Micronized AlloDerm appears to be a safe new material that is suitable for injection laryngoplasty. Long-term results are pending.

Nasopharyngeal stenosis is almost universally an iatrogenic problem resulting from surgical trauma after adenotonsillectomy or uvulopalatopharyngoplasty (UPPP). In addition, laser-assisted uvulopalatopharyngoplasty for the treatment of snoring may lead to the development of cicatricial scarring and stenosis at the level of the velopharynx. The most common mechanisms implicated in the development of acquired nasopharyngeal stenosis are the overzealous removal of inferolateral adenoid tissue and excessive excision of the palatopharyngeal arches. Symptoms generally relate to a disturbance in respiration, olfaction, voice quality, and deglutition, and are often poorly tolerated. Surgical options for the correction of this challenging problem include steroid injections, scar lysis, skin grafts, Z-plasty repair, and the use of various local mucosal flaps. We report the successful use of bivalved palatal transposition flaps performed through the transoral route for the correction of severe acquired nasopharyngeal stenosis following UPPP in two patients. Both patients developed delayed nasopharyngeal stenosis following their initial surgery and subsequently failed several attempts at surgical correction of the stenosis, including laser lysis of the scarred soft palate. Using this technique of repair, both patients achieved satisfactory resolution of their symptoms, including comfortable nasal breathing and normal speech. We have found that this is a simple and effective technique for the correction of severe nasopharyngeal stenosis.

Immediate and late failures of medialization laryngoplasty are due to several possible causes. Revision surgery is feasible and highly successful. To select between the surgical alternatives work up should include preoperative analysis of vocal function, videostrobolaryngoscopic analysis, and spiral CT of the larynx.

The results of liver transplantation in patients with cholangiocarcinoma have been poor. It has been suggested that elevated serum CA19-9 levels predict cholangiocarcinoma in patients with primary sclerosing cholangitis. We analyzed the predictive value of CAl9-9 antigen as a marker of cholangiocarcinoma in patients with primary sclerosing cholangitis evaluated for liver transplantation. We reviewed the charts of 26 patients with primary sclerosing cholangitis (stage IV) in whom preoperative serum CA19-9 levels were determined; 22 of 26 underwent liver transplant. Explant specimens were serially sectioned and examined for tumor. In 3 of the 26 patients, cholangiocarcinoma was diagnosed during pretransplantation evaluation; exploratory laparotomy on the last patient showed no evidence of cholangiocarcinoma, and this patient is awaiting transholangiocarcinoma (CCA) has a well-docu-C mented association with primary sclerosing cholangitis (PSC); 5% to 15% of patients with PSC are found to have CCA as well.' Accurate and timely diagnosis of cholangiocarcinoma in the presence of PSC can be difficult because of the lack of pathognomonic signs, laboratory data, or radiological findings. Detection of CCA is frequently delayed until an advanced stage, when a patient with previously stable disease begins to deteriorate rapidly.2 Earlier diagnosis via a sensitive and specific serum marker may allow surgical therapy and improved long-term survival.Liver transplantation in patients with cholangiocar- plantation. Twelve of the 26 patients had CA19-9 levels more than double the laboratory reference range (0-37 U/mL) (mean 183.1 f 103 U/mL, range 77-415 U/mL). Two of the 12 patients with elevated CA19-9 levels had cholangiocarcinoma. Of the 14 patients with normal levels, two had cholangiocarcinoma. No correlation between elevated CA19-9 and bile duct dysplasia was noted. Sensitivity for serum CA19-9 levels more than twice the reference range is 50%, specificity is 54.5%, positive predictive value is 16.6%. An elevated serum CA19-9 level in a patient with stage IV primary sclerosing cholangitis does not reliably predict coexisting cholangiocarcinoma. Persistently high or rising serum CA19-9 levels do not indicate more urgent need for liver transplantation. Copyright 0 1995 by the American Association for the Study of Liver Diseases cinoma has been associated with rapid recurrence and poor survival, both in recipients with overt CCA and in those in whom the lesion is found incidentally in the explant ~p e c i m e n .~-~ Because individuals with PSC comprise 10% to 24% of patients undergoing liver transplantation in the United States,' a reliable marker of CCA in such patients would be immensely useful. lo CA19-9 antigen, an easily assayed biochemical marker, is present in many gastrointestinal epithelial tumors. Several authors have reported the sensitivity and specificity of serum CA19-9 levels in detecting pancreatic cancer and de novo cholangiocarcinoma.l1-l6 Although its behavior in PSC is not well described, it has recently ...

Intraoperative PTH monitoring can serve as a therapeutic adjunct in the surgical management of parathyroid adenoma autoinfarction.