Block Plus Esketamine Improves Recovery vs Esketamine Alone in CRC Surgery

Key Takeaways

• Among adults aged at least 60 undergoing laparoscopic radical colorectal cancer surgery, a block–esketamine combination yielded a significantly higher day-3 recovery score than esketamine alone, but not a significant advantage over block alone.
• The combination yielded a significantly higher day-1 recovery score than either intervention alone.
• Day-1 pain scores and patient-controlled analgesia requests were lower with the combination than with esketamine alone.
• Intraoperative remifentanil use was lower in both block arms than in the esketamine-only arm, without a significant difference between block arms.

Dai and colleagues’ randomized trial in Drug Design, Development and Therapy enrolled adults aged at least 60 undergoing elective laparoscopic radical colorectal cancer surgery at one center in Hefei, China. The three-arm, placebo-controlled trial used blinded outcome assessment. 90 patients were randomized equally; 88 entered the per-protocol analysis, while the intention-to-treat mixed model retained baseline measurements from all randomized patients, including two without postoperative data. One group received bilateral ultrasound-guided QLB-LSAL plus saline infusion, another received esketamine without a sham block, and the third received both interventions. All received standardized general anesthesia and postoperative sufentanil-containing patient-controlled intravenous analgesia (PCIA). The prespecified primary endpoint was the postoperative day-3 Quality of Recovery-40 (QoR-40) total score. Recovery was assessed before surgery and on postoperative days 1 and 3; adverse events were tracked during the first 24 hours.

At the prespecified day-3 assessment, the combination exceeded esketamine alone by an adjusted 8.30 QoR-40 points (95% confidence interval, 4.37–12.23; Tukey P<0.001). The difference between the combination and block alone was not statistically significant.

On day 1, the combination exceeded block alone by an adjusted 6.03 QoR-40 points and also scored significantly higher than esketamine alone. Day-1 visual analog scale (VAS) pain scores were lower, and total PCIA compressions during 48 hours were fewer, with the combination than with esketamine alone. Both block arms used less intraoperative remifentanil than the esketamine-only arm, without a significant difference between block arms. Day-3 VAS pain, time to ambulation or first flatus, measured hemodynamics, and rescue analgesia did not differ significantly. An apparent day-1 Hospital Anxiety and Depression Scale anxiety-subscale (HADS-A) difference versus block alone did not survive adjustment; depression and day-3 mood scores also did not differ significantly.

Hypotension, nausea or vomiting, bradycardia, and postoperative agitation during the first 24 hours did not differ significantly among groups; this neither establishes equal safety nor excludes uncommon harms. The selected sample came from one Chinese center, the anesthesiologist performing the block could not be blinded, the esketamine-only arm had no sham block, and no arm received neither intervention. Total PCIA compressions reflect analgesia requests. The methods and limitations say effective PCIA-compression counts were unavailable, although the results also state that these counts did not differ between groups. Fewer total pump presses do not establish a lower delivered postoperative opioid dose.

Clinician Questions

Which older colorectal cancer surgery patients were eligible for the QLB-LSAL and esketamine trial?

Trial eligibility required elective laparoscopic radical colorectal cancer surgery, age 60 or older, body mass index of 18.5–25.0 kg/m², American Society of Anesthesiologists physical status I–III, and planned postoperative patient-controlled intravenous analgesia. Serious organ disease or inability to communicate or comply excluded participation.

What does the QoR-40 measure after laparoscopic colorectal cancer surgery?

The Quality of Recovery-40 (QoR-40) questionnaire measures physical comfort, emotional state, self-care, psychological support, and pain. Total scores range from 40 to 200, with higher scores indicating better recovery.