How do I manage the drain?

Post Surgery Instructions

The Recovery Period

The post operative recovery period at home is usually for a couple of weeks. There are not many precautions to be taken, actually. Most patients are discharged home with the drain tube (the tube which comes out from the arm pit and is connected to a container). Care of the tube is simple, patients are educated about the same. Following are few of the points which patients always wish to know, regarding the recovery period:

Diet: No dietary restrictions as such, except if there are undelying problems lile Diabetes etc. A good balanced diet is perfectly fine. Even an ice cream once in a while is ok!
Activity She can move around the house, can also go down for a walk in the garden. She can wear a 'sling bag' on the shoulder and place the drain in that bag and cover with a thin shawl or something; that way the drain can be hidden from public view. Walking in an open space is always helpful. At home, routine activities can go on, being careful about the drain. The only restriction is - Not to go near the gas - till the drain is not removed. And of course, she is expected to do the shoulder exercises regularly.
Drain care: Explained in detail below.
Pain around site of surgery: Explained in detail below.
Dressing: Breast cancer surgeries are 'clean' surgeries and repeated dressings are not needed. We just call the patient once, about a few days after discharge, to have a look at the wound and ensure it is healing well (once in a while, people do get wound healing issues, especially if diabetic).
Follow up visits: Explained in detail below.

Overall, it is generally a very smooth, almost painless recovery for most patients. In any case, if problems crop up, we are always around to help.

Care of Drain

The one thing which most breast cancer patients (who have undergone surgery), associate the recovery period with - is the 'suction drain'.

Why is this drain kept?

To make it simple to understand, read the following points about normal lymphatic system in the hand:
All of us have 'lymph nodes' in the armpit. Some may have 10 nodes, some may have 15, and some even more, or some may have less. Number is not fixed. These lymph nodes are small 'bean shaped' structures, normally less than a centimetre in size each.
Blood flows from the heart upto the hand and from hand back to the heart. In this process of blood flow as it reaches smaller and smaller blood vessels of the arms and hand, some blood gets filtered out into a clean fluid called - 'lymph'
There are lymphatic channels all over the body; these channels 'drain' the lymph from organs into the 'lymph nodes'. In the arms and hands, these lymph channels lie just below the skin. All the lymph generated around the hand, comes back by these channels, into those 'lymph nodes' in the armpit. They are the first 'relay' stations. From the nodes, further lymphatic channels take it to 'secondary' nodes (around the wind pipe) and finally, via one main channel, the lymph enters the blood.

Apart from hand, the lymphatic channels from the breast also, go into these lymph nodes in the armpit. Hence, in a breast cancer surgery, we 'remove' the lymph nodes in the arm pit, as we need to check if the cancer cells have reached there.
Now that we have removed the nodes in breast cancer surgery, what will happen to the 'lymph' generated at the hand? The lymph from the hand will reach the arm pit and find the channel is broken (it is open) and there are no nodes; it will start 'spilling out' into the arm pit! It will keep on collecting there till it finds a way out (and it does find new channles over time). Usually, in a few weeks, the lymphatic collection reduces, as new channels open up.
But till the time new channels open up, all lymph will collect in the arm pit. Daily, about 100 to 200 ml of lymph can form. In some it is less, and in some, it can be more. And over a few days, almost 400 to 500 ml lymph can collect in the arm pit. This will cause a strong pressure on the stitches and wound can open up. We want to avoid this wound opening up. Hence, we keep a tube there, and an actively sucking container, so that all lymph collecting in arm pit is brought out and there is no pressure on wound, so it can heal (usually takes 2 weeks to heal).
That is why , till wound heals in 2 weeks, we keep the drain in place. Once the wound has heled, if we remove drain, and fluid still collects, the wound will have strength to withstand the collection and will not open up.

How do we empty the drain?

There are five steps, see the images for guidance:

Step 1: Note the amount of fluid in the drain - there are markings in 'ml' in the container at the bottom. Keep a diary, with note of daily output.
Step 2: Close the 'stopper' on the tube (to block the tube).
Step 3: Rotate the tube from the container at the valve. Empty the container in the bathroom. No ned to wash it.
Step 4: Now fully 'compress' the empty container and re thread the tube on to it.
Step 5: Open the 'stopper' on the tube (which was cloed in step 1)

Scution Drain Management
Management of pain

Post Surgery Pain

This heading sounds as if there must be a lot of pain after breast cancer surgery, but No, it really doesn't pain much! This topic is just for knowledge, why occasionally there is a mild pain on and off and what can be done about the same.

