Objective To evaluate the efficacy and safety of ciprofol dosing calculated using different body weight scalars—total body weight （TBW）， adjusted body weight （ABW）， and ideal body weight （IBW）—combined with fentanyl for procedural sedation during gastroscopy in overweight and obese patients. Methods A total of 294 overweight and obese patients （BMI 25 - 40 kg/m2） undergoing sedated gastroscopy at The Seventh Affiliated Hospital， Sun Yat-sen University， between March and September 2024 were enrolled. Participants were randomly assigned in a 1∶1∶1 ratio to one of three groups （n = 98 per group） using a random number table： TBW group， ABW group， or IBW group. Anesthesia was induced with fentanyl 50 μg plus ciprofol 0.4 mg/kg （calculated according to the assigned body weight scalar）， followed by maintenance infusion of ciprofol at 1 mg/（kg·h） based on the same scalar. Primary outcomes included ciprofol rescue dose requirements and recovery time. Secondary outcomes encompassed sedation success rate， hemodynamic parameters （MAP， HR， SpO?） at predefined timepoints （T?： pre-induction； T?： scope insertion； T?： passage through piriform fossa； T?： pyloric examination； T?： procedure completion； T?： awakening in recovery room； T?： discharge from recovery）， and incidence of adverse events. Results Compared with the TBW group， the IBW group required a significantly higher cumulative rescue dose of ciprofol （P 0.05） and achieved shorter recovery time （P 0.05）. The ABW group also demonstrated shorter recovery time versus TBW （P 0.05）， with no significant difference in rescue dose requirements （P 0.05）. No significant differences were observed between the ABW and IBW groups regarding rescue dose or recovery time （both P 0.05）. The incidence of adverse events—including respiratory depression， hypoxemia， hypotension， bradycardia， involuntary movement， cough， singultus， dizziness， nausea， and vomiting—and the sedation success rate did not differ significantly among the three groups （all P 0.05）. Perioperative hemodynamic profiles remained stable and comparable across groups （all P 0.05）. Conclusion For overweight and obese patients undergoing sedated gastroscopy， a ciprofol-fentanyl anesthesia regimen with ciprofol dosing calculated by adjusted body weight （ABW） provides optimal balance between anesthetic efficacy and recovery efficiency， while maintaining a favorable safety profile comparable to TBW- or IBW-based dosing. ABW-based dosing is therefore recommended as the preferred weight scalar in this population.