The scandal of the great surgeon of deception in Barcelona

In Barcelona, he was known as Bello Paolo. He was charismatic. Seductive. Persuasive. Some even called him Little Frankenstein. For what he did inside the operating room. Paolo Macchiarini was head of the thoracic surgery department at Barcelona's Hospital Clínic for four years, until his contract was terminated on December 1, 2009. He moved to Florence, where he spent a short time, and then went to Karolinska Hospital in Stockholm, one of the most prestigious in the world, and later to Krasnodar, Russia. The documentary Bad Surgeon: Love under the Knife describes the therapeutic cruelty that Macchiarini inflicted on several patients from these countries. Many of them died in agony, and a Swedish court ultimately sentenced him to two and a half years in prison for aggravated assault on three patients to whom he transplanted a plastic trachea coated with stem cells. But the Italian crossed red lines outside of hospitals: he began a romantic relationship with the mother of one of the young men who died in his operating room.

Through around fifty sources, the ARA has reconstructed the four years that Macchiarini spent in Barcelona. Through conversations with doctors, nurses, managers and medical directors, heads of department, technicians, politicians... this newspaper has been able to establish this doctor's modus operandi. The Italian surgeon operated on patients for whom it was not essential to go into the operating room. Many people suffered agonizingly after their surgeries and ended up dying. He operated on a girl without authorization from the relevant agencies. He performed procedures without sufficient scientific basis and even falsified reports. Furthermore, he stole tissue from the hospital to operate in the private clinic and mistreated some of his team.

Four years after arriving in Barcelona, Macchiarini left Clínic through the back door. Quietly. This allowed him to continue his career, becoming one of the most famous and prestigious surgeons in the world. In part, because of an alleged operation in the Catalan capital that he never performed. He was credited with the first tracheal transplant in 2008: one of the ten greatest medical breakthroughs of the year for the magazine Time. In fact, he didn't transplant a trachea, but rather a bronchus. And the operation didn't end well. Although the Clínic, after a few months, marketed it as an international success, the patient had to undergo further surgery two weeks after entering the operating room.

Dazzled

They met him at a conference and were fascinated. That's why, in November 2004, Macchiarini was one of four candidates who applied for the position of head of the thoracic surgery department at Clínic. The appointment of managers was a challenge. Dr. Josep Lluís Pomar was one of his endorsers, but Macchiarini had the approval of other prominent figures, such as Dr. Joan Rodés. Shortly before the committee endorsed his incorporation, which required five out of eight votes, the head of pulmonology, Antoni Torres, received a letter from his counterpart at the Hannover Hospital, where the Italian came from, warning of the risks of the signing. "The day before, Torres came to the office and told me 'don't hire him'", recalls one of the committee members. But they didn't stop him: the selection process went ahead and, moreover, despite the warning that Torres conveyed, one of his endorsers calmed any doubts: "We are responsible for him".

And Macchiarini was dazzling. Because of the confidence he conveyed, but also because he had a great education –he had just finished training under the baton of Professor Philippe Dartevelle in Paris–. "From a technical point of view he was brilliant, he performed surgeries that we had never seen before", admit most of the sources consulted. Macchiarini quickly made the leap to the private clinic and the University of Barcelona. However, there were people who were against him and the doors of the August Pi i Sunyer Biomedical Research Institute (Idibaps), linked to the Clinic, were closed to him. "He wanted to do research, but he made a bad impression on us: as a researcher he was a disaster. There are minimums, protocols, a scientific basis, and he did not comply with them", says an authoritative voice from Idibaps.

His landing in Barcelona meant what the surgeon had already predicted to the committee that chose him. "He assured us that half the world would come to the Clinic," recalls one of the members. Said and done. "The work increased brutally, it was crazy," says a person from the department. The Clinic, in its response to questions from this newspaper –it took two months to process the request– denies the increase and assures that in 2005 there were 572 interventions, one less, for example, than in 2002. Since many surgeries were aggressive and did not go well, there was also a very high reoperation rate. On the other hand, at the Barnaclínic, the private branch linked to the hospital, in 2005 17 patients were discharged and Macchiarini performed 8 surgeries, while in 2007 there were 46 and 17, respectively.

