Original subtitles

This program me contains discussion of life and death stories

and 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.

If we get only one chance to get these cuts right.

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

Ooh, oh! We've got a hole in the vein.

OK, hold it, hold it. Clip, 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.

I've done a lot of things in my life.

I've been in the Army. I've done a lot of other things.

I've done a lot of good things, and I've done a lot of bad things.

But looking back on all of it, I have produced a good family.

I've got three daughters.

I've got 11 grandchildren

and one great—grandchild.

I'm good for breeding.

No, I'm not any more, I'm not, but I was.

I was bleeding in my mouth and my girls kept telling me,

"Go to the doctor's, Dad."

I said, "That's all right. It's only an abscess,"

because that's me, that is.

He's always wanted to protect us.

I understand that's the way you are, but it didn't benefit —

keeping it to yourself... No. ..that something wasn't right. Yeah.

I eventually went and saw a doctor.

There were large tumours. Hmm.

And I mean, they still are.

The radiation and the chemo hasn't worked on me.

When I go to a party and people ask me what I do, I say,

"I'm a cancer surgeon."

I do all cancers above the collarbone,

except the brain and the eye.

And the next question is,

"Tell me about the last complex operation you did."

And then I'm scratching my head thinking,

almost every operation we do is complex.

I can do something that is unique,

that changes a patient's life,

and, of course, that cures something

that was previously thought to be incurable.

Morning, young man.

I've known Peter for a year.

He's a lovely gent with a great sense of humour.

Let me get a word in, OK? I'm being quiet as a mouse.

No, no, you're not being quiet as a mouse.

He came to us with quite an aggressive cancer of the back

of his throat and his tongue.

That cancer hasn't responded to radiotherapy and chemotherapy.

So this needs urgent treatment.

And if we don't do something about it, we lose a window of cure.

So we are going to look inside Peter's throat

under anaesthesia and try and define how extensive the cancer is

and whether we can take this cancer out surgically.

It's definitely diseased, isn't it?

I didn't expect to see that.

Is that a radiation ulcer?

We need a biopsy that.

Yeah, this is a tumour.

A recurrent cancer for me is a puzzle

and the whole cancer puzzle keeps me going.

How can I take out the cancer,

do less damage,

and offer the patient a good quality of life?

That's a Holy Grail.

But how do we do that? How do we solve that puzzle?

Is his daughter here? I don't think she's here, but I'll give her a call.

PETER: All right, mate? I'm all right. How are you?

How are you feeling? Eh? How are you feeling?

All right. PETER SPEAKS INDISTINCTLY

Good news or bad news?

The cancer we can see on the scan...

Yeah. ..it looks like it'll come out. Right.

But I saw one more ulcer the back of your throat,

which wasn't there before,

which I think is caused by the radiation side effects.

Right.

Which we see from time to time. Yeah.

So I've taken some biopsies.

If that comes back as positive for cancer... Yeah.

...then it'll be difficult for us to do much.

HE MOANS DISAPPOINTEDLY

But if that's negative, then I'm still optimistic. Right.

Well, let's hope it's that, then.

But if it's not, there's nothing you can do?

I can't operate on you surgically, if that's positive.

Because it becomes too big then. Right. Yeah.

So the tissue has been sent away for testing. Right.

We'll see what comes back. OK. Thank you. OK? Yeah.

See you, doc.

Thank you very much. Thanks a lot, Professor.

Not quite the news we wanted to hear. No.

Still...

...it is what it is. So.

SHE SOBS Sh, sh, sh.

Come on. All right.

I've learned a lot from my patients with recurrent head and neck cancer.

They're the bravest patients.

The stakes are high across the board.

Families suffers.

I don't want to give up.

I want to try and cure them.

Frankie!

Come here.

Sweet. DOG BARKS

Good boy. Good boy.

It is finding one to make it work.

I used to drive a fairly big lorry.

There's not many women actually in cargo that do drive the lorries and tugs.

But I love the job.

