Efficacy of opioid-free versus opioid-inclusive anesthesia on postoperative nausea, vomiting, and quality of recovery in patients undergoing video-assisted thoracoscopic surgery: a systematic review and meta-analysis.

Abstract

Background: Postoperative nausea and vomiting (PONV) is common after video-assisted thoracoscopic surgery (VATS). Opioid-free anesthesia (OFA) may reduce PONV; however, procedure-specific evidence remains limited. This review evaluated the effects of OFA versus opioid-inclusive anesthesia (OIA) on PONV, pain, and recovery after VATS lung resection.

Methods: Randomized controlled trials (RCTs) involving adults who underwent VATS lung resection and compared OFA, defined as no intraoperative opioid use, with OIA, were included. MEDLINE, Embase, and Cochrane Central were searched until January 18, 2026, and ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform were searched on January 19, 2026. The risk of bias was assessed using the RoB 2 tool. Random-effects meta-analyses were performed, and the certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation framework. The primary outcomes were PONV and pain at 24 h.

Results: Eleven RCTs involving 1183 participants were included, all of which used regional anesthesia. Most studies were conducted in China (n = 8), with one study each conducted in Poland, Turkey, and South Korea. Across the included studies, the mean age of participants ranged from 44.6 to 67.8 years. OFA was associated with reduced PONV within 24 h compared with OIA (eight studies; risk ratio, 0.58; 95% confidence interval [CI], 0.41-0.81; moderate certainty). Pain scores at 24 h were lower with OFA (eleven studies; mean difference, - 0.30; 95% CI, - 0.54 to - 0.07), although the difference did not reach the minimally important difference. OFA improved the quality of recovery (QoR) at 24 h (three studies; standardized mean difference, 0.40; 95% CI, 0.07 to 0.72; moderate certainty). No meaningful difference was observed in postoperative opioid consumption, and adverse event findings were inconsistent.

Conclusions: In selected patients undergoing VATS lung resection within multimodal pathways including regional analgesia, OFA protocols probably reduce PONV and improve early QoR compared with heterogeneous OIA regimens, while having little or no clinically important effect on acute postoperative pain. However, the independent contribution of intraoperative opioid avoidance remains uncertain owing to heterogeneity in regional analgesia, comparator opioid exposure, antiemetic strategies, and anesthetic management.

Trial registration: PROSPERO CRD420261292925.