Germans, Russians and people from the Middle East began to parade through the Barnaclinic, in exchange for very large amounts of money. Some invoices exceeded 100,000 euros and Macchiarini took a substantial part of it. "Many patients did not contact the Clínic or the Barnaclinic, but he brought them directly. What they paid him was brutal. Before, doctors would tell you 'I want to charge 80,000, do as you wish'. Now it is more harmonised according to the specialty", details a high-ranking official. And how did they arrive? In part, because of the world fame that Macchiarini was beginning to have, who spent long periods of time travelling to hospitals around the world, but also because it is very common for these great specialists to send patients to each other in exchange for commissions. "They all take between 15% and 20%. I've only seen one who didn't ask for it," admits a renowned surgeon familiar with the case.

Some patients were admitted for many months. Tens of thousands of euros for families who went so far as to mortgage their house to put themselves in the hands of the prestigious doctor. When they had nothing left, some changed buildings. "In the morning they were discharged from the Barnaclínic and in the afternoon they went to the emergency room in the public part," explain several witnesses. However, they assure that, although some patients "passed by", "no patient was ever stopped operating" to intervene "those who came from outside" through the private part.

Hope

Many people flocked to Barcelona for the optimistic message that Macchiarini gave them. "You can't give hope to people who don't have it, he took advantage of people's weakness, a person would do anything to save themselves," says a manager at the Clinic. Many times they were patients who came from other centers around the world where they were told that it was unfeasible to operate on them. Macchiarini, on the other hand, offered them a "total innovation," things that "only he could do," recalls a nurse. "Things that other surgeons said were inoperable, he did. He believed he was above good and evil, he considered himself a God," adds a member of the management.

Two of the most repeated concepts among the testimonies collected are the "therapeutic cruelty" to which Macchiarini subjected his patients and the problem of indications. In other words, considering whether surgery was appropriate. Many times the interventions that the Italian doctor chose were not justified. "He complicated the lives of people who could live with their limitations," argues a physician. "In 2006 the house's protocols were very defined, there was a clinical basis, he did things that did not fit with the house's criteria," laments another area manager. "He was looking for people to be able to make his advances," relates with "disappointment" one of his patients.

One nurse remember the story of a young Russian woman in her early twenties. She had melanoma that had spread all over her body. "He painted her all over beautifully, but the post-operative period was brutal, she died before she was due," she explains. The girl would probably have died, but if she had not entered the operating room she could have lived longer. The other case is that of a German patient from whom Macchiarini removed a lung. The nursing team had to fill the entire chest cavity with compresses so that she would not suffocate. When they had to treat her, they had to plug the oxygen directly into the hole in her trachea. "They were real barbarities, savagery," says another nurse. An idea that is also shared by the other surgeons consulted. "He reached the point where he was carrying out therapeutic atrocities, operating on dying people who had no prospect of survival," admits the top brass of the Clinic.

Up to three sources with direct knowledge of how the thoracic surgery service worked indicate that Macchiarini's mortality rate was around 20%. The hospital lowers it and assures that during that time the expected average was between 3.5% and 4%, and that in 2005 the figure for the entire service climbed to 4.6% and then dropped below 3% –however, the center does not offer specific data on the Italian surgeon–. However, one of the resident doctors, as an example, claims that he even signed five deaths in a single weekend. "Until I left the Clinic, I thought that a bronchoplasty meant death, because that's what I had seen there," he concludes.

Young residents who worked under her direction recount how she once asked them to falsify the surgical reports and state that the patient was fine despite complications. Several sources indicate that Macchiarini changed the internal processes for patients undergoing surgery, shifting them from being under the supervision of intensive care pulmonologists to relying on residents "who were not prepared" to take on the task of monitoring patients in critical condition. This, in addition to creating anxiety among staff and tension between departments, served to keep patients under constant control and ensure no information leaked to the outside world.

The atmosphere within the department was poor. There was tension, mistreatment, sick leave due to anxiety, and confrontations. One team member, for example, was banned from going down to the operating room for six months because he had turned in an on-call shift for personal reasons.

