Increasing RTP Levels Reduces Bleeding, Improves Surgical Field-of-View in ESS

What is the optimum amount of reverse Trendelenburg position to reduce bleeding without compromising surgical technique in endoscopic sinus surgery (ESS)?

Background: Bleeding can significantly reduce visualization of the surgical field in ESS. Various measures can be used to reduce or control bleeding in ESS, including the reverse Trendelenburg position (RTP). The optimum angle of RTP that gives the maximum benefit for reduction of bleeding and does not interfere with surgical access has not been determined.

Study design: Prospective, double-blind, randomized, controlled study.

Setting: Rhinology Clinic, St. Paul’s Sinus Centre, Vancouver, British Columbia, Canada.

Synopsis: Seventy-five patients undergoing bilateral ESS for chronic rhinosinusitis with and without nasal polyps were evenly divided into each of the following groups: five-degrees RTP (5-RTP), 10-RTP, and 20-RTP. Parameters recorded included endoscopic field-of-view score (Boezaart scale), total blood loss, mean arterial blood pressure, total operating time, and blood loss per minute. The three groups were similar with respect to demographics, presence of polyps, and disease severity. The results included significant differences in the means of endoscopic field-of-view scores and total blood loss with increasing degrees of RTP. No significant differences were found in mean arterial blood pressure, operating time, or blood loss per minute. Pairwise analysis showed a significant difference in endoscopic field-of-view scores between only 5-RTP and 20-RTP, but not between the lesser degrees of difference in RTP. A drawback of this study is the inability to completely blind the surgeon (the only one to rate the degree of surgical field bleeding) to the degree of RTP of the patient. This can introduce bias into the subjective field-of-view rating. Increasing degrees of RTP can increase risk of surgical complication if the altered orientation of the skull base is not recognized.

Bottom line: Increasing levels of reverse Trendelenburg reduce bleeding and improve the surgical field-of-view in ESS, with 20-RTP offering the greatest benefit.

Citation: Gan EC, Habib AR, Rajwani A, Javer AR. Five-degree, 10-degree, and 20-degree reverse Trendelenburg position during functional endoscopic sinus surgery: a double-blind randomized controlled trial. Int Forum Allergy Rhinol. 2014;4:61-68.