Where does it pain?

Apart from a pain which can come up along the line of 'cut' of surgery, there is a peculiar form of mild pain, a heaviness, or a tingling sensation on the 'inner' side of the arm, the 'outer' side of the chest wall and occasionally the shoulder area, for most patients who have undergone a breast cancer surgery. The reason is, during surgery, in many cases, the nerve carrying sensation from the inner part of the arm, has to be divided, especially if nodes are positive. And these divided nerve ending is like a 'live wire' - very irritable. It can grow slowly in a hayward direction. It is irritation of this nerve, that causes the symptoms.

What are the 'types' of pain sensations that happen?

Heaviness: Most women will just feel little 'heaviness' in the arm, a feeling as if 'some swelling' is there, when actually, there is none. It is just a 'feeling'.
Tingling and Numbness: As there is no sensation from the inner half of arm, touching that area with opposite will feel like 'wad of cotton'. Sometimes, a pin pricking sensation may be felt. Similar sensation also happens at the area of scar of surgery on the breast and in the arm pit.
Constant mild pain: Some women tend to have a constant mild 'dragging' pain in the arm and armpit

So what can be done if such mild pain symptoms happen?

By far, for most patients, within a few weeks, the pain settles. Though it does come up again, once in a while. For a small percentage of patients, it may persist for some time - again, in most, it is very mild and doesn't disturb lifestyle. If it does affect, then we try a few medicines to help it settle down, and it does!

Follow Up Visits

Breast cancer surgeries are 'clean' surgeries and do not need regular dressing. Only one dressing, to assess the wound status, is enough. Every few days, the suction drain tube will develop some protein clots; most of the times, these clots will move out on own. Occasionally, the clot gets stuck in the tube and prevents fluid from coming down - this is when the clot may need to be removed. So it is for this reason mainly, that followups are done. Considering the day of surgery as 'Day 0', we usually call the patients for follow ups in the following manner:

Day 07: We assess the wound once, a week after the surgery, and also 'de clot' the drain tube, if needed. 'De clot' means, to remove that protein clot. Also, we assess once how is the patient doing the shoulder exercises. By this time, usually, the pathology report will have come and we review it. Details on same are in the next section.
Day 11 or 12: Usually, by 11th or 12th day, we are able to remove the drain. Sometimes, if drain output is still high, or if we feel, the wound healing is not adequate, we keep the drain for a few more days. if we do not remove the drain, we at least de clot it once more.
Day 14 or 15: On this day, we remove the stitches / staplers. For most, we may be able to remove it in one go. For some, we remove most of them, but leave behind a few and remove those few, after two or three days.

Timing of follow up visits

Our Approach at this Step

The recovery period at home for most patients is reasonably smooth. Some of them might have minor symptoms here and there, and they do call me on phone and I guide them out. The instructions I follow are well mentioned above. I encourage the patient to do a little bit of house work provided she is feeling comfortable. Sitting and doing nothing, for an active lady, is very painful. If they keep doing some work, they recover better. Let us see in the next section, how we read the Histo Pathology report and decide on the further treatment,

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Journey of BC: Diagnosis

1. I feel a lump! - The first visit to doctor
2. Is it really cancer? - Confirmatory tests
3. What is the stage? - Staging and fitness tests
4. Will it be surgery first? or chemo first? - Treatment planning and sequence

Journey of BC: Surgery

5. Should I conserve or remove breast? - Choice of Surgeries for breast cancer
6. How long will be the surgery? - Admission and Surgery
7. Care after surgery - Precautions and guidelines - You are presently on this page
8. What next? - The Pathology Report

Journey of BC: Further Treatment

9. How many chemo cycles? - Chemotherapy Consultation
10. Is a PORT necessary? - ChemoPORT insertion
11. Will I be normal during chemo? - The Chemotherapy time
12. Is Radiation painful? - Radiation Therapy
13. Yes!! I did it! - Treatment is over
14. How frequently do I meet doc? - Follow up guidelines

Other Topics

Risk Factors - The Risk Factors for Breast Cancer
Symptoms of Breast Cancer - Know the Symptoms of Breast Cancer
Early Detection of Breast Cancer - The Guidelines

Neo Adjuvant Chemotherapy (NACT) - For LABC
Sentinel Node Biopsy - How is it done?
Targeted Therapy - Trastuzumab
Hormone Therapy - Who gets it?