Bariatric surgery has the potential to change patients' lives, but they must commit to lifelong changes. Those changes begin with the comprehensive care your surgical program offers.

A safe and effective bariatric surgery program is founded on the procedure itself, from the involvement of trained, qualified surgeons and nurses to careful patient selection, risk assessment and outcome evaluation. But a successful program must also focus on the long term. A perioperative program for bariatric surgery patients educates those undergoing the procedure, demonstrates the guidelines for recovery and ensures that patients comply with them for continued health.

"It's a lifelong change. It requires a lifelong follow-up on the part of the practice," says Gerald Cahill, MD, FACS, of the Midwest Bariatric Institute in Evergreen Park, Ill. "Once you perform the operation, you're committed to the patient's long-term care."

For two bariatric clinic staff members - a social worker and a personal trainer - urgent patient care takes place outside the operating room. Here's how they created their perioperative programs.

The importance of support
"We started from scratch in November 1998," recalls Valerie Ross Homan, MA, MSW, LCSW, the coordinator of clinical support services for New York Bariatrics in White Plains, N.Y.

More than 500 patients later, the community-based clinic has found its support group program is among its most valuable tools.

"The after-care is for the rest of their lives," says Ms. Homan. "They can't just have the surgery and go off on their own. Their health could be seriously compromised."

After reading studies on the needs of bariatric surgery patients and talking with experts in the field, she also conferred with the clinic's surgeons and consultants for their views on a support group system.

"It's really important that if you're going to work together as a team, you have to meet regularly and communicate openly," says Ms. Homan. "It's not easy - everyone's busy - but it's important, for follow-up or even for troubleshooting."

She'd also gained an awareness of what was necessary from her own career. "As a clinical social worker at agencies, I'd supervised other human service programs," says Ms. Homan. "I took a lot of what I'd learned there and applied it to a bariatric surgery program."

Weathering the aftereffects of the surgery, she notes, seemed similar to withstanding other psychological and social adjustments involving body changes and behavior modification.

"Our groups are based on an addiction model," says Ms. Homan. "It's about lifetime recovery."

New York Bariatrics requires patients to attend a single-session patient education night, held twice a month, and encourages them to observe a post-operative support group in action before their surgeries. Attendance is arranged during pre-operative exams or psychological evaluations.

As with the human body, post-operative support comes in more than one size to better serve the patient. With the advice of the clinic's consulting nutritionist, says Ms. Homan, "we developed a support group that matches the dietary phases."

Twice a month, the "New Post-Op Adjustment Group" meets for patients who have undergone surgery within the last 12 weeks - "We take our patients through the first three months in a very regimented process," says Ms. Homan - and twice a month, the "Bariatric Surgery Support Group" gathers patients more than three months out of the operating room. "Those who were further along with recovery got tired of hearing about early dietary difficulties," she adds.

More than one year post-op, patients can attend long-term recovery groups, which meet periodically on such subjects as adolescent patients' concerns, getting back on track or relapse prevention.

"We try to be aware of the trends affecting our patients," says Ms. Homan. "If there seems to be a trend, we can offer a group for that."

Each group is led by a licensed clinical social worker or registered nurse who can monitor patient progress, identify problems and intervene if a patient isn't complying with optimal guidelines.

The continuing contact offered by active support groups provides a benefit for bariatric surgery professionals as well, notes Ms. Homan, especially into the future.

"No one is 30 years post-op," she says. "Who knows what we're going to discover down the road?"

"Exercise as a friend"
For the past three years, Craig Wittgrove, CPT, BSED, has been the fitness coordinator for the Wittgrove Bariatric Center in San Diego. During that time, he says, individualized post-operative exercise has become a more and more important consideration for the bariatric surgery community.

"It's as important as their nutrition," says Mr. Wittgrove.

Through his work at the center - founded by his father, Alan Wittgrove, MD, FACS, a past president of the American Society of Bariatric Surgery - Mr. Wittgrove has found that a guided, specific exercise program increases the percentage of excess weight lost after surgery. It also increases the percentage of muscle mass retained during the rapid weight loss.

He points out that it's important to impress this finding onto patients as early as possible. He meets some of the center's patients during pre-op education nights or medical examinations. The rest he meets shortly after surgery. The tone is always positive.

"I want them to look at exercise as a friend for the rest of their lives," says Mr. Wittgrove. "One of the big things is just getting over the fear and seeing the possibilities. Because we're adding years to their lives."

A post-operative exercise program can start with basic activity. "We want them walking as soon as they're discharged, for as long as they're comfortable," says Mr. Wittgrove. "Honestly, there's not a reason that they can't. And most patients actually feel good enough to."

As with recovery from surgery, however, one patient's exercise needs may differ from another's, and a program that promotes exercise should always keep individual cases in mind.

"We looked at the general guidelines that are given to everyone, and then we looked at our patient population," Mr. Wittgrove says. "We want them doing cardiovascular exercise, resistance training, flexibility activities, but we also want to look at their limitations, their co-morbidities. Do they have osteoarthritis? Is it best for them to do their exercises in the water?"

"From that point, it's unique to each individual," he adds.

The Wittgrove Bariatric Center has trainers on staff to work with patients on site. However, if that's not feasible for a clinic, contracting with outside consultants for the role is essential, says Mr. Wittgrove.

At a smaller, community-based practice like Homan's, that's the only practical solution. But you should do your homework first.

"When a program is new, and you can't afford to hire everybody full-time, it's a nice way of starting a program with quality people and not have to carry a lot of overhead," says Ms. Homan. "I think it is the only way a community program can do it."

It's the people
At New York Bariatrics, many roles were filled through recruiting the experts the surgeons had worked with in hospitals." Every person we have in our program has been hand picked," says Ms. Homan.

In addition, both Ms. Homan and Mr. Wittgrove agree that the attention given by non-surgical staff makes just as much of a difference as the operation itself.

"When you think about the long-term effects, it's the little things like that that are going to help them maintain the long-term lifestyle change," Mr. Wittgrove says, "and enjoy it a lot more."