Association of Remimazolam-Based Versus Desflurane-Based Maintenance with Early Gastrointestinal Recovery After Laparoscopic Cholecystectomy: A Single-Center Retrospective Cohort Study

Background/Objectives: In standardized low-event surgery such as laparoscopic cholecystectomy (LC), discharge-based outcomes may be insufficiently sensitive to capture differences in recovery trajectory. We investigated whether early gastrointestinal recovery after standardized LC differed according to anesthetic maintenance strategy. Methods: This single-center retrospective cohort study included consecutive adults who underwent scheduled LC between September 2023 and December 2025 within a standardized perioperative pathway. The primary exposure was anesthetic maintenance strategy, comparing remimazolam-based with desflurane-based maintenance. The primary outcome was time to first flatus. Key secondary outcomes included postoperative day 1 (POD 1) high-sensitivity C-reactive protein (hs-CRP), C-reactive protein-to-albumin ratio (CAR), diet delay, prolonged hospital stay, postoperative nausea and vomiting, and 30-day readmission. Associations were evaluated using a log-normal accelerated failure time model, multivariable logistic regression, and log-transformed linear models for inflammatory markers. Results: A total of 316 patients were included (remimazolam, n = 171; desflurane, n = 145). Time to first flatus was shorter in the remimazolam group, with an unadjusted median difference of 8 h (28.0 [24.0–37.0] vs. 36.0 [28.0–52.0] h). After adjustment, remimazolam-based maintenance remained associated with a 21% shorter time to first flatus (time ratio, 0.79; 95% confidence interval [CI], 0.72–0.86; p < 0.001), corresponding to an adjusted median reduction of 8.0 h. The remimazolam group also showed earlier flatus recovery across predefined time windows and lower POD 1 hs-CRP and CAR, whereas later outcomes were largely similar. Conclusions: In standardized LC, early gastrointestinal recovery appeared more sensitive to anesthetic maintenance strategy than discharge-based outcomes. These findings support the use of early functional recovery measures, in addition to discharge timing, when evaluating perioperative recovery in low-event short-stay surgery.