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

Objective: To critically evaluate and elucidate optimised, multimodal prevention strategies for postoperative nausea and vomiting (PONV) in metabolic and bariatric surgery patients within an Enhanced Recovery After Surgery (ERAS) framework. Data Sources: Clinical databases including the Swedish Perioperative Registry, extensive scoping reviews, and randomised controlled trials evaluating perioperative bariatric interventions. Review Methods: A comprehensive synthesis of empirical data was conducted to evaluate the efficacy of intraoperative anaesthesia choices, opioid-sparing analgesia, regional fascial plane blocks, and multimodal pharmacological antiemetics. Results: PONV affects 30%–80% of bariatric patients. Female sex, younger age, and laparoscopic sleeve gastrectomy are profound independent risk factors. Evidence strongly supports abandoning volatile anaesthetics in favour of propofol-based total intravenous anaesthesia (TIVA). Opioid-free anaesthesia utilising dexmedetomidine, lidocaine, and regional blocks (e.g., Transversus Abdominis Plane blocks) significantly mitigates PONV incidence compared to opioid-based regimens. Single-agent prophylaxis is unequivocally insufficient; a multi-receptor approach combining a neurokinin-1 receptor antagonist (e.g., aprepitant) with a 5-HT3 antagonist, a corticosteroid, and a dopamine/histamine antagonist provides the most efficacious pharmacological shield. Conclusion: Effective PONV prevention in bariatric surgery demands a universal, multimodal ERAS approach. Clinicians must prioritise TIVA, strict opioid-sparing techniques, and combined multi-receptor pharmacological blockade to accelerate recovery and minimise complications.