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

Key Takeaways

• Esketamine-led opioid-free anesthesia was associated with lower postoperative pulmonary complication rates and lower hypoxemia incidence in this randomized bariatric surgery trial.
• Twenty-four-hour opioid consumption was lower while postoperative VAS pain scores were comparable across reported time points, and the opioid reduction did not meet the authors’ 10-MME clinical-significance threshold.
• Nystagmus occurred only in the esketamine-led group, PACU stay was longer, and no other significant safety differences were reported.

In a randomized bariatric surgery trial, esketamine-led opioid-free anesthesia was compared with opioid-balanced anesthesia using sufentanil and remifentanil in patients undergoing laparoscopic bariatric surgery under combined intravenous–inhalation anesthesia. Postoperative pulmonary complications occurred in 26.0% of the esketamine-led group and 50.0% of the opioid-balanced group, with RR 0.52, 95% CI 0.30–0.89, and P=0.013. This was the trial’s primary reported endpoint.

This prospective randomized controlled trial enrolled patients scheduled for laparoscopic bariatric surgery. Of 263 patients screened, 100 were enrolled for the comparison. The study evaluated esketamine-led opioid-free anesthesia for bariatric surgery during combined intravenous–inhalation anesthesia. Patients were randomized to esketamine-led opioid-free anesthesia, labeled S-Ket, or opioid-balanced anesthesia with sufentanil and remifentanil, labeled SR-Fen. Postoperative pulmonary complication incidence was the primary outcome.

Respiratory findings in the abstract also showed less hypoxemia with the esketamine-led strategy. 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. Investigators also reported lower postoperative pulmonary complication incidence in the esketamine-led group. Both pulmonary measures favored the esketamine-led strategy.

Secondary findings showed significantly lower opioid consumption within the first 24 hours after surgery in the S-Ket group. Visual analogue scale pain scores were comparable at all reported postoperative time points. The authors noted that the opioid reduction did not reach their clinical-significance threshold of 10 morphine milligram equivalents. Nystagmus occurred only in S-Ket patients, at 56.0% versus 0, with P<0.001, while no other significant safety differences were reported. PACU stay was also longer with S-Ket. The regimen was associated with lower opioid exposure, longer immediate recovery, and more nystagmus.