That's Daniel and Abby walking Frankie.

Hasn't always been easy because I split from their dad,

and even though he's always been in their lives and still is,

I've more or less brought them up on my own.

I've just managed to work

and be around for them the whole time.

Just over a year ago, I started to get some pains

outside of my left ribs,

and I know now that it was a lymph node that was swollen.

And every time you pressed it, it's just like,

"Mm, that's uncomfortable."

So I went to hospital for a scan.

The ultrasound picked up a sort of a shadow,

and they said to me,

"It's cancer and it's in the pancreas.

"And we are referring you to the Royal Marden."

The first thing you think is, "Oh, my God, I'm going to die."

And then it's like, "How long have I got?"

And then you think of your family and friends and pets as well.

I don't like worrying people.

I don't really want the attention on me.

I'm just not that sort of person.

I can't imagine there's any part of a patient's life that remains untouched by pancreatic cancer.

I can only imagine how they must feel.

Here, everybody's striving to improve life for our patients.

The operations we do now, maybe ten, 15 years ago would not

have been possible.

The level of risk that we're willing to take on

on behalf of the patients has definitely increased.

So pancreatic cancer is known as the silent killer.

It often doesn't give any symptoms to the patient

until it's relatively advanced.

Thus far, Janet has had eight months of very strong chemotherapy

and radiotherapy in an attempt to shrink the tumour to the extent

that we can contemplate an operation.

I need to make sure that Janet understands the risks of surgery.

This is a big decision for her to take.

I was initially told that this may not be operable, which meant

I would have to live with a dormant tumour

that could start growing again at any time.

HE KNOCKS

When you initially had your scans early last year, you could see

that there was a fairly big tumour within this part of your pancreas.

Right. The good news is that has responded very well

to the treatment.

It has gone down from 45cm down to a centimetre.

It does give us the opportunity to think about an operation. OK.

We're going to remove probably around about 50% of your pancreas.

The difficulty for us is going to be the vein.

There's a blood vessel that comes from the bottom part of your tummy

and runs up to your liver.

This is called the portal vein.

So this supplies around about 80% of the blood to your liver.

And we could see on the original scan the tumour had actually wrapped

itself around this particular blood vessel.

That's part of the thing that adds the risk to this particular

operation, because there's a risk of bleeding

as we're manoeuvring the vein away from the tumour.

OK. Does that makes sense? It does.

Done the chemo, and the radio.

I would rather have the risk of the operation to take

the tumour away.

Every faith in you, Dr Bhogal. OK.

Thank you. OK, I'll see you soon. Thank you. OK.

Just relief, really, that it's going ahead.

And we've had that conversation today.

It's a fork in the road.

Janet, she hasn't got any other treatment option.

Which is, I think why you probably have a lot more angst

before the operation because you want to make sure you do

the right thing, because that's probably going to be your biggest

influence on patient survival.

WOMAN: Did you get much sleep last night? Not much, to be honest.

A bit nerve-racking.

We just have to wait for the biopsy results and see.

We wait until they tell us here now the bottom line...

...the best, the best that can happen and the worst that can happen.

And then I'll make the decision with you.

KNOCKING

Hello. Hello. Good morning.

How are you? OK. You OK? Yeah. OK.

I want to have one more look before we get chatting. OK? Right.

So the last time you were here, we had a look inside

and found a new ulcer. Here, let me show you.

This tumour is in the tongue and tonsil and soft palate.

You see this ulcer here? That's the one we biopsied.

So that is negative.

I'm convinced there's no tumour here.

It wasn't too bad, was it?

What you were saying was making me feel a little bloody better, I tell you that.

Yeah, it was making me feel I came here for doomsday.

So game plan? Based on all the assessments we have so far,

it looks like this is an operation that can be done.

It'll be a long operation. We're talking about 12 hours.

We'll split your lip and chin, take part of your tongue away.

The same time, we'll take tissue from your leg.

We'll bring it up, put it all back together

wire the jaws back together.

