Surgeons’ opinions about enhanced recovery after surgery for retroperitoneal sarcoma: A survey

Table 1 List of the items proposed, and the statement presented in the survey

n	Item	Recommendation	Ref.
Preoperative domain
1	Preoperative education	Patients should receive preoperative counselling	[24-33]
2	Centralization	Patients should be centralized to referral center and managed in a multidisciplinary tumor board	[20,21,27,34,35]
3	Prehabilitation	Alcohol consumption and smoking should be avoided for at least 4 weeks before surgery. Physical activity should be encouraged	[7,24-27,29-33]
4	Anemia	Anemia should be identified, investigated, and corrected preoperatively	[7,25,27,31,32]
5	Preoperative nutrition	Routinely preoperative nutritional status evaluation and preoperative oral nutritional support in malnourished patients should be offered	[21,24-32,35]
6	Bowel preparation	Mechanical bowel preparation (MBP) alone should not be used routinely but may be used in selected cases. In patients receiving oral MBP, oral antibiotics should be given	[25,26,29]
7	Preoperative fasting and oral carbohydrate loading (OCL)	Preoperative fasting should not need to exceed 6 hours for solids and 2 hours for liquids. Preoperative OCL should be administered to all non-diabetic patients	[7,24-26,28-33,37,38]
8	Prevention of postoperative nausea and vomiting (PONV)	All patients should be screened preoperatively for PONV risk factors and stratified. A multimodal PONV treatment should be provided according to present guidelines	[7,24-26,28-33]
9	Thromboembolic prophylaxis, skin preparation, and intravenous antibiotic prophylaxis	Patients should receive low molecular weight heparin once daily for 28 days after surgery, additional measures as mechanical thromboprophylaxis by well-fitting compression stockings and/or intermittent pneumatic compression should be prescribed until discharge. Preoperative skin preparation should be done with chlorhexidine-based solution. Preoperative intravenous antibiotic prophylaxis, administrating 3rd generation cephalosporine (plus metronidazole in case of planned colic resection) has to be done 60 minutes prior to surgery	[7,24-26,28-33]
10	Preoperative steroid administration	Administration of methylprednisolone at a dosage of 30 mg/kg 2 hours before surgery in non-diabetic patients is recommended when a concomitant liver resection is planned. The usefulness of routinary preoperative steroid administration before RPS surgery should be investigated	[28]
Anesthesiology domain
11	Preoperative sedative medication	Preoperative routine sedative medication should be avoided. Effective strategies to treat preoperative anxiety should be multimodal, comprising preoperative education. Pre-anesthetic medication with gabapentanoids agents, NSAIDS and acetaminophen to better control postoperative pain are safe and effective	[7,25,26,30-32,40]
12	Intraoperative anesthesia management	To attenuate the surgical stress response, intraoperative maintenance of adequate hemodynamic control, central and peripheral oxygenation, muscle relaxation, depth of anesthesia, and appropriate analgesia is strongly recommended	[7,25,29-33]
13	Perioperative fluid management	The goal of perioperative fluid therapy is to maintain fluid homoeostasis avoiding fluid excess and organ hypoperfusion, and a perioperative near-zero fluid balance is recommended. Goal-directed fluid therapy should be adopted. Inotropes should be considered in patients with poor contractility (CI < 2.5 L/min)	[7,24-33,39]
14	Preventing intraoperative hypothermia	Reliable core temperature monitoring should be undertaken in all patients and methods to actively warm patients to avoid hypothermia should be employed, as by using warming blankest and warmed gases and fluids	[7,25,26,28-32]
15	Perioperative multimodal analgesia	To minimize perioperative opioid use, a multimodal perioperative analgesia should be proposed according to latest guidelines and should include all opioid-sparing techniques as multipharmacological analgesia, thoracic epidural analgesia, tranversus abdominal plane blocks, intravenous lidocaine infusion and patient-controlled analgesia. The long-term impact on postoperative chronic pain should be evaluated	[7,24-31,33,40-42,44,45]
Intraoperative domain
16	Minimally invasive access	Minimally invasive approach should not be employed routinely in RPS surgery	[16-19,35,43]
17	Prevention of delayed gastric emptying (DGE)	Currently affecting about 40% of RPS patients and lacking specific evidence, DGE is a critical area of interest and should be studied. At date, no recommendation about DGE prevention can be made	[38]
18	Abdominal and chest drainage	A tailored drain minimizing policy should be advisable, although specific evidence is lacking. Early removal of drains after 72 hours may be advisable in patients at low risk of pancreatic fistula after pancreatic resection (i.e., amylase content in drain < 5.000 U/L) but the impact of such a policy over the risk of chyle leak and lymphorrhagia is a critical area of interest. In patient underwent diaphragmatic resection, one chest drain should be placed intraoperatively. Chest drain may be removed in the absence of air and chyle leaks with a serous effusion < 450 mL/24 hours	[25-28,33,44,45]
Postoperative domain
19	Nasogastric tube	Postoperative nasogastric tubes should not be used routinely; if inserted during surgery, they should be removed before reversal of anesthesia	[7,24-26,28-32,48]
20	Urinary drainage	Routine transurethral catheterization is recommended for 1-3 days after surgery. The duration should be individualized based on known risk factors for retention: Male gender, epidural analgesia, and pelvic surgery	[25,29,31,33,44,45]
21	Postoperative nutrition	Postoperative nutritional status evaluation and early per os realimentation should be provided in all patients. Nutritional support with both immunonutrition, enteral nutrition and/or parenteral nutrition, should be considered in malnourished patients and follow latest guidelines	[29,36,47]
22	Prevention of postoperative ileus	Moderate level evidence supports use of peripherally acting mu-opioid receptor antagonist as alvimopan, while low grade evidence suggests a possible role for magnesium oxide, bisacodyl, and coffee	[25]
23	Postoperative glycemic control	Insulin treatment is strongly recommended in intensive care unit setting for severe hyperglycemia. Recommendation to treat mild hyperglycemia, and inward patients is weak	[24-26,28,29]
24	Early and scheduled mobilization	Patients should be mobilized actively from the morning of the first postoperative day and encouraged to meet daily targets for mobilization	[7,24-33,44,45,48]
25	Audit	Systematic audit improves compliance and clinical outcomes	[7,24-33]

Evidence quality is reported according to the GRADE system. RPS: Retroperitoneal sarcomas; NSAIDS: Non-steroidal anti-inflammatory drugs.

Table 2 Inter-observer concordance with the reference group (median Kw) in the two rounds of the survey

Observer	Relevance (Kw)		Feasibility (Kw)
	Round 1	Round 2	Round 1	Round 2
11	0.5681	0.7001	0.2941	0.3531
2	-0.154	0.386	0.185	0.350
31	0.2191	0.4621	0.3331	0.1881
41	0.6151	0.7281	0.6471	1.0001
51	0.4091	0.7371	0.3641	0.6021
6	0.227	0.438	0.333	0.143
7	-0.099	0.088	-0.154	-0.083
8	0.881	0.361	-0.059	0.265
9	0.144	0.612	0.292	0.306
10	0.298	0.426	0.391	0.138
11	-0.008	0.337	-0.243	-0.143
12	-0.094	0.000	0.037	0.091
13	0.298	0.353	0.286	0.352
Median Kw (range)	0.227 (-0.154; 0.881)	0.426 (0; 0.737)	0.292 (-0.243; 0.647)	0.265 (-0.143; 1.00)

¹The surgeons constituting the reference group.

Kw: The weighted kappa statistic.