Original subtitles

This program me contains discussion of life and death stories,

scenes of surgery that some viewers may find distressing

The human body is an extraordinary machine.

Every day, billions of our cells are being replaced with new ones.

But sometimes things go wrong.

And when they are deemed untreatable,

people turn to us.

Because we take on some of the world's most difficult cases.

Patients come from far away

with the most complex medical problems in the world,

and we understand that this is their only hope.

The patients we see will die without our help.

And to save their lives, we have to push the limits

of what is surgically possible.

We get only one chance to get these cuts right.

If it goes wrong, it can do patients terrible harm.

Ooh.

We've got a hole in the brain.

Hold it, hold it. Hold it. Quick, please.

In the worst circumstances,

it could even mean not making it off the operating table.

You have to make sure that the risk is justified

by the opportunity to cure them.

Oh, wow.

It's a lot of pressure on you as a doctor.

I sometimes have sleepless nights.

The stakes are tremendous.

So you try your utmost to save every life coming your way

because you realise how fragile life is.

OK. So we'll go up to my daughter's room.

Watch the baby gate.

Can actually take them down soon,

now she's walking up and down the stairs on her own.

Hand painted by myself when I was...my belly was out here.

Her favourite colour is pink.

Everything's got to be pink.

SHE CHUCKLES

COUGHS

I was on maternity leave.

My daughter was six months old,

and I took her for a check at the GP.

And just at the very end of the appointment, my doctor said,

"And how are you?" I said, "|'m OK,

"but I've had a sore throat for about five weeks."

I was not worried at all.

I went to the appointment and she looked down and she could

see an ulcer. She said, "I don't think it's anything but

"I think it'd be safe to do a biopsy."

And we got the call and the doctor told me

it was squamous cell carcinoma.

I say, "Is that cancer?"

And he said, "Yes, it's cancer.

In your throat."

"It's a skin cancer in your throat."

I was just gobsmacked.

It was just so...just so emotional.

I just couldn't believe it.

Jade has had a lot of treatment, but unfortunately,

the tumour has now come back.

Now they want to remove my full voice box

to cure the cancer

and be left with a permanent...

I don't know the name of it — breathing tube —

so I wouldn't be able to speak to anybody, especially my daughter.

Wheee!

I just could not have this operation.

We need a miracle. We do need a miracle.

Most patients have been on quite a long journey

by the time they get to me.

They have had treatment.

They've been told the cancer has gone away.

And then the cancer strikes again.

If left untreated, the vast majority will die within three months.

So you try your utmost to save every life coming your way

because you realise how fragile life is.

Jade's had radiotherapy with chemotherapy for her

throat cancer, and despite that, the cancer's come back.

So the only option that jade has is for us to go in

and cut this cancer out.

Jade's cancer is there.

It's quite low down in her throat.

The conventional operation for jade would be

to take the entire voice box out just to get to that.

But jade won't have that.

She tells me that removing her voice box

is not a negotiable option at all.

But I think we could potentially use a robot to go in through the mouth

and take the cancer out while leaving her voice box behind.

Over the last few years, robots have changed the way

we perform cancer operations.

But for jade, I won't know until I examine her

if this is possible at all.

I'm one of those people who will push the boundaries as much

as I can for curative treatment where it is feasible.

Jade, how are you?

I'm all right, thank you.

SHE COUGHS

I have a wig on. I can take it off if you want.

I could barely make out it's a wig, gosh, if you hadn't told me.

It's a real hair one. Ah. OK.

Your neck feels wonderful, but we need to look inside.

SHE GROANS

Oh! It really hurts. Sorry.

OK. Your tumour is here.

Say, "Eeee," jade.

Eeeee.

COUGHS

Sorry, apologies. Deary me.

Coming out. Coming out.

So, this is your throat, and your cancer is low down

on the right-hand side here.

I think we might be able to remove the cancer through the mouth

using a robot, but it is unusual for us

to go that low in an operation

simply because the access gets very crowded.

What's your mouth opening like?

