Consensus Guidelines on Perioperative Care in Primary Retroperitoneal Sarcoma Surgery

Primary retroperitoneal sarcomas (RPS) represent a rare group of malignancies requiring aggressive surgical management. While Enhanced Recovery After Surgery (ERAS) protocols have improved perioperative outcomes across many surgical disciplines, disease-specific guidance for RPS is lacking. This consensus aims to standardize perioperative care in primary RPS surgery on the basis of current evidence and expert opinion.

A multidisciplinary panel of experts was convened under the auspices of the Spanish Society of Surgeons and the Portuguese Sarcoma Group. Between January and June 2025, a modified Delphi process was conducted, incorporating systematic literature review, subgroup synthesis, and four structured voting rounds. The strength of each recommendation was graded using the GRADE framework, and consensus was defined as ≥80% agreement among participants.

A total of 42 recommendations were proposed, addressing preoperative (e.g., anemia correction, smoking cessation, nutritional optimization), intraoperative (e.g., antimicrobial prophylaxis, goal-directed fluid therapy, multimodal analgesia), and postoperative care (e.g., ileus prevention, early feeding, opioid-sparing strategies, mobilization). In total, 33 recommendations reached consensus-17 with weak consensus and 16 with strong consensus-while 9 did not meet the predefined threshold. Most recommendations were supported by indirect evidence from major abdominal and oncologic surgery literature.

These are the first consensus-based, multidisciplinary perioperative care guidelines tailored to primary RPS surgery. They aim to harmonize clinical practice, reduce variation, and improve surgical and recovery outcomes in high-risk patients. Prospective validation and international collaboration are encouraged to further refine and implement these recommendations.