insertion of a straight 10G endoprosthesis. These patients represented 70% of a cohort in which stent insertion had been attempted. The majority (63%) had pancreatic carcinoma, but 22% had malignant hilar obstruction. Five patients (12%) died within a few days of stent insertion; ERCP may have contributed to two deaths. Jaundice was relieved in all survivors. Median hospital stay was 6 days (range 2-32 days). After further investigation, nine patients were thought to be potentially curable and underwent laparotomy. Late complications after stent insertion alone included cholangitis (26%) and recurrent jaundice (28%). Only one patient developed gastric outlet obstruction and needed a gastroenterostomy. Median survival in the endoprosthesis group was 11 weeks (range 2-84 weeks). Survival was longer for patients with bile duct (14 weeks) rather than hilar strictures (6 weeks). Median survival after subsequent surgery was 40 weeks (range 4-80 weeks) with two long-term survivors. This study confirms that ERCP and stent insertion is a useful initial treatment for obstructive jaundice due to a biliary stricture, being both diagnostic and therapeutic. Subsequent evaluation for curative surgery is not precluded and in the majority of cases worthwhile palliation may be achieved by stenting alone.