Your mouth opening is excellent, which is a positive thing for me,

but it looks like we can do this through the mouth without

taking your voice box off.

Do you think so? Yeah, yeah.

So, my voice, will it be the same as it is now? No.

Because of where the tumour is,

because of the way we do this, a lot of inflammation spreads

into the surrounding areas.

So your healing takes place up to two or three months.

And we can do many things to make your voice better

in the long-term.

This is a low throat tumour.

And if I can't get to the bottom end, I might have to abandon

the operation. And that would leave the cancer behind,

and the cancer would then progress.

The longer I spend in this field, the unfairness of it all strikes me.

You know, sometimes life can be incredibly unfair

to some patients.

Right now, we can see a future again, which is everything.

So there is some hope...

...for me and my family.

It all started here.

This is the father and the mother of all.

Before it started showing,

it was...it was just that you could feel it like a rock or like a bone,

and I didn't know what it was.

It wasn't hurting in the beginning, so I let it grow.

But when I saw it climbing up on my arm, I said,

"OK, I need to go check it."

Everyone's been telling me that this is an aggressive cancer.

There is a great possibility we could be losing the whole arm.

But not just that, but losing the shoulder.

It seems like half of your body.

I'm a self-taught photographer and film—maker.

That requires both of my arms and all of my fingers.

Here's a picture I took in, er...

This is in Manhattan Beach in Los Angeles, California.

I think that this photo tells a few things about my character.

I've always wanted to look like I'm brave and strong, you know

what I mean? And now getting hit by this illness is actually telling me,

like, "You're not as strong as you think."

Dimitrios has a rare sarcoma.

You would struggle to find another patient in the UK who presented

in the same way in the last 10 or 20 years.

Sarcoma arises anywhere in the body — muscles, fat or fibrous tissue.

There are more than 50 types,

which can make it extremely difficult

to find treatments which are effective.

So we've got Dimitrios's PET scan here.

This scan lights up cancer cells if they're metabolising glucose.

If you follow his hand down, you can see a big bit of activity there

over the finger. As we walk up the arm, you see another bit

there and another bit there.

And this is picking up deposits which are probably

five, six millimetres or greater.

So it probably is the case that there's more disease in here.

Dimitrios has been on a new drug on a trial for a year now.

The disease has stopped progressing, but it's still very much there.

So the worry that we have is that, at some point, one of these tumours

is going to release sufficient number of cells around the body,

they're going to land elsewhere.

Normally, the only option would be to amputate the whole

of his arm. But, to save his arm,

we have to think a little bit out of the box.

Hi, Dimitrios, how are you?

Very good. And you? Do you want to bump elbows?

Right. So, um, I think we're going to do something for you.

There's a rare technique called isolated lymph effusion

where we blast the arm with an incredibly high

concentration of chemotherapy.

OK. But this would be far too dangerous for the rest

of the body, so it's done during an operation.

We'll physically isolate — this is why it's called isolated —

the blood supply of the arm from the blood supply

of the rest of the body. So we can administer chemotherapy

into the circulation of the arm only.

Side-effects — your arm is going to be red hot, swollen.

It's going to feel like really bad sunburn.

For how long?

It can go on for six weeks.

I've had one limb loss in a very elderly patient.

I just have to mention that, that that has happened.

The most serious thing is to survive this whole thing. Correct.

Before I got diagnosed, I used to be a lot different.

I was always living in the future.

Always in a rush, always stressed.

No matter what I did, it wouldn't give me happiness.

But now, I understand the whole picture better.

This life here is not forever.

It took me years to build up the courage to start

doing arm effusions.

Making sure that you have an isolated circulation in some

very delicate blood vessels is technically demanding.

If it goes wrong, that potentially can be catastrophic.

PHONE RINGS

Hello. You're speaking with Macmillan. How can I help?

Yes, certainly. I bet they've been a real relief

when you've been going through your treatments.

Yes.

PHONE RINGS

OK.

Did you notice a mole that had changed or an area of skin?

It's the big C, isn't it?

As a society, we have tuned to the fact that cancer means death.

