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post-mortems are tightly controlled and access to them is strictly limited to protect the privacy and dignity of the deceased filming is not usually allowed but for this post-mortem we have been allowed in to help understand a problem that costs the nation billions and ruin so many lives obesity carla valentine and dr.. mike osborne are the specialist team responsible for carrying out the postmortem? carla is an anatomical pathology technologist and technical curator of the pathology museum at london's, queen mary university for this postmortem. i'll be carrying out the evisceration which means we're moving all of the organs being part of a filmed postmortem is a very unique opportunity death terrifies some people, but what it also does is it eventually gives you a real sense of the fragility of life?

the topic of obesity is a huge problem, and it's something that i get to see quite a lot but it's not something that i get study in depth mind is a consultant pathologist and fellow of the royal college of pathologist he's been working with death and disease for over 20 years obesity is very much there. it's seen but i think it's very very poorly understood it seemed that making this film would be a way of exploring that and allowing a broader public to learn about the problems that are associated with obesity caller and mike have performed thousands of post-mortems, but always behind closed doors today

we will witness what really happens in an autopsy and discover what the body of our donor can tell us about the creeping effects of obesity over time we don't know this woman's name, but we do know a few details about her to within our only 65 foot size almost 17 stone and just like a quarter of people in the uk clinically obese but where did she come from and how did she end up here on a post mortem table in london? and

finally she arrived in london her body remains in a pool chamber for ten days to allow it to fall completely before it was brought to the post-mortem table the first stage of every post-mortem before any cuts is made to the flesh is an external examination of the body the donors id number is confirmed against her medical records which details the cause of her death heart disease and that you'd only had minor surgery and drank minimal alcohol but what will her body go on to reveal about the way that she died? this lady's died of heart disease. which is one of the things that is associated with obesity and interestingly already in this lady. we've got signs of heart failure because if i press here particularly on this side you can say i'm very demanding there, and that's because you've got too much fluid and that's the side effect of heart failure

the other obvious external damage to our donor are the blisters on her skin? they are one of the earliest signs of her body decomposing after death, and they're particularly noticeable on larger bodies but they're not what mike and carla are focusing on the most important thing about this lady is that the obesity that she's got is centered on her abdomen, so this lady's carrying a lot of weight around her tummy that's associated with more of the complications than if somebody weighs the same but they carry their weight around the bottom and around the thighs so that's less associated with complications. that's more associated with complications so we can see the

distribution of the fats from the external exam but once we actually get inside we'll see more of how that's affected the inside of her body and her internal organs as well when we open this lady there may be other findings that are less easy to diagnose before somebody has died that won't have killed her but are examples of problems that can get worse and leads to illness and death in other people so we may find some of those we may not to uncover if there are deadly medical truths lying, beneath the skin calamus first cut open the body

the incision is a large and deep single vertical cuts beginning at the suprasternal notch at the base of the neck and ending at the top of the pubis it's a skill that requires both great precision and intense concentration especially performed on someone with so much fat so what i can feel at the moment is an awful lot of yellow very sort of greasy fatty tissue which is quite a thick layer in the body to size? reflecting the skin back from the ribcage here, and what that means is. i'm just kind of loosening it away with the muscle and give me a bit of room to maneuver within the body

what we seem to have here is a breast implant. this is an incidental find sometimes when we do post mortems it's not just about what we're expecting to find and it's incidental there is a very large amount of fat here and the reason it makes it so difficult is it actually is greasy it feels very much like butter so what i'm doing here is just trying to make sure that my knife doesn't slip too much on it mike did you want to come and take a look at it okay? so

we can see immediately the thickness of fat that is here and even though there is a large amount on the anterior chest wall the front of the chest but there's also a very large amount around the abdomen the abdominal fat that is the most dangerous associated with the problems of obesity it's quite a lot of fat around the organs it's fatter in the amendment it would appear that this lady is carrying much of her way in the abdominal fat and possibly around organs as well so there's lots of changes which i think we'll get a better view of when we've opened the rest of the body everybody knows what obesity looks like from the outside

