Esketamine-Led Opioid-Free Anaesthesia Lowers PPCs in Bariatric Surgery

Key Takeaways

• Postoperative pulmonary complications were lower with the esketamine-led approach than with opioid-balanced anesthesia.
• Opioid use during the first 24 postoperative hours was lower, while pain scores stayed similar and the reduction remained below the stated 10 MME threshold.
• Hypoxemia was less frequent, whereas nystagmus occurred only with esketamine-led anaesthesia and PACU stay was longer.

In a randomized bariatric surgery trial, esketamine-led opioid-free anaesthesia was associated with fewer postoperative pulmonary complications than sufentanil-remifentanil opioid-balanced anesthesia in patients undergoing laparoscopic bariatric surgery. Postoperative pulmonary complications occurred in 26.0% of S-Ket patients and 50.0% of SR-Fen patients, yielding RR 0.52, 95% CI 0.30-0.89, and P=0.013. The comparison focused on clinically observed postoperative respiratory events in bariatric surgery. The central finding was a lower incidence of postoperative pulmonary complications in the esketamine-led arm.

This prospective randomized controlled trial enrolled patients scheduled for laparoscopic bariatric surgery under combined intravenous-inhalation anesthesia in a defined perioperative pathway. Investigators screened 263 patients and enrolled 100, creating a randomized cohort for perioperative comparison.

Participants were assigned either to the esketamine-led opioid-free S-Ket group or to the SR-Fen group using sufentanil and remifentanil. Postoperative pulmonary complication incidence was the primary outcome, while secondary measures included total morphine milligram equivalents and visual analogue scale pain scores. The trial focused on pulmonary events and early recovery measures within the same operative setting and postoperative observation window.

Among the specific pulmonary findings, hypoxemia showed the clearest between-group difference after surgery. Hypoxemia occurred in 22.0% of S-Ket patients and 42.0% of SR-Fen patients, with RR 0.52, 95% CI 0.28-0.97, and P=0.032. Opioid consumption during the first 24 postoperative hours was significantly lower with S-Ket, with P=0.025. Visual analogue scale pain scores were comparable between groups at all reported postoperative time points, and the opioid reduction did not reach 10 MME. Together, these findings showed lower early opioid exposure without a measurable difference in reported postoperative pain intensity across the recorded time points.

Nystagmus appeared only in the S-Ket group, affecting 56.0% of patients versus none in SR-Fen, with P<0.001. PACU stay was also longer in S-Ket, with P=0.039 for that difference. No other significant between-group safety differences were reported in the available summary of postoperative adverse events and recovery findings.

Overall, the randomized comparison published on 06 May 2026 paired fewer pulmonary complications with mixed recovery and safety observations in this bariatric cohort.