But that's not strictly the case.

PHONE RINGS

I took her to nursery yesterday morning, and I didn't want her

to think there was anything unusual going on

so I tried to do a normal goodbye.

I did have a few extra kisses,

and then I just said, "Love you, baby bear."

When a cancer returns after treatment,

it's often very aggressive.

Surgery is a last resort to save life,

and sometimes that means losing a part of you.

See you later. Love you.

But some patients draw red lines.

They say, "I'm not having that. I'd rather die. Do something else."

Forcing us to innovate.

Robotic surgery low down in the throat is difficult

because the throat narrows down like a funnel as we get lower.

If I can't get the cancer out through the mouth,

then this cancer will progress. We have no doubt about that.

I remember the first patient who died on my watch.

Um, I was training in India.

A bit more. Yeah. Stop. Good.

He was 13 years old.

His anatomy was so badly changed,

we just couldn't find his normal airway.

That was hard, watching him die.

And even today, when I deal with a difficult airway, that plays

back in my head. Even today.

I'm never going to let that happen on my watch.

You can see the tumour here.

So that's the cancer.

Are we good to start?

So I'm making those initial cuts.

These tools give me superb vision,

and I'm depending on my vision

to make that distinction between what is tumour

and what's not tumour.

Suction here. Thanks.

Is that part of the tumour or...? No, it's not.

VOICE OVER: We need to be delicate with this tumour,

because if we damage it, we can't be completely certain

that we got all the tumour out.

OK. just drop it down now. Let's make that cut a bit more.

Thank you.

Careful, careful. The tumour.

VOICE OVER: The margin of error is limited.

We're talking about millimetres here.

And I know that my decision-making causes ripple effects

well outside the operating room.

# Happy birthday to you... #

Yay!

The minute she hears me, she knows it's me.

Safety, security.

The way I say things to her, she knows whether it's, you know,

OK or not OK.

I joke around with her and use my jokey voice.

To maybe be faced with blank looks of confusion

if I couldn't talk to her...

Aww!

It's Mummy's voice, which is so important.

MONITOR BEEPING

We're getting close to the lower end of the tumour,

below the Adam's apple, which is a cartilage

that protects the voice box.

Let's see where we need to go with this.

John, can you push on the cartilage?

This looks so odd.

That's the bottom end, isn't it?

That's the lower limit, isn't it?

Yeah.

We didn't expect that. It changes the game completely.

If you look here, the tumour's actually grown

into the Adam's apple.

The scans didn't show this at all.

I'm going to have to change my plan for surgery now.

I'll need to cut out half the Adam's apple

with the cancer, through the mouth.

But this has never been done with a robot before

and the space is so tight.

I'll have to be incredibly careful making my cuts

so I don't damage Jade's throat.

We get only one chance to get these cuts absolutely right for jade.

Yeah, and that's cartilage.

Yeah, and we know we're below the tumour there.

Yeah, let's make that cut.

Yeah. That plane there. Yeah, that's it. That's it.

The tumour's nearly out.

Going to make the final cut.

OK.

Tumour's coming out.

That is a beauty.

I've never actually taken half the Adam's apple out

through the mouth.

Jade made us do something we'd never done before.

She was offered a full laryngectomy,

and I would've done the same thing. No questions.

But jade said, "I can't have that."

The next time a patient with a similar cancer comes along,

I won't be offering the patient the conventional gold standard.

I will say, "Is this something you would like?"

So we learnt a lot from jade.

A lot.

When cancer forms,

it has an inherent tendency to spread.

In the process of spreading,

cancer will replace and destroy normal tissue.

And it is inevitable that a life-changing event like this

will change the way you perceive life.

Is that the one she's sleeping on?

Yeah.

LIZZIE LAUGHS

How did you guys meet?

On Tinder.

We both swiped right.

LIZZIE CHUCKLES

We always joke, cos...

Well, so, Andy's search radius was one mile,

which is, like, nothing.

Luckily, the school I worked in was about a mile. About a mile.

Otherwise, we never would have met.

