Enhanced Recovery After Surgery in Lower-Extremity Sarcoma Reconstruction: A Scoping Review of Reported Components and Outcomes.

Abstract

Oncologic lower-extremity sarcoma surgery with flap reconstruction is associated with a high risk of postoperative morbidity. Enhanced Recovery After Surgery (ERAS) protocols have been implemented in various surgical fields to improve postoperative outcomes, but ERAS protocols have not yet been adapted specifically for lower-extremity sarcoma surgery. This scoping review maps ERAS-reported components in the literature on lower-extremity sarcoma reconstruction to inform future protocol development. We searched PubMed/MEDLINE, Embase, Web of Science, and Cochrane Library from database inception to August 24, 2024, according to PRISMA-ScR guidelines and JBI guidance. Eligible studies assessed patients undergoing lower-extremity sarcoma resection and reconstruction and evaluated ≥1 ERAS-related perioperative component. Data extraction included study design, demographics, flap reconstruction, tumor types, ERAS components, surgical interventions, and primary and secondary postoperative outcomes. The primary search strategy identified 637 articles; 35 studies met the inclusion criteria. Across multiple studies, current smoking and higher preoperative and postoperative glucose levels correlated with higher rates of infection and major wound complications. Prolonged drain duration (≥14 days) was associated with higher surgical-site infection (SSI) rates in one cohort. In the PARITY randomized trial, 24-hour postoperative antibiotic prophylaxis yielded similar SSI rates but fewer antibiotic related adverse events than a 5-day regimen. We mapped commonly reported ERAS components (nutrition optimization, glucose control, multimodal analgesia, drain use, smoking status, antibiotic duration), highlighting evidence signals and identifying existing gaps in the research. Further research is needed to establish lower-extremity sarcoma-specific, evidence-based ERAS pathways.