What is the primary cause of postoperative death after primary retroperitoneal sarcoma surgery in a high-volume center? A nationwide study by the French Sarcoma Group

Background: Studies on primary retroperitoneal sarcoma (RPS) surgery report morbidity rates between 15 % and 20 % and mortality rates between 3 % and 4 %. They do not specify the causes of postoperative 90-day mortality (POM). Aim: We aim to identify the causes of POM following primary RPS surgery and assess whether these causes were preventable. Methods: In this retrospective cohort study, data from French high-volume sarcoma centers (NETSARC+) were collected to identify patients who underwent surgery for primary RPS between 2015 and 2022. The causes of POM were analyzed. Preoperative risk factors were defined as Eastern Cooperative Oncology Group (ECOG) performance status of 3 or 4 and/or malnutrition. Perioperative risk factors were defined as pancreatic resection, great vessel resection or reconstruction, and/or significant bleeding. Results: Eleven NETSARC + centers provided data on 1081 patients who underwent surgery for primary RPS. Among these, 21 (1.9 %) died postoperatively. Preoperative and perioperative risk factors were identified in 18 (86 %) and 15 (71 %) of the patients, respectively. The median estimated blood loss was 1250 mL (range: 100–18,500 mL). Ten of the 21 patients (48 %) died due to hemorrhage, while respiratory failure accounted for the second most common cause of death (24 %). The third most common cause of death was digestive ischemia (14 %). Conclusion: POM following primary RPS surgery in specialized sarcoma centers is low (1.9 %). While aspiration pneumonitis could be prevented by the use of a nasogastric tube, hemorrhage and mesenteric ischemia were primarily due to extensive surgical indications, highlighting the importance of careful patient selection.