Yeah. Had I not met you, then... You might have given up.

I might have given up for a while,

so it was good timing.

About nine months ago,

this thing on my adrenal gland showed up,

and this thing just kept growing.

Then the scans also showed some areas of activity in my liver

and my lymph nodes.

And that's when they decided that they should do surgery

on all of the areas.

But I know it's to treat it, not cure it.

In 2018, when I was first diagnosed with stage four bowel cancer,

I was told I was incurable.

Since then, I've had loads of operations,

but the cancer will keep coming back and keep coming back.

And so we never know how long I've got.

You say when you meet someone and fall in love,

you don't expect this to be the way your life goes.

Especially not so young or so soon. Yeah.

In many patients when they've got cancer,

the ultimate goal is a cure.

But in some patients, like Lizzie, the cure isn't possible.

But although they're incurable,

it doesn't mean they're without treatment options.

They're not without some form of hope.

Lizzie's been a patient at the Royal Marsden

for just over three years.

She's had numerous surgery,

including bowel surgery, liver surgery,

and she's had a lot of chemotherapy.

So, this is Lizzie's PET scan,

and we can see three areas of disease.

This bright spot is a tumour within Lizzie's right adrenal gland.

As we move forward, this is within the liver and then further down,

this hotspot here is within her lymph gland.

We know if we leave the areas,

they will grow and likely spread around the rest of the body.

So, the goal of the operation is to cut the three areas of disease

that we can see on the scans out.

However, because Lizzie's had so many operations,

there can be a lot of scarring,

a lot of tough tissue,

a lot of fibrotic tissue throughout the abdomen.

So we're going to have to cut all these areas out of the way

to get to the areas that we need to get to.

We may end up damaging major blood vessels,

so the risk of the operation is very high.

With Lizzie, I ask myself over and over,

"Should I do this? Should I be doing this case?

"Does it offer Lizzie the best chance of life?

"Or could something happen on the table?"

Hi. Are you OK? Yes, yeah.

So, your liver lesion is tiny, it's here,

and on the scans it's measuring a maximum

of about seven millimetres in size. OK.

However, the main blood vessel is running very close here. OK.

Because of the previous operations that you've had on your abdomen,

we're expecting to encounter significant scarring

and there is a risk of bleeding

while we're moving all these scar tissues out of the way.

If at the time of the operation

we find that these are absolutely plastered,

we may have to stop the operation.

Does that all make sense? Yeah.

That's all right. Yeah, that does make sense.

We're all OK to go ahead.

Cool. OK.

Sometimes I do get a bit like, "Well, what is next?"

They trust that they'll throw everything at it...

...to sort of keep me alive for as long as possible.

But they worry about not having a good quality of life

because of treatment.

Lizzie's a little bit younger than I am.

She's already had so many operations done.

Would I have the same courage? Would I say,

"Yes, I'm willing to take this risk on this operation?"

Um... It's... I don't...

I don't know what I would do in all honesty, I really don't.

I am very lucky to still be here after three and a half years

and still having surgeries.

This isn't the case for most people who were diagnosed in 2018

with stage four bowel cancer.

Most of them aren't here right now.

We're going to get you... Hello. Hello, yes. I'm OK.

Hopefully at the end of this surgery,

I'll have no evidence of disease again.

It is going to be a risky operation.

We're combining three surgical approaches in one sitting.

The complexity will be increased

because of the extensive surgery that Lizzie's had before.

We often find the tissues that are in the abdomen become very hard,

almost like rock.

And if there's a major blood vessel and we hit it,

we can get ourselves into a lot of trouble with bleeding.

In the worst circumstances,

it could even mean Lizzie not making it off the operating table.

You always know that no two operations are going

to be exactly the same.

In your mind, you're double checking, triple checking things.

They are ultimately putting their future in our hands.

Starting.

The first task will be to get the adrenal gland out,

which is behind the liver.

The liver's quite stuck to the abdomen from the scar tissue.

If we cut too deep, it could have catastrophic

consequences for Elizabeth.

