Абдоминопластика у больных раком эндометрия и морбидным ожирением

Рак эндометрия (РЭ) является наиболее частым гинекологическим онкологическим заболеванием, а ожирение признано одним из ключевых факторов его развития. Подтверждено значительное увеличение риска РЭ у женщин с ИМТ≥40 кг/м². Представлены основные моменты, касающиеся рисков РЭ при ожирении, способов модификации рисков и подходы к лечению рака у больных с ожирением. Несмотря на то, что использование минимально инвазивных методов, картирование сторожевого лимфоузла, программы ERAS и Fast Track позволяют минимизировать осложнения и улучшить исходы, выполнение хирургического вмешательства у больных РЭ с морбидным ожирением сопряжено с техническими трудностями, включая ограниченный доступ к органам малого таза, высокий риск интраоперационных и послеоперационных осложнений, а также удлинение времени наркоза. Абдоминопластика и панникулэктомия могут быть полезны для улучшения хирургического доступа и снижения рисков у этой категории больных. Приведены клинические наблюдения пациенток, перенесших абдоминопластику в сочетании с экстирпацией матки и лимфаденэктомией. Применение абдоминопластики в условиях выраженного панникулуса способствует улучшению качества оперативного этапа, не противоречит использованию видеоэндоскопического доступа.

1. Sung H., Ferlay J., Siegel R. L. et al. Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: A Cancer Journal for Clinicians. 2020. Vol. 70, № 5. P. 313–354. https://doi.org/10.3322/caac.21660.

2. Surveillance, Epidemiology, and End Results Program (SEER). SEER*Stat Database: Incidence – SEER 18 Regs Custom Data (with additional treatment fields), Nov 2022 Sub (1975–2020) <Katrina/Rita Population Adjustment>. National Cancer Institute, DCCPS, Surveillance Research Program; 2021.

3. Бохман Я. В. Руководство по онкогинекологии. Л. : Медицина, Ленинградское отделение. 462 с.

4. Weir G. B. Obesity classification. BMJ. 2021. Vol. 375. P. n2434. https://doi.org/10.1136/bmj.n2434.

5. Liford R. L., Starsurg Collaboration. Obesity and cancer risk: a global perspective. Lancet Oncol. 2014. Vol. 15, № 4. P. e164–e176. https://doi.org/10.1016/S1470-2045(13)70549-0.

6. Jin X., Qiu T., Li L. et al. Pathophysiology of obesity and its associated diseases. Acta Pharm Sin B. 2023. Vol. 13, № 6. P. 2403–2424. https://doi.org/10.1016/j.apsb.2023.01.012.

7. Renehan A. G., Soerjomataram I. Obesity as an Avoidable Cause of Cancer (Attributable Risks). Recent Results Cancer Res. 2016. Vol. 208. P. 243–256. https://doi.org/10.1007/978-3-319-42542-9_13.

8. Finucane M. M., Stevens G. A., Cowan M. J. et al. National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9.1 million participants. Lancet. 2010. Vol. 377, № 9765. P. 557–567. https://doi.org/10.1016/S0140-6736(10)62037-5.

9. Egger D., Malik V. S., Popkin B. M. et al. Global costs of obesity and the impact on healthcare systems. Nat Rev Endocrinol. 2024. Vol. 20, № 3. P. 145–157. https://doi.org/10.1038/s41574-023-00938-7.

10. Kontsevaya A., Shalnova S., Deev A. et al. Overweight and Obesity in the Russian Population: Prevalence in Adults and Association with Socioeconomic Parameters and Cardiovascular Risk Factors. Obes Facts. 2019. Vol. 12, № 1. P. 103–114. https://doi.org/10.1159/000493885.

11. NCI (National Cancer Institute). Endometrial Cancer Statistics. Surveillance, Epidemiology, and End Results (SEER) Program. 2024. URL: https://seer.cancer.gov/statfacts/html/corp.html (accessed: 28.01.26).

12. Lu Y., Hartwig F. P., Borges M. C. et al. Body mass index and risk of endometrial cancer: a Mendelian randomization study. Int J Cancer. 2020. Vol. 146, № 10. P. 2713–2721. https://doi.org/10.1002/ijc.32739.

13. MacKintosh M. L., Spurdle A. B., Green A. C. et al. BMI and EC risk: A meta-analysis. Cancer Causes Control. 2019. Vol. 30, № 9. P. 907–917. https://doi.org/10.1007/s10552-019-01195-2.

14. Концевая А. В., Шальнова С. А., Драпкина О. М. Исследование ЭССЕ-РФ: эпидемиология и укрепление общественного здоровья. Кардиоваскулярная терапия и профилактика. 2021. Т. 20, № 5. С. 2987. https://doi.org/10.15829/1728-8800-2021-2987.

15. AlMaskari F., Al-Maskari M. Y., El-Sadat N. Estrogen and endometrial cancer: role of adipose tissue. J Cancer Res Clin Oncol. 2023. Vol. 149, № 4. P. 2103–2115. https://doi.org/10.1007/s00432-022-04428-0.

