The role of esketamine in enhancing postoperative recovery and pain management in laparoscopic surgery: a meta-analysis of randomised controlled trials.
Abstract
<h4>Background</h4>Effective analgesia in laparoscopic surgery remains challenging due to visceral pain and postoperative nausea. NMDA-receptor antagonists such as esketamine may enhance peri-operative analgesia, mitigate opioid related side effects, and it also shows potent antiemetic properties.<h4>Objectives</h4>This meta-analysis evaluated whether intra-operative esketamine improves postoperative pain and other outcomes in adults undergoing laparoscopic procedures.<h4>Study design</h4>The study followed PRISMA guidelines and was registered with PROSPERO (Registration No: CRD420251039241). The search for studies was carried out in the PubMed, Embase, Scopus and the Cochrane Library from inception to 1 March 2025.<h4>Eligibility criteria</h4>Eleven RCTs (<i>n</i> = 1036 patients) met inclusion criteria. Outcomes included postoperative pain scores (0-6 h, 12-24 h), opioid consumption, PONV and adverse effects. Data were pooled using standard techniques. Evidence certainty was assessed by GRADE methodology.<h4>Results</h4>Esketamine significantly reduced pain scores at 0 to 6 h (MD = -0.32, 95% CI: -0.40 to -0.25, <i>P</i> < 0.001) and 12 to 24 h (SMD = -1.07, 95% CI: -1.22 to -0.91, <i>P</i> < 0.001). It lowered the risk of requiring rescue analgesia by 38% (risk ratio = 0.62, 95% CI: 0.38 to 1.00, <i>P</i> = 0.05) and reduced PONV incidence by 26% (OR = 0.74, 95% CI: 0.56 to 0.97, <i>P</i> = 0.03). No significant differences were found in emergence time, postanaesthesia care unit stay or cumulative 24-h opioid consumption. Heterogeneity was substantial for some outcomes. Evidence certainty was moderate to low.<h4>Conclusion</h4>With a low to very low level of certainty, esketamine appears to improve early postoperative pain control and selected recovery parameters (enhancement of analgesia with both reduced rescue analgesia needs and reduced PONV) in laparoscopic surgery without increasing adverse events. It represents a valuable adjunct in multimodal analgesia, though standardised dosing. However, considerable heterogeneity in esketamine dosing, mode of administration and background analgesic regimens across included trials limits definitive conclusions and highlights the need for standardised, high-quality randomised trials.
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