I must be up front — even if we do the operation,

the chance of being disease-free is around 15% or so

at five years.

Is it worth going for it?

That's a decision that... I can't make that decision for you.

What's the other alternative? ls

support you with your symptoms, with pain control,

and then manage them as we go along.

How long's the piece of string?

So it ranges from one month all the way to 12 to 14 months.

Right. But the mid line, the middle is about six to nine months.

Well, six to nine months.

I'm going... I'm going for the surgery.

I mean, what have we got to lose?

Let's go for it. Let's go for it.

I'll tell you now, because I saw it in her eyes.

I saw it in her eyes straight away.

These are difficult decisions to be made for Peter and his family.

The chance of curing this cancer with surgery is between 15% and 20%.

But Peter is very clear in his mind.

He wants the operation, he wants to grasp at that chance of cure.

PHONE RINGS OPERATOR: Good afternoon, Macmillan. How can I help?

PHONE RINGS

OPERATOR: It's difficult, isn't it? Trying to balance everything, I guess.

The word cancer elicits fear, elicits worries about survival,

but with appropriate treatment, especially if the cancer is early,

the chances of defeating the disease are very high, indeed.

PHONE RINGS

If possible, every patient coming under my care must get a shot

at curative treatment.

I will push the boundaries as much as I can.

Mum, can you see me? OVER MOBILE: Yeah. OK. Venga.

Because he's going in at 8.30. I'm going in at 8.30, babe.

Yeah, OK.

Peter's cancer's centred around the side of his throat

at the back on the tonsil.

It goes up to his palate and goes down into his tongue base.

And there is some tumour in his lymph nodes as well.

It's about 45cm in size.

Love you, babes. Good luck.

This operation is as complex as it gets.

We're going to work around fairly large arteries and veins

that take blood to the brain.

And we have to create tissue from the thigh to reconstruct

a soft palate on the side of his throat.

We're ready. We're ready? Right.

I feel like Rocky.

I'm not exaggerating when I say that Peter can say set the limits of surgical resectability.

If it is any bigger, if it's gone any lower,

we'd be not offering Peter the treatment.

I love you.

You get one shot at these things. DOORBELL RINGS

Oops, excuse me.

There's no chance of going back and rectifying your mistakes.

Bye, Dad. We'll look after him.

Yeah. OK. Quickly. Sorry, he's one of those.

All right. I need my huggies. He needs his hugs.

I hope we get this right for him, poor guy.

Hello, sir! Welcome. Hi-de-hi-de-hi.

Let's keep you covered behind.

And get up on the bed and make yourself comfortable.

And then we'll restore some dignity to this entire situation.

No peeking. I've absolutely no way.

It's a long operation. So let's see how it goes.

The idea of not having him around is something I'm finding hard.

I want him to have a shoulder. That's what family is for.

All done. Sweet dreams. You've done it.

We're going to look after you now, OK, Peter? We are going to look after you.

PETER: I just want to have a good quality of life, what's left.

And I will take it day by day.

I'll be at home with my family.

And I'll carry on lying to them when they ask me how I feel.

If I feel rotten, I'll tell him I feel great.

I don't want to pass any suffering or pain on to them.

Because I know they're going through it anyway, just looking at me,

to see me like this.

I've been a fighter all my life, so I'm not going to change now I'm old.

The first step in the operation is to open up Peter's neck

so that we can remove his lymph nodes.

We need to be careful here

because we're going to be working around the jugular vein.

So that's the tumour here.

You're doing really well.

While we're working on the cancer,

we're also simultaneously preparing the tissue in Peter's leg,

and that'll be transplanted later on into his mouth and throat.

So I'm going to now cut his lip.

Seems brutal, but you have to split the jaw to get to Peter's tumour.

So that's it. We split the jaw now.

I'm fighting a battle for the patient.

I need to get this right.

And I'm invested quite heavily in getting this right.

That's interesting.

Hang on a minute. Well, there's one more tumour there.

We've just found another tumour.

It wasn't seen on the scan.