We have to just go slowly and make sure that we're not damaging

anything in and around the liver.

It's coming, it's coming.

TOOLS WHIR

That's the adrenal, there.

Yeah, that must be.

It's in an awkward position, so it'll be tough to cut out.

Can I get my fingers around it?

It'll come.

Absolutely, absolutely.

We're almost there, almost there.

OK. Great. Yeah, that's it.

Right, adrenal out.

RICKY EXHALES

So, that's one down and two to go.

With surgery, there's a road map.

But with these patients, it's very unpredictable.

Before my diagnosis,

we were planning to have children and live our lives.

I was very driven.

I was very ambitious.

The ambitions are just, you know, to stay alive now.

Well, here's the liver lesion.

It's right next to the blood vessel going into the liver.

If anything happens to that,

it'll lead to massive complications and catastrophic bleeding,

so we have to be very careful.

This is probably going be the more difficult one to do.

As the surgeon, you're orchestrating the operation

and you're the conductor, you're leading the team.

You have to remain focused.

We're making very slow, deliberate movements

to try and manoeuvre the lump away from the blood vessel.

It's very stuck.

Ooh, there's something.

OK. Oh. Oh.

Stitch, please. Stitch.

Hold it there, hold it there. Hold it, hold it.

Hold the bowel, hold the bowel, hold the vowel, hold the bowel.

OK, forearm, clench it, clench it, clench it.

We've got... We've compressed the liver.

Clench it.

Gentle, gentle, gentle.

OK, I need another one of these.

Quick, please.

OK.

Drop that and follow me.

Yeah, OK.

Drop. Yep. OK, we've got control.

HE EXHALES

Bloody hell, that's... Nicely controlled. Thanks.

When something doesn't go right,

you'll always go back and analyse

what could you have done to make it go better?

I always equate these things back to football.

It's like when you take a penalty.

If you miss a penalty, you'll always go back and think,

"Should I have changed my mind? Should I have done this?"

Maybe I could have stopped it going over the bar.

So, I think it's natural.

Scissors, please.

We've just got the last bit to cut round to get the tumour out.

Caught it. Lovely.

Fine, all right. Nice.

Elizabeth lost a lot of blood very quickly.

A bit of extra excitement that we didn't need,

but we repaired the vein and now the lesion's out.

That's what we want.

Finally, we can now remove the tumour in the lymph nodes.

PHONE RINGS

Yeah.

It totally makes sense, yeah.

You really need to break things down

and take them a day, a week, at a time.

Thank you. Don't think too far ahead.

Because you don't know what is going to happen.

SIREN WAILS

You know, when I was diagnosed with sarcoma,

everyone was telling me, like, there is a strong possibility

of losing the whole arm.

With the shoulder, as well.

But now, the ILP has given lots of hope for me.

INDISTINCT CHATTER

If it works, then we get to keep our arm.

An isolated lymph effusion is a means of giving a turbo-charged

dose of chemotherapy only to the arm

to save the patient's limb, but also the patient's life.

And at the moment in the UK,

we're the only centre that's offering this.

What we're going to do is

we're going to take these artificial silicone cannulas

and we're literally going to plumb them into Dimitrios's arm.

And then we'll connect this up to this heart and lung machine,

which takes the blood and circulates it,

which will keep the arm alive.

And we'll inject the high-dose chemotherapy drugs

and then we're going to wash them all out.

But if that level of chemotherapy were to go around the body,

that could be fatal.

So we put a really tight tourniquet around the arm,

so the drugs cannot go around the body.

When we take on a high risk, a difficult case,

are you questioning your skills?

Absolutely, you question your skills.

We're operating on the only artery to the arm.

If you were to do a non-repairable injury,

then the arm couldn't survive,

which would be a catastrophe.

Incision.

So, the first thing we need to do is find the artery and a vein.

The artery is carrying the blood from the heart

and the veins pump it back,

and they all have to do exactly the same job

in the perfusion circuit.

So the vein needs to be big enough to do that.

Now we've got a view of the deeper system.

Hm, yeah, they are just tiny.

