Pharmacological Modulation of Perioperative Pain in Laparoscopic Bariatric Surgery: An Updated Evidence-Based Narrative Review of Intravenous Lidocaine, Dexmedetomidine, Opioid-Free and Opioid-Sparing Anesthesia, and ERAS-Based Protocols

Zavaleta-Corvera C.; Pachari E.A.; Espinoza-Portilla J.; Farfán-Martinez W.; Bolarte-Arteaga M. · Anesthesiology Research and Practice (2026) · DOI: 10.1155/anrp/6019290

Resumen

Laparoscopic bariatric surgery is associated with specific analgesic challenges because opioid-related adverse effects may be especially relevant in patients with obesity, obstructive sleep apnea, and cardiometabolic comorbidities. Inadequate perioperative analgesia in this population may impair early mobilization and functional recovery, while excessive opioid use increases the risk of respiratory depression, postoperative nausea and vomiting (PONV), and prolonged hospital stay. This narrative review synthesizes and critically appraises contemporary evidence on intravenous lidocaine, dexmedetomidine, opioid-free or opioid-sparing anesthesia, and enhanced recovery after surgery (ERAS)–based perioperative strategies in adult patients undergoing laparoscopic bariatric surgery. A structured literature search was conducted in PubMed/MEDLINE, Embase, Scopus, and the Cochrane Library from January 2018 to May 2026. A total of 41 studies were included, comprising randomized controlled trials, observational studies, pharmacokinetic investigations, systematic reviews, meta-analyses, and ERAS implementation studies. Methodological quality was appraised using RoB 2.0, ROBINS-I, and AMSTAR-2 according to study design. Evidence for intravenous lidocaine remains heterogeneous and appears dependent on dosing strategy, infusion duration, and perioperative context; its antiemetic and anti-inflammatory effects may be more consistent than its analgesic benefit when infusion is limited to the intraoperative period. Dexmedetomidine has been associated with reductions in perioperative opioid exposure and PONV through alpha-2-mediated sympatholysis and opioid-sparing mechanisms, although effects on pain scores are variable and hemodynamic monitoring is required. Opioid-free or opioid-sparing strategies may reduce opioid exposure and PONV, but superiority over conventional anesthesia for pain control or length of stay is inconsistent, and protocol heterogeneity limits generalizability. ERAS pathways represent the most comprehensive and evidence-supported framework for perioperative optimization, with benefit proportional to adherence and independent of any single pharmacologic agent. These pharmacologic strategies are best understood as mechanism-based adjuncts to be selectively integrated within high-adherence ERAS programs, not as universal standalone interventions. Rigorous multicenter randomized trials with standardized dosing, detailed ERAS adherence reporting, patient-centered outcome measures, and subgroup analyses by procedure type, OSA status, and PONV risk are needed. Copyright

Instituciones: Universidad Científica del Sur; Universidad Continental