but unless you do a job like ours most people don't see what obesity looks like inside i've done thousands of post-mortems it's always a fascinating procedure even if it's a case where you've seen lots and lots of similar cases in the past that particular case will be individual and you'll certainly learn from that we'll never know exactly why our donor became so overweight the reasons for obesity are multi-layered and complicated a mixture of lifestyle and environment biology and psychology but now that overweight is the new normal weight in the uk there is a whole new young generation living with the consequences of obesity i'm going to take my rib shears, and we use these specifically for this job as they can cut through bone and

what i'm going to do is just make some very even cuts right through all of these bones you can hear the bones of snapping this lady isn't exactly young and the older people get the more calcified their bones become so they become very very crunchy whereas younger people ten have much more soft bones in order to do this job you have to be stronger stomach to start with but i think that's just something you even know or don't and i never would have considered doing this job. if i didn't know i had a strong stomach

i'm now removing the breast bone or the breast plate sternum with upward strokes, and this way i don't damage any of the pericardium which is the sac that keeps the heart safe the first time i saw somebody doing a post-mortem i think i was just absolutely rapt i was fascinated and it's because the human body is an incredibly complex machine to open human being to see all of that absolutely perfect sort of jigsaw of organs and perfectly in place. it really did make me feel very we would

when you do an autopsy on somebody who's very slim the organs are there and they're very evidence? it's like a game of of operate should all like one of those anatomical models that you would use at school in a woman this size a lot of it is really hidden by this extra yellow bar it is making it quite difficult to see the structures and much more difficult than it would if she was a person before color removes the heart and lungs mike want to take a look at the organs while they're still in the body to see if we will discover any early indications of trauma or damage you can see the heart here

there's a large amount of fat around the heart there's more here than you would see normally quite considerably more underneath the heart and lungs in this area here is what you call the diaphragm it's a big muscle that helps you breathe evenly and the diaphragm i was going to ask you very fatty for me right even even on the surface with a heart fat in the diaphragm i'm eating there's more fat than usual and actually the thing you can see most is an extremely, enlarged liver this is very very large and it's got what we call fatty liver change, so this is a fatty liver and fatty liver is very much associated with obesity

you can see there's a lot of fat around these organs, so what would be between my hands now would be the kidneys now the kidneys always have fat around them i think it's important while we're talking about the fat to realize that is a normal thing everybody has fat in however thin you are there will be some fat and fat it's got very very important roles and one of those roles is to protect things is that too much fat that is the problem five is made up of cells called adipocytes which are fat cells and really for a long long time until very recently people thought that that was just an inert substance that just sort of sat bone didn't really do anything, but it's becoming increasingly

understood now that that is actually a very active substance fat cells work almost like an endocrine organ the people would have heard of some endocrine organs things like the thyroid gland which related to how much energy you have how cold you are? and so forth the ovaries the testes so obviously these hormones related to the ovary in the testes define whether you're going to be a man or you're going to be a woman so those are the sorts of activities hormones have so they're very very powerful things they become obvious that the adipocytes the fat cells duclair an endocrine type role, and so have some very powerful effects that were previously unknown the next stage of the post-mortem is the dissection of the heart and lungs for might to be able to do this carla needs to remove the cardiorespiratory block from the body

i'm cutting through the diaphragm here just to make sure that i freeze the lungs completely see them along spine here i'm going to do the exact same thing on the other side and chop across the esophagus metric area here and then all i need to do is basically pull the organs towards me at the same time as releasing these sort of white fibrous tissues that holding the organs for spine and then we'll get to a point where this blocks the cardiorespiratory block is completely free then we can take this out as one block and we've got the heart and the lungs and the heart sac the

pericardium when you initially carry out post mortem? and you hold an organs such as the heart in your hands and the heart is very symbolic and you know using all sorts of logos. it's it has a sort of power and a sort of agency that makes you kind of stop and think because it looks, so mundane, but then you realize that within it has the electrical impulses to keep a person alive with the cardiorespiratory block removed from our donors body mike can start his dissection of her lungs will we uncover any evidence of damage linked to her obesity? i'm going to detach the lungs

