Hey doc, when can I go home?

Weight loss surgeons have their own protocols as to when you can leave the hospital. Some are more conservative than others. These are dependent upon several factors: first you have to be able to take in enough liquids so you won’t become depleted. Second, you have to be comfortable enough on oral pain medicine. Some weight loss surgeons like you to pass some gas (flatus not burps) before leaving, and others want you to have a bowel movement. There are other non-descript things also—one of my bariatric patients was ready to go home on Thursday, but wanted to wait a day—so Friday morning I was pleased to start signing her discharge papers, and she was getting a bit anxious. A friend of mine called me and said, “Don’t you understand, she wants to go home when her mom gets in town,” (her mother was coming on Saturday). “Her husband probably won’t do anything with the kids and this lady has to go home and do everything.” She was right—so Samantha stayed an extra day until her mom arrived there to take care of all the household chores. Sometimes even we weight loss doctors have to know patients a little bit—or as my friends from the east would tell me, “Doink!”

Laparoscopic weight loss surgery patients, depending upon the procedure, the bariatric surgeon’s protocol, and a few other assorted things, can go home anywhere from the second postoperative day onward. Bariatric patients who have had “open” weight loss surgery can go home anywhere from the third postoperative day onward. Again, this is highly dependent upon what your weight loss surgeon wants you to do. If they want you to wait until you have passed a bit of gas—that is fine.

A few tubes—how to care for them

Every weight loss surgeon uses a different number of them that go in various body cavities. Some bariatric surgeons use every one known to man, and some use very few of them.

Tube TypeUseWhen it is removed
Foley catheterThis is placed in the bladder of the bariatric patient and helps to monitor urine outputOften removed the first or second day after weight loss surgery if urine output is steady
Nasogastric
The NG
This goes from your nose into your stomach or pouch. It is used to decompress the stomach to avoid it from stretching too fastRemoved after a leak test confirms no leak. Some remove these the first to third day after weight loss surgery
Drainage tubes
Jackson-Pratt (JP)
Blake
Hemovac
Penrose drain
These are various types of drains that are placed in the abdomen. They can drain an abscess, a leak, bile, etc.Removed anywhere from a few days to a week. If there is a leak these remain in place until the body has sealed the leak
Gastrostomy
“G” tube
This goes into the main body of the stomach. It is can be used to keep the stomach decompressed or to feed the bariatric patient, or both.These can be removed anywhere from week 2 and beyond. Once the patient is doing well.
JejunostomyThis goes into the small bowel and is used to feed the bariatric patientOnce the weight loss surgery patient is able to take nourishment by mouth these can be removed
G-J tubesThese have a portion in the stomach, to decompress the stomach, and another portion in the small bowel to feed the patientAgain, these are removed when the bariatric patient is doing well enough to feed him or herself
Central lineAn intravenous line that goes into a vein in the neck (the jugular) or the chest (the subclavian). They can deliver nutrition much better than a standard ivSometimes these lines are put in at the time of weight loss surgery in patients who are “hard sticks.” They can be removed at discharge
PICC lines
Peripherally inserted central catheter. Sometimes placed by a radiologist or a specially trained nurse
These, like central lines, can be used for nutrition, antibiotics and blood drawsThey can be taken out once the weight loss surgery patient no longer needs intravenous access

Not everyone has all of these tubes and lines, and some of them are only used in weight loss surgery patients who have had some problems or difficulties. They are all useful, and they can all be lifesaving. But, you probably really wanted to hear about my Foley catheter.

When I had my knee operation, as you may recall from carefully reading this book, I was on a lot of Demerol and my brother had brought a six-pack of beer. One nurse came by and told me that I shouldn’t be drinking while I had the narcotics—I looked up and informed her that I wasn’t planning on driving that night. Besides relieving pain, Demerol can keep a sphincter closed. The next morning I woke up and felt as if my bladder was filled with a watermelon. I was in this machine to keep my leg moving, so I called for the nurses to give me a hand. They sent in this tiny little nurse’s aid, and I told her that I thought if I could just stand up, I could pee in this jug. She dutifully helped me out of the contraption and I leaned on her while holding the jug in the appropriate position.

