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Purpose Laparoscopic Nissen fundoplication has been traditionally performed with extensive esophageal dissection to create 2 to 3 cm of intraabdominal esophagus. Retrospective data have suggested that minimal esophageal mobilization may reduce the risk of postoperative herniation of the wrap into the lower mediastinum. To compare complete esophageal dissection to leaving the phrenoesophageal attachment intact, we conducted a 2-center, prospective, randomized trial. Methods After obtaining permission/assent, patients were randomized to circumferential division of the phrenoesophageal attachments (MAX) or minimal mobilization with no violation of the phrenoesophageal membrane (MIN). A contrast study was performed at 1 year. The primary outcome variable was postoperative wrap herniation. Results One hundred seventy-seven patients were enrolled in the study (MIN, n = 90; MAX, n = 87) from February 2006 to May 2008. There were no differences in demographics or operative time. Contrast studies were performed in 64 MIN and 71 MAX patients, respectively. The transmigration rate was 30% in the MAX group compared with 7.8% in the MIN group (P = .002). The reoperation rate was 18.4% in the MAX group and 3.3% in the MIN group (P = .006) Conclusions Minimal esophageal mobilization during laparoscopic fundoplication decreases postoperative wrap transmigration and the need for a redo operation.

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Anomalous 'Lossen-Type' Rearrangement. Synthesis of Functionalized Imidazolinones.-Treatment of the pyrroloimidazole derivative (I) with ammonia produces the ureidoimidazolecarboxamide (IIa) or the carboxylic acid (IIb) depending on the reaction conditions. The ester (IIc) is prepared in the presence of ethanol (III). The compounds (II) are further subjected to acid-or base-induced degradation, forming the imidazolones (IV). The transformation of (I) into (III) involves a Lossen rearrangement with trapping of the intermediate isocyanate by the vicinal amide moiety. -(CASTEEL, D. A.; GEPHART, R. S.; MORGAN, T.; Heterocycles 36 (1993) 3, 485-495; Div. Med. Nat. Prod. Chem., Coll. Pharm., Univ. Iowa,