Comparison of dexmedetomidine and remifentanil for postoperative recovery and pain control in laparoscopic sleeve gastrectomy: a double-blind randomized controlled trial

Optimizing perioperative management in bariatric surgery is crucial for improving patient outcomes. Evidence comparing the efficacy of dexmedetomidine and remifentanil in morbidly obese patients undergoing sleeve gastrectomy remains limited, particularly regarding optimal dosing strategies. In this exploratory, double-blind randomized controlled trial, patients undergoing laparoscopic sleeve gastrectomy were randomly assigned to receive either dexmedetomidine or remifentanil infusions. To reduce the risk of delayed emergence, all drugs were dosed according to ideal body weight (IBW). The primary outcome was the binary incidence of postoperative pain, while continuous pain scores (VAS), postoperative nausea and vomiting (PONV), and hemodynamic stability were evaluated as secondary outcomes. A per-protocol analysis was performed, and sensitivity imputations for the 11 excluded patients (11.2%) supported the primary findings. Both agents provided acceptable perioperative conditions; however, dexmedetomidine significantly reduced the incidence of PONV and intraoperative bradycardia compared with remifentanil ( p < 0.05). Due to the pharmacokinetic limitations of IBW-based dosing, which likely resulted in underdosing, no statistically significant difference was observed in continuous postoperative pain scores between the groups. Dexmedetomidine offers superior antiemetic and sympatholytic benefits compared with remifentanil in sleeve gastrectomy. Future adequately powered trials using lean body weight (LBW) dosing scalars are required to conclusively evaluate its analgesic non-inferiority or superiority. The study protocol was registered prospectively with the Iranian Registry of Clinical Trials on 07/02/2026 (registration ID IRCT20250331065185N1).