Hassan S Allam, Mohammed Malibary
Obesity is associated with increased perioperative morbidity and greater operative complexity in gynecologic oncology surgery. Minimally invasive approaches may reduce some obesity-related complications, while adiposity and body composition measures may provide more accurate perioperative risk stratification than body mass index (BMI) alone. This systematic review evaluated obesity-related predictors of perioperative morbidity following gynecologic oncology surgery, with a specific objective of comparing BMI with alternative adiposity- and body-composition-based measures as predictors of perioperative outcomes. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 guidelines and was registered with the Open Science Framework (OSF) Registry (doi:10.17605/OSF.IO/4TY9B). Several databases were searched for studies evaluating obesity, BMI, and adiposity-related measures as predictors of perioperative morbidity after gynecologic oncology surgery. Records were screened in Rayyan, data were extracted using standardized forms, and risk of bias was assessed using Joanna Briggs Institute tools. Among 371 screened records, 73 studies were included in the final analytical synthesis. Endometrial cancer represented the largest evidence group. Obesity, elevated BMI, and adiposity-related measures were most consistently associated with wound complications, surgical site infection, venous thromboembolism, lymphatic morbidity, operative difficulty, and prolonged recovery-related outcomes. These associations were particularly evident during open surgery and high-complexity procedures. Minimally invasive and robotic-assisted approaches generally demonstrated favorable perioperative outcomes in selected obese and morbidly obese patients. Direction-of-evidence mapping qualitatively showed that most included studies reported significant associations between obesity-related measures and perioperative morbidity. CT-defined visceral obesity, waist-to-hip ratio, perinephric fat, and body composition measures frequently provided additional perioperative risk stratification beyond BMI alone. Obesity, elevated BMI, and adiposity-related body composition measures are important predictors of perioperative morbidity in gynecologic oncology surgery. Minimally invasive and robotic approaches may reduce selected obesity-related complications, while CT-derived visceral adiposity and body composition parameters appear to offer more precise perioperative risk stratification than BMI alone, supporting individualized surgical planning and perioperative care. However, these findings are based predominantly on heterogeneous observational studies and should be interpreted cautiously until confirmed by prospective research.