To the Editor
We read with interest the study by Togioka et al,1 which demonstrated that sugammadex showed no significant faster gastric emptying compared to neostigmine-glycopyrrolate, but exhibited a shorter time to neuromuscular blockade reversal and an earlier first bowel movement. We appreciate their contribution to the field of postoperative gastrointestinal function recovery in colorectal patients following sugammadex administration. However, there are several aspects of the methodology and results that we would like to discuss further.
First, although randomization in a randomized controlled trial is expected to ensure comparable baseline characteristics between groups, the study did not describe or statistically verify whether the preoperative gastric emptying rate (AUC150),1 a critical baseline parameter, was balanced between the 2 groups. When interpreting the primary outcome—gastric emptying—the potential risk of baseline imbalance should be carefully considered. Furthermore, postoperative differences in AUC150 compared to preoperative values, or differences in plasma drug concentrations at specific timepoints (eg, the 150-minute mark), might more accurately reflect the impact of different neuromuscular blockade antagonists (sugammadex vs neostigmine-glycopyrrolate) on gastric emptying.2 Future clinical studies are encouraged to further investigate these aspects.
Second, in the study, the administration of neuromuscular blockade antagonists occurred at the initiation of skin closure. Sugammadex achieved complete reversal significantly faster than neostigmine-glycopyrrolate (5.2 minutes [6.3] vs 17.5 minutes [10.1]; mean difference = 12.3 minutes, 95% CI, 9.2–15.4, P <.001). Sugammadex has a rapid onset of action (within minutes) and its reversal efficacy increases with higher doses.1,3,4 However, in real-world clinical practice—particularly for open abdominal surgery—the duration from the start of skin closure to complete surgical closure often exceeds 10 minutes. Premature reversal of neuromuscular blockade before full surgical completion may increase the risk of complications such as abdominal wound dehiscence and delay postoperative recovery.5 Given the rapid and effective action of sugammadex, its administration in the postoperative period should not be initiated too early.
Finally, it is well established that perioperative opioid use influences postoperative gastrointestinal function recovery.6 In the study, sugammadex achieved a significantly shorter time to first bowel movement compared to neostigmine-glycopyrrolate (mean difference = 16.7 hours, 95% CI, 2.3–31.1; 44.3 hours [33.8] vs 61.0 hours [43.0], P =.02). However, regarding opioid consumption, the study only reported intraoperative and post-anesthesia care unit (PACU) opioid use, without including opioid consumption during the postoperative 24-hour, 48-hour, or inpatient periods. Analyzing these additional timepoints would provide deeper insight into the potential role of sugammadex in accelerating postoperative intestinal recovery following colorectal surgery.
Dan Zhao, MM
Department of Anesthesiology
Binzhou Medical University Hospital
Binzhou, Shandong province, China
Lin Chen, MM
Department of Anesthesiology
Binzhou Medical University Hospital
Binzhou, Shandong province, China
Hongkun Wang, MM
Department of Rehabilitation Medicine-Rehabilitation
Intensive Care Unit
Binzhou Medical University Hospital
Binzhou, Shandong province, China
wanghk_byfykfk@126.com
REFERENCES
- 1.Togioka BM, Rakshe SK, Ye S, et al. A randomized controlled trial of sugammadex versus neostigmine for reversal of rocuronium on gastric emptying in adults undergoing elective colorectal surgery. Anesth Analg. 2025;141:373–383. [DOI] [PubMed] [Google Scholar]
- 2.Willems M, Quartero AO, Numans ME. How useful is paracetamol absorption as a marker of gastric emptying? A systematic literature study. Dig Dis Sci. 2001;46:2256–2262. [DOI] [PubMed] [Google Scholar]
- 3.Groudine SB, Soto R, Lien C, Drover D, Roberts K. A randomized, dose-finding, phase II study of the selective relaxant binding drug, Sugammadex, capable of safely reversing profound rocuronium-induced neuromuscular block. Anesth Analg. 2007;104:555–562. [DOI] [PubMed] [Google Scholar]
- 4.Abou Nafeh NG, Aouad MT, Khalili AF, Serhan FG, Sokhn AM, Kaddoum RN. Use of Sugammadex in “cannot intubate, cannot ventilate” scenarios: a systematic review of case reports. Anesth Analg. 2025;140:931–937. [DOI] [PubMed] [Google Scholar]
- 5.Sandy-Hodgetts K, Carville K, Leslie GD. Determining risk factors for surgical wound dehiscence: a literature review. Int Wound J. 2015;12:265–275. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Lacy BE, Cangemi DJ. Opioids and the gastrointestinal tract: the role of peripherally active µ-opioid receptor antagonists in modulating intestinal permeability. Am J Gastroenterol. 2024;119:1970–1978. [DOI] [PMC free article] [PubMed] [Google Scholar]