Intraoperative Esketamine to Reduce Postoperative Pain and Opioid Consumption in Bariatric Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND

Bariatric surgeries cause severe pain, often requiring opioids that have significant side effects. Esketamine, an NMDA receptor antagonist, is proposed as an opioid-sparing adjunct, but evidence remains unclear in this population.

METHODS

Following PRISMA guidelines, we searched PubMed, Scopus, and Web of Science until July 2025 for RCTs comparing intraoperative esketamine to control in adult bariatric surgery. The primary outcomes were postoperative pain and opioid consumption. Secondary outcomes included patient recovery and other perioperative metrics. We used a random-effects model for pooled analysis.

RESULTS

Six RCTs with 582 patients were included. For the primary outcomes, esketamine showed no statistically significant difference in VAS pain scores (MD = 0.14; 95% CI: -1.23 to 1.51) and a non-significant reduction in rescue analgesic use (RR = 0.53; 95% CI: 0.20 to 1.41). Regarding secondary outcomes, there was a statistically significant but clinically modest improvement in early patient recovery on postoperative day 1 (SMD = 0.44; 95% CI: 0.13 to 0.75). Other metrics like extubation time, length of hospital stay, and PONV showed no significant differences.

CONCLUSION

Intraoperative esketamine does not significantly reduce postoperative pain intensity or overall opioid consumption in bariatric surgery. While it offers a statistically significant but clinically modest benefit for early patient recovery, its routine use as a primary opioid-sparing agent is not strongly supported, however the observed suggest that esketamine may hold potential as an adjunctive treatment, though further large-scale, international research is required to fully determine its clinical utility.