from the heart so we'll start off with the right lung so just cutting through where the lung is attached, and that's the right lung detached to the left lung. i'm detaching there i'm just going to make some cuts across the lung just to see what the surface of the lung looks like these lungs actually look quite healthy there's no tumors or masses or anything like that in these lungs but what there does seem to be and which should be evident now if i pick this lung up and squeeze it is you can see the fluid dripping out of these lungs, and this is what we call pulmonary edema. that's

essentially heart failure fluid this fluid is basically water. i know it looks red that's because obviously it's within the body, and it's been mixed with blood. it isn't blood is much much thicker than that this is really just a watery fluid and this is collected because this lady's got heart failure this lady died from heart failure from hypertensive heart disease but this lady is also obese she did not die from the obesity the obesity increased the risk factors and was associated with the problems that led to her death? fluid has built up in this lady's lungs because her heart isn't working properly she'd have probably been short of breath and had possibly had a cough

but also because the fluid sits in the chest when you lie flat and that would have given her a sensation almost of drowning when you become a doctor one of the questions that they teach you very early on is how many pillows do you sleep with and that tends not to be because they're asking how comfortable you are at night? it's because if somebody says oh, i can't sleep in a bed doctor i have to sleep in a chair or i have to sleep with eight pillows sitting up that is very indicative of heart failure and the startling discovery mike has made in our donors lands we now know that she would have felt the impacts of her obesity and heart failure every single day heart failure is not the same as a heart attack when a heart fails

it doesn't fail immediately in this type of circumstance it fails over a long period of time, so the symptoms are gradual so she met this lady may have been able to walk up ten flights of stairs three years ago then she suddenly found she got very breathless after five flights of stairs then she found that she was found it very very difficult to even walk up one flights of stairs or even carry her shopping it would have been a progressive disease as the heart became worse and worse and worse now the final event obviously when this lady's heart stopped working that would have been an instantaneous event and led to her death now it's time for mike to examine in detail the organ that catastrophic lee failed in our donor what will we find out about how and why she might have died?

you can't really see the heart yet because the heart is sitting in a bag this is called the pericardial sac i'm just going to open that so i can reflect that but and that's the heart there, so the heart now is in my hand and you can see all the fat. i was talking to about earlier really isn't around the heart it's really around the pericardium. there is a bit of fat around the heart which is here this is absolutely typical in everybody's heart even a thin person's heart would have this and i'm going to cut off the pericardial sac

this big blood vessel here is the aorta this is the vessel that takes all the blood from the heart around the body when i feel this heart it feels baggy a heart in someone who is very athletic their heart would be very tight very firm it would be like always picking up a piece of steak. this is more like a bad what i'm going to do now is weigh this heart so this heart is 449 grams that's a heavy heart this lady is despite her weight this lady is actually quite a petite person. so you would expect her heart to be perhaps 275 grams something like that so this is very much heavier than you would expect and that is the sort of sized heart you would expect

in someone who has got heart failure due to high blood pressure which is what this lady suffered from the heart basically has to pump to keep up the pressure the heart gets bigger and bigger and bigger but there becomes a point where the heart can't get any bigger and it basically exhausts itself now that he has discovered the shocking state of our donors heart might want to look at it from the inside he cut some slices so he can examine the ventricles the walls of the heart that pump the blood if you're 6 foot 8 all black second-row, or you're you know one of the professional footballers running around the pitch you need a lot of blood so the wall of the

left ventricle in a young fit person it's usually an inch thick muscle all the way around now if you look at this lady this lady's left ventricle is very very thin this is 8 millimeters something like that that's because she developed high blood pressure to start off with the heart had spunk harder and harder in the end what you get to is a state where the muscle can't keep the high blood pressure up and it starts to get thinner and thinner and thinner and basically go from a thick muscular pump through to a paper bag that's not capable of pumping blood adequately around the body and we see a lot of these hearts. we see them on a background of hypertension this is a common finding and becoming more common hypertension is high blood pressure obesity is well known to be one of the major risk factors for high blood pressure