The beginning of the end

In 2008, everything came crashing down. Macchiarini's success meant his own grave. In November 2008, all the media reported on the world's first trachea transplant. A successful operation on a young Colombian woman named Claudia Castillo, carried out by Dr. Paolo Macchiarini. In reality, the operation that the Clinic sold as historic and pioneering was not such. There was no trachea transplant, but a trachea from a cadaver was used to replace a bronchus of the patient (later, in Sweden, synthetic tracheas were used). Castillo entered the operating room on June 12, five months before she appeared in the international press. The trachea was decellularized and regenerated in a laboratory in the United Kingdom with cells from the same patient. But, what's more, it didn't go well. She became infected, collapsed and on June 26 she underwent a bronchoscopy and a Dumon stent, a hollow silicone tube, was placed in her, an intratracheal prosthesis, to help her breathe. The operation was unsuccessful.

Castillo, who declined to speak to ARA, had tuberculosis. Although she suffered limitations due to problems in her bronchi, she was not in a critical situation. On the other hand, in his reports Macchiarini maintained that she had a "very poor quality of life" and that it was impossible to "apply other therapeutic alternatives". A fact that is questioned by the doctors with whom ARA spoke and who also treated the patient.

In 2008, Macchiarini published an article in the prestigious journal The Lancet in which he explained the successes of the intervention and assured that the only "conventional option" was pneumonectomy (removal of the lung), a procedure that involved "high mortality rates", but based on the "successful preclinical work" that he had done, the best alternative was the "resection" of the bronchus and its replacement with a "bioengineered human trachea". Five years later, in January 2014, in a new article, the doctor reported that the patient's follow-up showed that the intervention had gone well. It was false. That same year, Castillo had returned to the Clinic after going through several centers. And in 2016, one of her lungs was removed. In March 2019, out of time, the Clinic sent two letters to the journal. The second, by the then head of the service, Laureano Molins, explained the patient's condition and detailed the facts that Macchiarini had omitted: for example, that a few days after her operation she had needed a Dumon stent placed. The Lancet, which published Molins' second letter, claims that the Clinic "never asked" for the articles to be retracted. It was in September 2023, following an investigation by the Swedish authorities, that The Lancet retracted Macchiarini's two articles because they contained "inventions and falsifications".

To add even more seriousness to the case, the operation was not authorized by the National Transplant Organization (ONT). Macchiarini was required to submit all the documentation to conduct a clinical trial, with all the research and scientific basis duly detailed, but he never completed it. Instead, on April 17, two months before Castillo's operation, he obtained authorization from the Clínic itself—endorsed by the Research Ethics Committee—and from the Catalan Transplant Organization (OCATT) for compassionate use, that is, a "one-off, one-off" permit granted when it is considered nonexistent. This authorization should have been endorsed by the Transplant Commission of the Interterritorial Council of the ONT, but it received no requests. "The question is whether compassionate use was justified," several sources question. The Clínic maintains that it had authorization from the Spanish Agency for Medicines and Medical Devices (AEMPS), but the latter denies any involvement: it was a matter for the ONT.

In fact, two sources indicate that compassionate use came at the last minute. "They notified us that the operation had been performed, and that same afternoon we made compassionate use to cover the patient and the hospital," maintains a senior official at the OCATT, who recalls that the trachea had been provided to carry out a clinical trial. "The rules were broken. We spoke with the medical management and demanded greater care with the procedures," acknowledge those at the Clínic. However, these two versions do not coincide with the official explanations from the OCATT and the hospital, as well as with the Health Department resolution to which ARA has had access, which indicates that the authorization was given two months before the intervention.

Lung transplant

The other decisive case was that of a 17-year-old patient, who was brought in by another doctor from the pulmonology area. Macchiarini convinced the girl's family to have the operation. Several sources say that he did it to get the Generalitat to authorize the Clinic to perform lung transplants, one of the great objectives pursued by the center but which the Generalitat denied. "The girl was on extracorporeal circulation in the cardiac ICU for many days, this greatly deteriorates the red blood cells, the platelets, the blood... The machine destroys you," explains a worker at the Clinic who experienced it firsthand. "They couldn't wake her up, she was connected to keep her alive, with her entire chest open, it was a disaster," adds a person who intervened. The Health Department, through OCATT, denied permission and sent a team from the Vall d'Hebron Hospital, the only center accredited to perform this operation, to the Clinic to try to save the life of the young woman, who had pulmonary hypertension. Dr. José Antonio Maestre performed the operation. The next day, the girl was transferred to the Vall d'Hebron, where she ended up dying a few days later. "She died from infections, because she was open for many days," they conclude. "It was a problem of indication, which happened in many cases. The operation was not indicated. This issue was the final straw, because she was discharged from the hospital," says a head of department.