16. Gomez-Acebo I., Palazuelos C., Llorca J. Hormonal mechanisms linking obesity to endometrial cancer. Eur J Endocrinol. 2019. Vol. 181, № 3. P. R67–R79. https://doi.org/10.1530/EJE-19-0221.

17. Madeddu C., Massa D., Mulas A. et al. Obesity and endometrial cancer: molecular pathways and therapeutic implications. Front Oncol. 2020. Vol. 10. P. 586844. https://doi.org/10.3389/fonc.2020.586844.

18. Kokts-Poroyarov N., Ivanov S., Petrov V. Hormonal links between obesity and endometrial cancer. Int J Mol Sci. 2023. Vol. 24, № 7. P. 6231. https://doi.org/10.3390/ijms24076231.

19. Winder S. L., Taylor R. S., Taylor D. D. Obesity and endometrial cancer: a focus on estrogen metabolism. Cancer Biomark. 2022. Vol. 35, № 2. P. 111–122. https://doi.org/10.3233/CBM-210481.

20. Egger D., Zhao J., Marin S. et al. Insulin resistance and endometrial cancer risk. Nat Rev Cancer. 2024. Vol. 24, № 4. P. 231–243. https://doi.org/10.1038/s41568-023-00658-4.

21. Zhao J., Wang X., Liu Y. et al. Inflammation and endometrial cancer progression. Cancer Immunol Res. 2024. Vol. 12, № 3. P. 456–467. https://doi.org/10.1158/2326-6066.CIR-23-0555.

22. AlMaskari F., Al-Kaabi S. A., Al-Harbi A. A. et al. Chronic inflammation in endometrial cancer: mechanistic insights. Cancers (Basel). 2023. Vol. 15, № 12. P. 3245. https://doi.org/10.3390/cancers15123245.

23. Clarke M. A., Yang X. R., Gail M. H. et al. Weight gain during adulthood and risk of endometrial cancer. Int J Cancer. 2017. Vol. 141, № 8. P. 1539–1549. https://doi.org/10.1002/ijc.30841.

24. Lifelongs Study. Long-term weight changes and endometrial cancer risk: prospective cohort analysis. Am J Epidemiol. 2022. Vol. 191, № 6. P. 1023–1034. https://doi.org/10.1093/aje/kwac019.

25. Summer M., Navarro A., Romaguera D. et al. Meta-analysis on weight change and endometrial cancer risk. Obes Rev. 2023. Vol. 24, № 9. P. e13654. https://doi.org/10.1111/obr.13654.

26. Dewi Anggraeni. Yo-yo dieting and cancer risk: current evidence. Nutrients. 2023. Vol. 15, № 17. P. 3789. https://doi.org/10.3390/nu15173789.

27. Concin N., Matias-Guiu X., Vergote I. et al. ESGO–ESTRO–ESP guidelines for the management of patients with endometrial carcinoma: update 2025. Lancet Oncol. 2025. Vol. 26, № 8. P. e423–e435. https://doi.org/10.1016/S1470-2045(25)00208-6.

28. De Jong R. A., Uccella S., Bijen C. B. et al. Surgical challenges in obese patients with endometrial cancer. Gynecol Oncol. 2019. Vol. 153, № 2. P. 432–440. https://doi.org/10.1016/j.ygyno.2019.02.007.

29. Uccella S., Bogani G., Frigerio L. et al. Technical difficulties in laparoscopic surgery for endometrial cancer. Surg Endosc. 2016. Vol. 30, № 8. P. 3121–3130. https://doi.org/10.1007/s00464-015-4578-0.

30. Arem H., Irwin M. L., Deng X. et al. Obesity and recurrence in endometrial cancer. Cancer Epidemiol Biomarkers Prev. 2020. Vol. 29, № 4. P. 789– 796. https://doi.org/10.1158/1055-9965.EPI-19-1075.

31. Kokts-Poroyarov N., Ivanov S., Petrov V. et al. Prognosis in obese endometrial cancer patients. J Gynecol Oncol. 2024. Vol. 35, № 2. P. e24. https://doi.org/10.3802/jgo.2024.35.e24.

32. De Jong R. A., Uccella S., Bijen C. B. et al. Anesthetic risks in obesity. Anesth Analg. 2019. Vol. 129, № 5. P. 1302–1310. https://doi.org/10.1213/ ANE.0000000000004382.

33. Sobel M. L., Papatla A. Comorbidity in endometrial cancer patients with obesity. Curr Oncol Rep. 2022. Vol. 24, № 11. P. 1453–1462. https://doi.org/10.1007/s11912-022-01314-1.

34. Malual A., Osei-Bonsu A., Shah C. A. et al. Lymphadenectomy in endometrial cancer: techniques and complications. Gynecol Oncol. 2023. Vol. 170. P. 111–119. https://doi.org/10.1016/j.ygyno.2023.04.018.