so in this lady they were not able to control that that led to changes within the heart which meant the heart failed it couldn't work properly, and that's what this lady died from the next block of organs to be removed are the organs of the digestive system called the celiac block? what i'm to do here is make sure that i've got the stomach and the lower bowel liver and sleeve all together in one block for mike to take a look at and not damage the kidneys but at this point i don't think i'm going to be able to damage them anyway because they also surrounded by such a large envelope of fat so we've got some people mouth and we've got

scott and bile and and then obviously a lot of blood the blood is mixed in with fat which is yellow so that's giving us some orangie fluids so multi-sensory rainbow at the moment every single thing that is in each of these blocks is incredibly important and you know just amazing jobs for our body, and it's just a taste of it's not very pleasant once they stopped working and they started to decompose a little bit to completely free the organs carla needs to cut through the fibrous membrane that holds them to the spine at the back of the body so this is a huge celiac block. it's incredibly heavy and the liver as you can see is taking up most of it you can just see the spleen there and also the stomach and a bit of the small bowel as it hatched as well

when i first encountered a deceased person i think what really struck me was just the stillness um and the cold because of course i'd never that point felt flesh that was so cold and it gave me a real sensation of kind of dipping my toe into very cold water and then once i've done it that feeling had never quite left, and it was like if other subterranean world in the next stage of the post-mortem will we find any evidence of stack damage in the organs of our donors digestive system this is the organs that include the liver the spleen

the stomach and the pancreas now this is much heavier than i would expect it to be in a smaller individual largely because the liver is so big first mike is going to take a look at the organ that most people associate with obesity. this is the stomach basically just like a bag holds the food before the food goes through into the bow where it's actually digested and there are actually many of the treatments associated with obesity deal with the stomach and what they try to do is reduce the size of the stomach so that people have a feeling of being satisfied for meeting without eating so much so there's a whole variety gastric bands fits around the stomach there's those i pass operations and so forth the stomach is very good at dilating

so if this lady had had a very large meal before she died and had not had opportunity to digest it the stomach would be much more obvious, but this is a fairly typical sized stomach next mike will dissect the liver the organ he discovered showing such dramatic change when he saw it in the open body but what would it reveal to us about the consequences of fats building up where it shouldn't? first thing i saw when we opened the abdomen was the size of this liver and the fact that this liver showed marked fatty change i'm going to make some slices through the liver just so i can see what the surface cut surface if the liver looks like the sponge so i don't cut myself so i've made some cuts across the liver there

and you can see that the surface of the liver is this sort of pinky color that's very characteristic of fatty liver change, it's very soft it almost feels like pate and consistency normal liver is quite soft, but not as soft as this in it and it has a much meteor much redder bloody colour dark red the lightness in this is caused by the fat within the liver and the fat is deposited within the hepatocyte which other liver cells and this fat would obviously be pale in color and liver cells themselves a dark, so the combination of the two gives uses light sort of pink color as much much lighter color than you'd expect a normal liver to be that is a classic sign of fatty liver disease, and it's becoming a major problem

and is one of the major reasons for liver transplant in the world the most common cause of fatty liver at the moment is alcohol-related fatty liver, but we know that this lady drunk almost nothing so it's very unlikely that this change is due to alcohol consumption almost certainly an obesity related change fatty liver causes damage to the liver it can lead on to cirrhosis, and it can actually lead on to cancer as well but even if people do not develop cancer or cirrhosis it can lead to liver failure so there's a multiple ways that it can actually lead to the death of a patient it didn't lead to the death of this lady really because her heart was itself so bad, but this is very dramatic change within this liver

before the post mortem we could never have known how dramatically damaged our donors liver would be or that should be carrying a second life threatening disease but excess internal fat doesn't have to be a death sentence the good news is the fight to beat the dangerous invisible fat can be won it is a daily struggle but the prize is big next karla will remove the final group of organs, but even in the last stages of the postmortem. she takes nothing for granted people who donate their bodies to medical science. we are giving a gift? it's a gift that keeps on giving actually because as