This seems to be confined to the lining of the throat.

So that wasn't expected.

We just have to take a bit more tissue.

Peter so needed this done.

We've taken away the cancer.

Now we can use the tissue from Peter's leg to reconstruct

the soft palate and throat.

We're transplanting living tissue here, so we need to establish

a blood supply and connect it, otherwise this tissue will die.

We have one artery and one vein, and both of them

have to work at 100%.

The human body is an amazing thing.

We can transfer a piece of leg tissue covered with hair

into the mouth and neck, and over time the skin will adapt

to its new environment.

My colleagues now need to reconnect the artery and the vein

from the leg tissue to the new blood vessels.

And this is tricky because they're only a couple

of millimetres in diameter.

This is a stitch in going in.

It's quite a nice match in terms of size of vessels.

Clamping the flap side off first.

Just here, there's a leak.

We'll need a stitch back again, please.

Stop. Let's get the bleeding sorted.

Loads of blood coming out of that vein.

The vein's now isolated, which stopped the blood coming out.

These are the crucial blood vessels.

If those blood vessels don't work, then the whole flap will fall apart.

But Peter's blood vessels are good, so we are optimistic.

As we had to split Peter's jawbone

and I had to put it back together, using metal plates and screws.

Now we're going to close the lip off and put it all back together.

I'm going to ring his daughter now.

PHONE RINGS Hello.

Hi, Luann, it's Vin.

I'm just calling to say Peter's operation has gone really well.

Oh, brilliant. So we've got all the cancer out.

Nothing to worry. We're really happy. Thank you, Professor.

Morning, Peter. Good to see you. How are you feeling?

It's gone really well. Gone very well.

You have every reason to be positive about this.

I was very comfortable with the margins.

It looks like you're not in pain and difficulty.

So we'll just wait this out, I think.

He's saying thank you. My pleasure.

Oh! You've got good strength now.

That's good going. Oh, God, no, that hurts!

We'll get you sat up and get you walking around. I'm really pleased.

Yeah. Great. Take care, Peter.

He looks amazing today.

He's got his naughty smile back on his face.

You can see that.

Things can go wrong and that's always a worry for us,

especially with Peter.

So we will assess that.

But I'm cautiously optimistic.

PHONE RINGS

OPERATOR: Good afternoon. Macmillan Support, how can I help?

PHONE RINGS

OPERATOR: So you are really concerned about it returning?

That fear is very common.

You're not alone.

PROFESSOR VIN: We don't have a good grasp on why some cancers progress

despite treatment while others don't.

It is completely unpredictable.

PHONE RINGS

MN". I'm nervous.

It's almost like you've been preparing to go away on holiday.

Make sure this is done. And then it's about what you pack.

What do you pack?

I've popped over to see my friend, Dani.

SHE SNIFFLES

Cos I had to speak to her about looking after the kids...

...In case I didn't pull through.

Try not to think about things like that, but, you know,

it is a reality.

DR BHOGAL: Before the operation, I think for me,

it's a psychological weight, really.

Particularly the morning before, your mind will keep going back to,

"How am I going to do it if this happens?

"What will I do if I encounter this? Will I stop? Will I go ahead?

"How about something really terrible happens?

"How am I going to get myself out of this problem?"

It's having plan A, B, C, D in your mind before you go in.

Morning, Janet. Hello.

Everything been OK since I saw you in clinic? Yeah, yeah, fine.

No changes? No. OK.

What we end up doing exactly in the operation will depend

on exactly what we find. Yeah.

It's now very difficult to even see the tumour on the scans,

it's responded so well to the chemotherapy and radiotherapy.

If, when we remove this, there isn't much pancreas left,

we may just have to remove all the pancreas,

which is a bigger operation.

If I have to remove all of it,

then you're going to become a diabetic straight after the operation.

OK. I'm in your hands. We'll do our best, Janet.

OK. Thank you. All right.

That shook me.

I don't think I've ever appreciated having a pancreas so much.

