UROGENITAL TRAUMA

Damage Control Management of Experimental Grade 5 Renal Injuries: Further Evaluation of FloSeal Gelatin Matrix
Pursifull NF, Morris MS, Harris RA, Morey AF
Urology Service, Brooke Army Medical Center, Fort Sam Houston, Texas 78324, USA
J Trauma. 2006; 60: 346-50

• Background: We developed a porcine grade 5 renal laceration damage control model to evaluate the hemostatic efficacy of FloSeal gelatin matrix (Baxter Healthcare, Corp., Deerfield, Ill).
• Methods: Ten commercial swine underwent celiotomy, contralateral nephrectomy, and cooling to 32 degrees C after a well-established hypothermia protocol to simulate a damage control scenario. Following prospective randomization, a complex grade 5 renal injury was uniformly produced on the remaining kidney. Control animals (group 1, n = 5) were treated with direct manual compression with a gelatin sponge. Experimental animals (group 2, n = 5) were treated by application of FloSeal gelatin matrix followed by direct compression with a gelatin sponge. Operative blood loss and efficacy of hemostasis were compared. Creatinine levels were obtained daily until postoperative day 7. Abdominal computed tomography was performed at 10 days.
• Results: Use of FloSeal gelatin matrix hemostatic sealant resulted in significantly less mean blood loss than gelatin sponge bolster compression alone (202.4 mL vs. 540.4 mL, respectively, p = 0.016). Hemostasis was complete in 60% (three out of five) of experimental animals after 2 minutes, but was incomplete in all control animals. After an initial increase, serum creatinine approached baseline by postoperative day 7 in all animals. Axial imaging 10 days postoperatively revealed no evidence of significant delayed perirenal hemorrhage.
• Conclusions: FloSeal gelatin matrix performed well as a rapidly deployable, effective hemostatic agent in a hypothermic grade 5 renal injury damage control model. The absence of delayed bleeding and nephrotoxicity suggests a possible increased role for FloSeal in the treatment of devastating renal injuries in damage control surgery.
  
  
• Editorial Comment
  This article illustrates nicely the concept of damage control and the use of a pig model. Damage control is the concept that an abdominal trauma surgery is abbreviated to control hemorrhage and fecal and urinary contamination, to not perform the definitive repair until a planned staged re-operation improves survival, and to resuscitate the patient in the ICU before any prolonged reconstructive surgery. Such a policy of staged, abbreviated operations, has clearly been shown to improve overall survival, and helps the avoid the lethal triad of cold (body temperature), coagulopathy and acidosis.
  The use of fibrin sealants in urology has been particularly popular recently, due to its use in laparoscopic kidney surgery. With the expanding role of laparoscopy for partial nephrectomy, methods to better control urinary leak or bleeding have been explored. Aside from direct suturing of the collecting system and vessels, fibrin sealants have been the “suspenders” to the “belts” of suturing. The current commercially available sealants are Tisseel “fibrin sealant”, (by Baxter, a mix of fibrinogen aprotonin solution, Factor XIII, and human derived thrombin), FloSeal “gelatin matrix” (by Baxter, a mix of human derived thrombin and bovine derived gelatin matrix), and BioGlue “surgical adhesive” (by Cryolife, a mix of bovine serum albumin and gluteraldehyde).

Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, USA