WHO ARE THE SUPER-OBESE PATIENTS AND WHAT TYPE OF OPERATION CAN BE PROPOSED TO THEM ?
Doctors have singled out a population of obese patient, called superobese patients. They have a Body Mass Index (BMI) of more than 50 kg per square meter (whereas morbid obesity is defined by a BMI of 40). Some of them are even sicker, they are called "triple obese or super-supra obese patients", and have a BMI above 60, going up to 300-450 kg. One can easily understand that this group is much more likely to suffer from related diseases or comorbidities: diabetes mellitus, cardiovascular diseases (hypertension), respiratory syndroms, disabilities related to joint-arthritis, etc. Thus bariatric surgery is often indicated in such patients, because diet and regular treatments fail to improve their health. Today in the United States, these patients represent the majority of the candidates to bariatric surgery. One can even state that the very beginning of bariatric surgery, some 40 years ago, owes to the emergence of this population in the post second world-war era. In the mean time, this procedures were uncommon in the rest of the world (and often disapproved of).

There is currently a tough debate over the type of operation that should be proposed to these patients. Are they a different group of patients with different causes of obesity? Then they would not respond the same way as the standard morbid obese population. Some surgeons think so. Actually, the current success of simple operations such as Adjustable Laparoscopic Gastric Banding has brought up controversy and debate. It is indeed a purely restrictive operation, acting on satiety and the ability to swallow small amounts of food, whereas digestion remains the same. A diet follow-up is mandatory, and a balanced diet is imperative (avoiding sugar and milk products).
In the United States, operations such as gastric bypass are now leading the way* (RYGBP for Roux-en-Y-Gastric-Bypass). It can be performed through the laparoscopic approach if the surgeon is properly trained. RYGBP is supposed to be more efficient in the long run in terms of weight-loss. Surgeons argue over the selection of patients pre-operatively. For some of them, the Lap-banding could be proposed only to the morbid obese patients, namely within the range 40-50 of BMI, whereas RYGBP (or another advanced technique) would be the method of choice for superobese patients. It has also been suggested that the Intra-gastric Balloon (BIB) should be used pre-operatively in order to "prepare" patients for bariatric surgery**. All this makes a lot of sense, but very good results have been obtained in superobese patients with the lap-banding too. Some will definitely fail to reach a significant weight-loss, and most of them will remain morbid obese after surgery, with an average BMI around 36. Nevertheless, other
procedures will fail in some cases too; besides, the chief goal is not to obtain a "normal" weight, but to decrease the related medical risk and to improve the quality of life, which is most often obtained from the Lap-banding. A reasonable proposal for superobese patients would be Lap-banding in the first place***, and in case of failure a "second step" option like bypass. And this should be performed by highly trained surgeons!

* AC Wittgrove, GW Clark. Laparoscopic gastric bypass Roux en Y- 500 Patients: technique and results with 3-60 months follow-up. Obesity Surgery 2000, 3: 233-239.
** R Weiner et col. Preparation of extremely obese patients for laparoscopic gastric banding by gastric balloon therapy. Obesity Surgery 1999, 9: 261-264.
*** J Dargent. Faut-il opérer les superobèses par anneau ajustable gastrique sous coelioscopie? Expérience de 1104 cas sur 8 ans. Journal de Coeliochirurgie, n°45, mars 2003, 63-66.