I just hope that I can keep as much of it as possible.

It's quite scary.

So I'm feeling a little bit nervous.

I think you always do before an operation like this.

Once we divide Janet's pancreas, we're going to send a sample

of it to our pathology colleagues

to make sure that area is clear of any tumour.

So this is an operation that does make you sweat.

There's going to be three or four important steps

that we're going to have to make.

Once we've made those, there's no way back we go.

In you go. OK.

How are you? Nervous. My name is Adam. Nervous, yeah?

Nice to meet you. That's normal. OK.

If they don't operate and take out the tumour,

I will basically be lucky to have two years to live.

The thought of death scares me.

I want to do whatever I can to make sure that I survive.

All I want is more time

with friends and family.

We're starting.

I'm going to begin by just starting to lift the duodenum away

from the back of the abdomen, so we can get close to the pancreas.

This is the pancreas.

I mean, it's really, really shrunken.

There's quite a lot of reaction here to the radiotherapy,

quite a lot of inflammation.

So we just have to go a bit carefully, a bit slowly here.

Bloody hell.

Oh, my God. Like rock.

It's really stuck here.

The stomach is getting in the way.

There is vein involvement here. Hmm?

Feels pretty stuck.

HE EXHALES FORCEFULLY OK.

That's where we're going to do divide it

if we want to get a clear margin. Yeah.

Tie it up.

My hands please.

It needs another stitch. Yep. To remount the needle for me.

Let me put it in now.

Suction, please.

Stay in, stay a bit longer.

When we're trying to get the pancreas off the vein,

we've had a bleed into the main vein,

so we've just controlled that with sutures.

It's a bit risky here.

I think we should divide everything now.

It's getting unsafe.

We're getting into bleeding we can't get control.

Hopefully...start to try and take the tumour out.

OK. We're going to divide the pancreas now.

Yeah. Beautiful.

Very nice.

We're almost there now. We're almost at the point we're going to take the cancer out.

Go into the vein.

The back of the portal vein.

You sure? Yeah. Yeah. There it is.

Got it? Yeah, yeah. So now it's real clear, that.

Scissors.

The cancer now is hanging on the last thread.

That is the specimen.

That area there is the pancreas.

It's completely rock solid from the radiotherapy.

Normally the pancreas is about that size, but it's tiny.

And the tumour is here.

So what we're going to do now is we're going to go upstairs to the pathology department.

What we want to make sure is that there's no cancer there.

If he said it's all OK, we'll come back and we'll do

we'll do three joints.

If he says no, we'll come back and remove the rest of the pancreas

and then we'll have to do two joints.

Andy, hi. The tumour, it's all been pulled in here.

We've divided it in the body and taken everything this way.

There's about that much pancreas left.

She's 55, and we're keen to try and maintain some pancreas if we can.

OK. Thank you very much, Andy.

JAN: Just can't wait to start putting my life back together.

There's some things I'd like to do.

I want to get back on the horse as soon as possible.

There's places that I want to go, round the Devon coast.

Clovelly, I want to go back there one day.

I'd love to be able to take my mum. That'd be nice.

There's just dozens and dozens of things.

It's just I want to do this and I want to do that. I want to do everything.

He's had a look at it under the microscope

and there's no evidence of cancer.

It means that we don't have to remove the remaining part

of the pancreas, that can stay in place.

So that's a good news.

So the pancreas is now joined back to the valve.

It's looking good. Should be OK.

Put the first one around and then put the drains in...

Yeah, yeah. Thanks.

It was a good effort, guys.

That's a team effort. It's not a one-man job, that.

It's very, very tough to do. That was a difficult one.

Thankfully it's all gone very well.

We get this moment of elation, where we think,

"Yeah, we've done it, we've got it."

But there's always a wait until we get the full histological results back.

These are the operations that give us grey hair.

Morning, Janet.

How are you? A bit better?

Janet, the operation went pretty much as planned.

So we've taken the tumour away and taken a bit more of the pancreas than we would normally do.