Thirty minutes passed and this nice lady sighed and said, “Dr. Simpson, I’m getting tired.” I knew what had to be done, and told the nurse I thought I would need to have a Foley catheter. Now all of the nurses had known me for years, and perhaps that was the reason, but none of them wanted to put this catheter in me. So they called the “urology technician.” The tech was a nice fellow, had most of his teeth and shaved on alternate weeks. He placed the catheter in me and a liter and a half of urine came out. Everyone knows that a doctor who treats himself has a fool for a patient, and this doctor was no exception—normally if there is more than 300 cc after placing a catheter it is standard to leave the catheter in for a couple of days—not me. That night the same urology technician had to replace the catheter—and the second time it felt as if someone had made the catheter out of sandpaper.

So many tubes in weight loss surgery…they seem to be a bit overwhelming

It is difficult for family members to see tubes of various sorts coming out of their loved ones, but they can be lifesaving.

Tubes in the stomach have one of two uses: either to decompress the stomach or to feed the weight loss surgery patient. If the stomach isn’t able to empty it will distend, and early post operative, a stomach that distends too far inward can rupture at the staple line, causing a leak. Three things cause stomachs to distend: the first is anything that a bariatric patient drinks, the second is air that a patient swallows (one reason some weight loss surgeons and nurses don’t allow you to drink from a straw or swallow ice) and the last reason is that the stomach makes juices (gastric juices). Stomachs don’t work well after they have been cut, stapled, or sewed. Most stomachs recover in 24 hours, although some are delayed for days or even weeks. This is why some bariatric patients have either a G-tube or a nasogastric tube after weight loss surgery. While it sounds troubling to have a “nose hose”, they do prevent vomiting, and sometimes if a patient has persistent vomiting placing a nasogastric tube is a kind thing to do.

Some weight loss surgeons use no drainage tubes in the stomach whatsoever, and some use more than one. If there is a leak a tube allows the contents to drain, then when the body seals that leak it can be removed. While it doesn’t always work that way, it does provide a bit of protection. Since leaks occur in one to three per cent of bariatric patients, some weight loss surgeons feel more comfortable having a tube present. Some patients will develop an abscess following weight loss surgery, and a radiologist may need to place a drain into the abscess as a part of the therapy—every now and then, a weight loss surgery patient has to have an operation just to place a drain.

A gastric tube is placed directly into the stomach from the belly wall. For RNY weight loss surgery patients, these are placed in the lower pouch. In that manner the lower pouch can be decompressed and if need be, the bariatric patient can be fed through this tube. The Fobi pouch always has a G tube placed in the lower pouch.

A jejunostomy tube is placed in the small bowel. The weight loss surgery patient is fed through this. If a patient has a leak or is having severe protein malnutrition, it can provide a safe source for feeding the gut while the body recovers.

The G-J tube is placed in the stomach with an extension into the jejunum. These have two uses—they can decompress the stomach through one port and feed the bariatric patient through another port.

An IV is essential in the hospital, and it is difficult to find a vein in some weight loss surgery patients.For these bariatric patients there are two solutions: one is a central line that goes into a large vein in the neck, the chest, or rarely in the groin. The other is a PICC line that a specially trained nurse or a radiologist will place. These lines can also be used to feed weight loss surgery patients where a regular IV in the arm, hand, or leg cannot be used for these special solutions. Often if a patient is a “hard stick” for an IV, I will ask the anesthesiologist to place a central line while we are doing weight loss surgery, and we remove that line before the weight loss surgery patient goes home.

How we remove them

…or linguini with drain sauce

Removing any of these tubes is not difficult, and most weight loss surgery patients describe their removal as feeling like linguini is being removed from their body. Usually a bit of local anesthesia is injected at the site of the tube, the suture is cut, the weight loss surgeon counts to three and he pulls the drain out. Some have balloons that are deflated, and there are all sorts of variations. Every now and then a tube causes a problem and breaks off, requiring a simple operation to get it out, but that is pretty rare. The weight loss surgeon usually removes then in his office, and the only advice I give is this—if your drain is going to be removed, be sure to wear something that is old and you don’t care if it gets stained.