These are piddly.

Piddly, piddly, piddly.

So, this is the artery and this is the vein next to it.

And they are both worryingly small.

Actually, I don't think I could physically get a cannula

into this vein.

As I see it, we would struggle to do a perfusion.

Sometimes there are difficult decisions which have to be made,

and there are plenty of times where the choice which you make is

this is not the right treatment.

And that is really upsetting.

It's not your fault, but you always feel it's your fault.

The good news, the deep veins in the arm were absolutely tiny.

Actually, he's got a really large, superficial vein.

Look at the size of that.

Even I could get into that.

Venous cannula, please.

So, the blood vessels are ready for cannulation

and I'm going to cannulate the vein first

to check that there's enough flow to pump the blood back to the machine.

OK.

Right, Jonathan, will you come out on the vascular clamp?

Thanks very much.

That looks quite optimistic, doesn't it?

If we get blood coming back quite rapidly.

Now for the artery to complete the circuit.

We have to use a cannula big enough to get the blood pressure we need

into an artery that's so much smaller than I'm used to.

Pop scissors to me.

It all hangs on this now.

If I can't get it in, there's no ILP

and damaging the artery could potentially mean losing the arm.

It's pretty bloody small, isn't it?

Show me the arterial cannula.

Hm, looks a bit big, doesn't it?

HE HUMS

CHATTER Shush.

Success.

Now you can take the vascular clamp off.

The arm has its separate blood circuit,

but we have to make sure it's truly isolated

before we can give the chemo.

OK, so, let's get the tourniquet.

We inflate the tourniquet to stop any of these toxic drugs

getting to the rest of Dimitrios's body.

OK, Judith, let's see if we've got a flow.

For the procedure to work,

the machine will need to pump enough oxygenated blood around the arm

to keep it alive.

But if the flow isn't high enough,

you can't give any of the drugs.

Does it look good?

Have you got anything?

I'm HAPPY-

Good, good, good.

OK, shall we start making up some drugs?

Chemotherapy works by killing cells

which are growing rapidly.

So it'll just kill the dividing cancer cells.

OK, infuse for an hour.

Good.

Within minutes, the chemo will travel to every structure

in Dimitrios's arm, the tissues, the muscles,

but crucially, the tumours.

It's going to be about six weeks before we know

whether we've saved the arm or if the cancer is spreading.

The ILP worked.

They shrank the tumours, but not completely.

So, some months after, I had hand surgery.

Ah, it looks good.

There's a lot of people who actually, I tell them to count,

but the human brain doesn't get it.

If you don't count, you think that the hand is normal

and it has all its fingers.

The only way you can tell right away is this side.

Now you can tell that something is missing.

The ILP dissolved most of the tumours in the arm.

Unfortunately it didn't dissolve the one around the finger,

so I did have to remove that.

But we managed to save his arm

and I hope that I managed to save his life.

Before cancer, I was lost.

And it's a terrible journey to go through,

but cancer helped me find myself.

My mentality has changed and the way I see things have changed.

So this was something great that happened to me.

How are you getting on?

The surgery was successful.

It removed the cancer that was showing on the scans at the time.

But there's a new spot showing on my liver that...

Yeah, we weren't really expecting. I was, yeah...

We were quite surprised that something had come...

...come up so quickly.

Have they told you what this means?

It should...should be treatable.

We'll just carry on carrying on, really.

It's like a punch in the gut,

because we're all pushing in one direction.

We're all trying to get the patient better

for a significant length of time.

And ultimately, if you don't hit that aim,

you're always going to feel as though

you've fallen short.

I'm hopeful we'll still be able to offer Lizzie treatment

in the future, but it does become more risky each time.

Jade's recovered well from surgery.

She has her own voice to speak to her daughter,

which is what she wanted, which is fantastic.

And jade has certainly changed the way that I now think about

some aspects of surgery.

This operation is as complex as it gets.

We've just found another tumour. That wasn't expected.

So I'm feeling a little bit nervous.

She essentially hasn't got any other treatment option.

All I want is more time.

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