a patient i think we all would prefer that our doctors and our surgeons have learned on something you know realistic to their job before they're let loose on other human limitations you know you wouldn't really know a mechanic. take care of your car if you've never touched an engine, and it's very much the same thing with this wheel bodies are very unpredictable and very tale set compared to anything you don't fake anything like a virtual reality or a fake together because if you look here what you should be able to see are the kidneys granted they always have a tiny capsule fat around them a bit like a sort of edamame being that you can pop out and but these fatty capsules are very very large so all that you can really see at this point is a kind of yellow glistening mess, really

so this is again indicative of the fact that she has an awful lot of extra fat around her organs so i'm just slicing through the fibrous tissues and a bits of muscle that are keeping the kidneys attached to the spine and it's really exactly the same thing that i've been doing with the rest of the organs and that is releasing them from the spine which is what? anchors them in place and then i tend to deflect them all the way down and pull them out and this is the genitourinary block and this is at least slightly smaller slightly easier to manage because we've only got the kidneys in this

how much fat you? might need to dissect the kidneys to find out just how much damage has been caused by all that excess fat in the right kidney this is the left kidney this in the middle is the big blood vessel that carries blood all the way down the body and the most important and the first thing i can see is there's an unusual amount of fat around these kidneys now the kidneys always have fat around them kidneys are not protected by bone which means that they can be bashed and they can be here if you walk into something or something hits you so this fat protects them this lady has much much more fat than i would expect what i'm going to do first is just cut through

this fat which is called the peri renal fat you can see quite clearly how much fat there really is in a thin person? this would probably be half of a third as thick as i can see here this is bad news for this lady it means that she's more likely to have the complications of obesity because of the way she's carrying the fat this pale area here is the kidney. i'm just going to cut into the kidney so the kidneys got a thick capsule around it now there's a small amount of fat in the middle of the kidney that's completely normal

that's where basically the kidney is responsible for filtering your blood and for making the urine that urine has to go somewhere so your kidneys got a funnel that collects all the urine from all the bits of the kidney takes it down through your ureter into the bladder and then when you want to go to the loo it goes out so this bit of fat sits around that funnel area and is quite normal i'm going to take the thick capsule off of the kidney surface to see what the surface of the kidney looks like the surface of the kidney ideally should be very very smooth this kidney has got some scarring on the surface

there's areas of indentation and pop marking there is clear damage to this kidney which would be associated with high blood pressure, and we know this lady had high blood pressure which is what led to her the changes within her heart and which led to her death the visible scarring and pot marking we've discovered on our donors kidneys are the last of the revelation she will yield before carla completes the post-mortem and closes the body forever one like finished his examination. i then begin the reconstruction and in a way that's one of the most important parts of the postmortem what i do is i place all of the organs into a special viscera bag which will contain all of the elements that we've removed in the different blocks and i place that into the body cavity

and then i use very heavy post-mortem twine to stitch as neatly as i can right along the incision. i made and we describe this as a baseball stitch. it does look very much like a zig zaggy stitch each post-mortem is unique and everything they reveal valuable this donors gift was an opportunity for mike and carla to unveil the shocking truths hidden inside one body irreversibly damaged by too much fat the evisceration occurred and it wasn't as easy to do as it would be with a slightly smaller patient and it takes a lot more

strength to cut through this this yellow adipose tissue which kind of blooms out of the abdomen and in this you know practically neon yellow and and it looks very much like butter, and it has a greasy feel and it makes you suddenly very aware of the fact in your own body well it made me me aware of that in my own body and the effect of that might have on my organs the strain it might put on my heart and the way it may affect my liver. i think they're doing a post-mortem and such as this is a really fantastic way for people to consider their own health and their own mortality you

you never really know what we're going to find when we examine the patient the first thing i noticed when the body had been opened was the markedly fatty liver i know from the history that was provided that this lady died from heart failure, but the findings in her heart are extremely marked and the severity of them actually surprises me, but before we did the post-mortem there was no indication that this lady had a fatty liver and it's a possibility that even if this lady had not developed heart failure she may have gone on to develop liver failure due to the fatty change within the liver we already knew a little about the way that this woman lived and how she died what we couldn't have known before the post-mortem was the extent to which obesity would have ravaged her internal organs

from the suffocating fluid in her lungs to her scarred kidneys creating a potent mix of life-threatening obesity-related disease

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