Theft of fabrics

In the final stage of Macchiarini's stay at the Clinic, it was suspected that a trachea had left the center without authorization. The Department of Health carried out an inspection that culminated in two disciplinary proceedings. "The absence and lack of traceability of 2 of the 10 tracheal tissue specimens that had been obtained during 2008 is noted," the file says. The inspector requested information from the Italian doctor, who was responsible for the trachea bank, but did not receive a response. "We understand, therefore, that the penultimate tissue was stolen by Dr. Macchiarini to carry out the second (unauthorized) transplant at the Dexeus clinic facilities," the file states, which speaks of "negligent" action and considers it a serious offense that resulted in a fine of 9,000 euros. Dexeus, which has avoided responding to the ARA, was fined 5,000 euros for having performed the implant in its facilities without authorization and because the patient's informed consent was not included in the clinical history. It was a woman, D.D., on whom Macchiarini performed a tracheal resection and a tracheal tissue graft with stem cells on October 15, 2009, and who required a new operation four days later. A few months earlier, in March, the Clinic rejected a second "transplant proposal" because the surgeon changed "the graft preparation technique" and "there was a lack of experimental evidence once the first transplant was evaluated", that of Claudia Castillo. The Clinic was beginning to see Macchiarini's deceptions.

Untenable

In 2009, Dr. Álvar Agustí took over the management of the Institute of Thoracic Surgery and Pneumology, which included the service that Macchiarini led. "Agustí started talking to everyone and saw that it couldn't be. A doctor also presented him with a series of cases in which there was malpractice, 8 or 10 clinical histories in which it is seen that people who were not supposed to be doing surgery were operating," explains a prominent figure within the department.

The Clinic defends that they never received any complaints or claims about Macchiarini's malpractice. In fact, in a file, the center argues that the "disagreements and disagreements" he had with the medical management led to his contract being terminated on December 1, 2009.

"There were a series of warnings and the institution was not alert," assumes a former head of service. Psychiatrist Joan de Pablo, who saw many of Macchiarini's patients, speaks of the doctor's "narcissistic and psychopathic" traits, two descriptions repeated by many witnesses. The "fantastical" speech and often full of "falsehoods" was accompanied by a "great capacity for seduction" that caused "people of indisputable value such as the leaders of the Clinic" to be "deceived".

"They didn't want to see the dangers. Those who made the decision to bring him in were left with their asses in the air", assume sources of the board. For this reason, Macchiarini left through the back door. However, those responsible at the time maintain that "they knew everything at Karolinska". In fact, a delegation from the Clinic was having dinner at the home of the then CEO of the Swedish hospital and they told him everything they knew about the surgeon, who had already had problems with the justice system in Italy. "Thanks for the information, but he's a genius," was the response Catalan doctors received when they warned about Macchiarini's "lack of rigor." Four years after this meeting in Stockholm, three doctors at Karolinska accused the Italian of falsifying data. The management of the Swedish center, despite having to admit certain errors, renewed it and ended up firing the surgeons who had uncovered the fraud. Until a documentary by SVT, the country's public television, revealed new evidence: Macchiarini had not conducted prior tests on animals to be able to perform the transplants with the synthetic tracheas. A scandal that led to the resignation of the top management of the prestigious Stockholm hospital, and Macchiarini's contract was terminated. It was too late. Along the way, many patients had lost their lives.

He will now have to serve a two-and-a-half-year prison sentence in Spain. The National Court has accepted Macchiarini's request to enter a Spanish prison – probably a Catalan one – since the surgeon resides in Cabrils, where his wife and children also live. On the advice of his lawyers, Macchiarini has avoided speaking to ARA.