Opioid-Free Versus Opioid-Based Anesthesia in Pancreatic Surgery

Background: Opioid-free anesthesia (OFA) is associated with significantly reduced cumulative postoperative morphine consumption and postoperative nausea and vomiting in comparison with opioid-based anesthesia (OBA). Whether OFA is feasible and may improve outcomes in pancreatic surgery remains unclear. Hence, we retrospectively reviewed a consecutive cohort of patients undergoing pancreatic surgery. Methods: : Perioperative data from 77 consecutive patients who underwent pancreatic resection under OBA or OFA were included. Patients received either an OBA with intraoperative remifentanil (n=42) or an OFA (n=35) with a combination of continuous infusions of dexmedetomidine, lidocaine, and esketamine. In OBA, patients also received a single bolus of intrathecal morphine. All patients received intraoperative propofol, sevoflurane, dexamethasone, diclofenac, neuromuscular blockade, postoperative continuous wound infiltration, and patient-controlled morphine. The primary outcome was postoperative pain (Numerical Rating Scale, NRS). Opioid consumption within 48h after extubation, length of stay (LOS), adverse events within 90 days, and 30-day mortality were included as secondary outcomes. Episodes of bradycardia and hypotension requiring rescue medication were considered as safety outcomes. Results: : Compared to OBA, NRS (3 [2-4] vs 0 [0-2], P <0.001) and opioid consumption (36 [24-52] vs 10 [2-24], P =0.005) were both less in the OFA group. LOS was shorter by 4 days with OFA (14 [7-46] vs 10 [6-16], P <0.001). OFA ( P =0.03), postoperative pancreatic fistula ( P =0.0002) and delayed gastric emptying ( P <0.0001) were identified as only independent factors for LOS. The comprehensive complication index (CCI) was the lowest with OFA (24.9±25.5 vs 14.1±23.4, P =0.03). There were no differences in demographics, operative time, blood loss, bradycardia, vasopressors administration or time to extubation among groups. Conclusions: In this series, OFA during pancreatic resection is feasible and independently associated with a better outcome, in particular pain outcomes. The lower rate of postoperative complications may justify future randomized trials to test the hypothesis that OFA may improve outcomes and shorten length of stay.