**5. Other challenges**

Despite all efforts, sometimes surgery fails, and there is the weight regain. It is more common in the case of restrictive procedures, as sleeve gastrectomy. For those cases, new and ingenious surgical techniques were created [29, 30]. The basic concept is that reducing the length of the small intestine will proportionally reduce nutrient absorption [31]. Therefore, even if the patient overeats, it will not put on weight. But, sadly, the absorption of vital elements like vitamins will also be jeopardised, and these patients will need close, continuous medical surveillance and chronic dietary supplements [32–34].

Another serious challenge has been the anaesthetic and the surgical procedure themselves.

The anaesthetic itself is full of scary moments [35]. Intubating these thick necks are not that easy, especially when also arthrosis appears with age. Getting good venous and arterial lines can prove exasperating. The lung and heart functions are already at their limits, only to mention a few challenges [36, 37]. Nevertheless, the whole endocrine system is altered because of adipose tissue, with its way of behaving in metabolism terms, and we can carry on.

As far as surgery is concerned, the introduction of endoscopic techniques in the nineties made it possible to reduce surgical aggression regarding access to the anatomical structure to be treated, be it the stomach or the small intestine [38]. But with this advancement, another challenge arose. Insufflating CO2 inside the abdominal cavity to get space for the surgical manoeuvres increases the abdominal pressure, pushing the diaphragm, thus increasing intrathoracic pressures [39]. Another challenge for the anaesthesiologist is the juggling to keep the venous return and the cardiac output within reasonable functional limits [40].

The final challenge is the patient. First, because lifestyle changes need to be maintained, the team must support the patient, but the patient must cooperate in the months following and the rest of their life. Second, the scars of the whole process will be there, showing up in the form of skin laxity, which will require, on many occasions, plastic surgery intervention, which will, in turn, will also leave its scars.

## **6. Conclusion**

Hence, this book attempts to be a global thought on obesity and its treatment before, during and after the surgery itself, and, most importantly, in the following months and years [41]. After all, nothing is less disheartening than seeing how relentlessly some patients put back some if not all the weight lost after the bariatric surgery because long term eating habits prove to be as essential as stomach or small intestine reduction [42, 43].

Nevertheless, other essential aspects of treatment need attention before and after bariatric surgery, such as physiotherapy, micronutrient deficiencies, and psychological attention. And yet, this is not all. Many will need repeated plastic surgical procedures to recover a body image they can feel proud of, and finding a new job or a promotion in the present or a new sentimental relationship are final aspects to consider [44–47].

To conclude, obesity is much more than just a high body mass index. It entails lousy eating habits, many coming from a faulty family raising, a change in mentality about what eating must mean to keep a healthy body and understanding that others are not going to be of help through a bariatric surgery if the patient him or herself do not take an active part in the process. Bariatric surgery is a long way, but neither the patient nor the surgeon is alone. Our role as doctors in the process is tiny, and we are members of a team that will have to be around this process for long and watch for any aspect that can be improved through our help and care.
