Optimization of Postoperative Nausea and Vomiting Prevention in Bariatric Surgery Patients as a Component of Enhanced Recovery After Surgery

Abstract: Introduction. Bariatric surgery, the most effective long-term treatment for morbid obesity, is often complicated by a high incidence (30% to 80%) of postoperative nausea and vomiting (PONV) despite the use of Enhanced Recovery After Surgery (ERAS) protocols. Unmanaged PONV critically heightens the risk of catastrophic anastomotic leaks by inducing dehydration and generating intense mechanical stress, driven by a complex pathophysiology including altered neurohormonal profiles and systemic inflammation. Purpose. This research critically evaluates current empirical evidence to construct an evidence-based, multimodal antiemetic blueprint tailored to the extreme physiological demands of bariatric patients. The goal is to define optimal anaesthetic techniques, opioid-sparing co-analgesics, and superior multi-receptor pharmacological regimens that systematically minimise PONV incidence, safely accelerate oral intake, and fulfil the core mandates of ERAS. Materials and Methods. This analysis synthesises data from the Swedish Perioperative Registry (n=8,426), a scoping review of 81 RCTs, and early dietary trials. Crucially, it integrates prospective data from Tashkent State Medical University (n=120) evaluating triple-therapy antiemetics and results from metabolic syndrome cohorts. These sources collectively assess pharmacological, anaesthetic, and multimodal interventions for PONV in bariatric populations. Results and their Discussion. Epidemiological data identify female sex (aOR 2.21) and younger age as dominant risk factors for early PONV. Laparoscopic sleeve gastrectomy carries an aOR of 1.69 for PONV due to continuous mechanical stretch signalling from the low-compliance gastric remnant. Pharmacologically, volatile inhalation anaesthetics and cholinergic reversal agents (neostigmine) act as major emetogenic triggers and must be replaced by Total Intravenous Anaesthesia (TIVA) using propofol and non-cholinergic reversal (sugammadex). Since systemic opioids severely depress the enteric nervous system, an Opioid-Free Anaesthesia (OFA) paradigm—utilising dexmedetomidine, systemic co-analgesics, and regional fascial plane blocks—is essential to mechanically intercept somatic pain. Crucially, single-agent prophylaxis is obsolete. Modern pathways demand a "four-pillar" multi-receptor shield combining an NK-1 receptor antagonist (aprepitant) with a 5-HT3 antagonist, a corticosteroid, and a D2/H1 antagonist. This aggressive combination, particularly when paired with TIVA and P6 acupressure, can drop PONV incidence to 13.0%. Conversely, forcing early high-protein liquid diets yielded an 89.3% PONV incidence, proving that central emesis must be pharmacologically suppressed before introducing complex macronutrients. Conclusions. Singular, reactive interventions are profoundly inadequate for preventing PONV in bariatric surgery. A maximally aggressive, universally applied multimodal ERAS approach is strictly required. This entails abandoning volatile anaesthetics and opioids in favour of TIVA, regional mechanical blocks, and a proactive "four-pillar" multi-receptor antagonist regimen. Integrating these evidence-based strategies ensures minimised complications, accelerated patient recovery, and a structurally safe pathway for treating metabolic syndrome.

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