So you've still got a part of your pancreas gland in place.

It all looks very, very good.

It's equivalent to winning a lottery.

So I couldn't ask for better news.

Um, I know it all hurts, but that will recover in time.

I think celebrations are in order.

JAN: I have a new name for the chicken house.

It's the first job I've done.

That's it, I'm done for the day.

Look at this space.

It's peaceful. It helps me relax and to recover quicker.

Today is a follow—up call from Mr Bhogal, the surgeon.

Part of the pancreas was sent off for analysis,

so there might be some information on that.

I hope I'm cancer-free.

PHONE RINGS OPERATOR: Are you there?

Hello. DR BHOGAL: Hey. Hello there.

You're looking very well, Janet.

Yeah, I feel much, much better.

I feel less pain each day.

Janet, I've got some good news for you. OK.

When we've had a look at what we sent at the time of the operation,

it's all clear.

Fantastic. Brilliant. OK. That's the best news I could wish for.

Thank you so much.

OK. Right. Take care. All the best. Bye-bye. Bye.

MOBILE TRILLS

Hello? You all right?

Yeah, right now I've got some news for you.

Yeah? I've spoken with Mr Bhogal,

and he's now said that I'm cancer-free.

Mum! Good.

No, it's good news.

So a roller-coaster ride over.

Yeah. Why is the dog in the washing basket?

Send me a picture of him, right? Love you, bye. Bye.

Probably have a good cry now.

There's Frankie on top of the washing basket.

Just elated. Just...

Just a year's horror story out the way, just gone.

Just put it behind me.

Well, I just want to go and shout and tell everybody I'm free.

I'm free.

Yes. That's fantastic news. Yes.

Over the moon.

PROFESSOR VIN: The human body is in a constant state of change.

There are billions of cells that make our body,

and these cells are dividing every single second.

When this happens at such a frenetic pace, things can go wrong.

Peter's so gung ho.

And he told me each time, "Go ahead, do it." And he wanted that chance.

We gave him the chance.

So that swelling is new, on the tip of the epiglottis.

We are seeing a new growth on this voice box

and I need to figure out what it is.

I need to get some new scans done.

I didn't expect to see that. It worries me. Yeah.

PETER: Yeah.

I'm sorry to keep you waiting. That's all right.

How are you, Mrs White? Fine, thanks.

Yeah, I do.

Uh-oh. I'm sorry. It's not good news on the MRI scan, Peter. Uh-oh.

So the cancer's come back.

Yeah.

I know we went through a long journey with this. I'm so sorry.

I won't say a couple of years.

If you look at the scan from a couple of months ago,

there was no tumour,

because if he had seen this on the scan from two months ago,

we wouldn't have done the operation in the first place.

Right. So this is new tumour and I think it's growing fairly rapidly.

PETER CHUCKLES

You're amazing with your resilience and your sense of humour and...

Yeah. Absolutely.

I feel...| feel gutted.

Yeah, yeah.

I feel awful that we just didn't control it for a good enough time.

We have tried.

PETER COUGHS

Thank you.

You think that you would get better with that.

You'd learn to do it better as time goes on.

But the older I get, it becomes even more difficult to break bad news.

It's really horrendous.

You do it because you think it's going to benefit him,

but it hasn't.

It's come back so rapidly.

It's the worst part of this job.

He's lovely as well, he and his wife. That's hard.

Hmm. Let's go see the next one.

HE GROANS

Right.

I know in my heart of hearts that we've given them the best

possible care we can, but I get frustrated that we can't do better

for the patient.

I get frustrated that we don't have any other medicines available

to make the patient better, to cure the cancer.

And you carry the sadness.

You're never free of it.

These patients, they become friends.

It's VERY hard to lose a friend.

The tumour is enormous.

We've got a table, guys?

It weighs 7.5kg. Oh, wow!

We're going to reconstruct the throat.

And I'm invested heavily in getting this right.

I'm going to fracture the voice box. BONES CRACK

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