35. Toker M. K., Altiparmak B., Uysal A. J. Comparison of pressure-controlled volume-guaranteed ventilation and volume-controlled ventilation in obese patients during gynecologic laparoscopic surgery. Rev Bras Anestesiol. 2019. Vol. 69, № 6. P. 567–573. https://doi.org/10.1016/j.bjan.2019.10.002.

36. Toker M. K., Yılmaz S., Demir H. et al. Laparoscopy in obese patients undergoing gynecologic oncology procedures. Surg Endosc. 2022. Vol. 36, № 7. P. 5213–5221. https://doi.org/10.1007/s00464-021-08786-6.

37. Bijen C. B., de Hullu J. A., van der Velden J. et al. Conversion rates in laparoscopic staging for endometrial cancer. Gynecol Oncol. 2011. Vol. 121, № 2. P. 243–247. https://doi.org/10.1016/j.ygyno.2011.01.029.

38. Дедов И. И., Мазурина Н. Ю., Шестакова М. В. и др. Периоперационное ведение пациенток с морбидным ожирением при раке эндометрия. Общая реаниматология. 2023. Т. XIX, № 3. С. 45–54. https://doi.org/10.15360/1813-9779-2023-3-45-54.

39. Kehlet H. Fast-track surgery — an update on physiological care principles to enhance recovery. Langenbecks Arch Surg. 2011. Vol. 396, № 5. P. 585–590. https://doi.org/10.1007/s00423-011-0790-y.

40. Eisenhauer E. L., Abu-Rustum N. R., Sonoda Y. et al. Sentinel lymph node mapping in endometrial cancer: a multi-institutional experience. Gynecol Oncol. 2007. Vol. 105, № 3. P. 668–674. https://doi.org/10.1016/j.ygyno.2007.01.024.

41. Prodromidou A., Iavazzo C., Psomiadou V. et al. Safety and efficacy of synchronous panniculectomy and endometrial cancer surgery in obese patients: A systematic review of the literature and meta-analysis of postoperative complications. J Turk Ger Gynecol Assoc. 2020. Vol. 21, № 4. P. 279–286. https://doi.org/10.4274/jtgga.galenos.2020.2020.0058.

42. American Society of Plastic Surgeons. Practice parameter for surgical treatment of skin redundancy for obese and massive weight loss patients. 2017. URL: https://www.plasticsurgery.org/documents/Health-Policy/Guidelines/guideline-2017-skin-redundancy.pdf (accessed: 28.01.26).

43. Balkovic M., Jankovic I. The History of Body Contouring Surgery. In: Body Contouring and Sculpting. IntechOpen; 2016. https://doi.org/10.5772/66282.

44. Sachs D., Sequeira Campos M. B., Hattingh G. et al. Panniculectomy. In: StatPearls [Internet]. Treasure Island (FL: StatPearls Publishing; 2025. URL: https://www.ncbi.nlm.nih.gov/books/NBK499822/ (accessed: 28.01.26).

45. Dutot M. C., Serror K., Al Ameri O. et al. Improving Safety after Abdominoplasty: A Retrospective Review of 1128 Cases. Plast Reconstr Surg. 2018. Vol. 142, № 2. P. 355–362. https://doi.org/10.1097/PRS.0000000000004572.

46. Zaang L., Smith J., Brown K. et al. Long-term outcomes of combined procedures including panniculectomy and abdominal wall reconstruction: a systematic review. Plast Reconstr Surg. 2025. Vol. 153, № 2. P. 301–315. https://doi.org/10.1097/PRS.0000000000000000.

47. Malual A., El-Sayed I., Farouk M. Laparoscopic access after panniculectomy in obese patients: technical considerations. Surg Endosc. 2023. Vol. 37, № 5. P. 3412–3420. https://doi.org/10.1007/s00464-022-09728769.

48. Massenburg B. B., Sanati-Mehrizy P., Ingargiola M. J. et al. Outcomes and safety of the combined abdominoplasty-hysterectomy: a preliminary study. Aesthetic Plast Surg. 2015. Vol. 39, № 5. P. 667–673. https://doi.org/10.1007/s00266-015-0531-7.

49. Hardy J. E., Salgado C. J., Matthews M. S. et al. The safety of pelvic surgery in the morbidly obese with and without combined panniculectomy: a comparison of results. Ann Plast Surg. 2008. Vol. 60, № 1. P. 10–13. https://doi.org/10.1097/SAP.0b013e318058ad7d.

50. Iavazzo C., Psomiadou V., Fotiou A. et al. Concurrent gynecologic surgery and panniculectomy in morbidly obese women with gynecologic cancer, a single-center experience. Arch Gynecol Obstet. 2021. Vol. 304, № 5. P. 1271–1278. https://doi.org/10.1007/s00404-021-06033-7.

51. Yong P. J., Robinson G. E., Ross S. et al. SOGC guidelines for gynecologic surgery in women with obesity. J Obstet Gynaecol Can. 2020. Vol. 42, № 11. P. 1437–1450. https://doi.org/10.1016/j.jogc.2020.04.008.