In Italian hospitals – especially in smaller ones – too many useless operations are practiced. Often, in fact, we prefer to “cut” instead of contacting other specialists. Or because patients are afraid of aggravations.
“Never leave a surgeon only with the patient, you turn around for a moment and he is already taking him to the operating room to cut him,” he tells us smiling the primary of a large emergency room, which cares about his safety and the good relationship with his colleagues and asks to remain anonymous. But beaten separately, and the disagreements between internists and surgeons that are part of hospital life, in lane the problem of too much surgery has always existed. And it can have heavy consequences both on the quality of life of patients and on public finances. The data and studies are transversal, affect almost all kinds of the most common interventions and do not concern only Italy, but all western countries.
From the hip prostheses to the hernias of the disc, from thyroid interventions to removal of the uterus to cholecystectomy or bariatric surgery to lose weight (Although there are now effective drugs that can help obese without the use of scalpel), there is almost no surgical field that is not growing. Everything appropriate, the result of better screening and attention to health? Or many of these interventions could be avoided not stopping at the first opinion? “To be sure to be able to correctly evaluate the options, it is essential to rely on well -structured centers” warns Alberto Benetti, director of internal medicine -alto complexity of the Niguarda hospital in Milan. «This is because in today’s medicine the approach to the patient and the pathology must always be multidisciplinary. A patient must be evaluated in his globality, from a team where the surgeon, the internist, the emergency doctor and the anesthesiologist is present, to understand in detail the risk-benefit relationship. For example, an intervention could be technically feasible in a patient who, however, perhaps would not endure the duration and intensity of surgery, or would not have such benefit in terms of quality of life as to justify an operation. Multidisciplinarity guarantees maximum appropriateness ».
Too bad it is not always that easy. The National Plan results drawn up by Agenas, Compendium of the care activities carried out every year in Italy, it tells us that in 2023 almost 60 thousand hysterectomies were carried out (total removal of the uterus) with an increase of 10 percent compared to 2022. The operation is performed not only in the event of carcinomas, but also for benign fibroids. “Much responsibility is to be attributed to the” defensive medicine “” says Antonino Trovatello, primary of general surgery at the Umberto I hospital in Syracuse. «Women with fibroids in the uterus, totally asymptomatic and discovered by chance, are not candidate for intervention unless there is bleeding or pain and impact on the quality of life: they are benign pathologies to be kept under control. But if patients are afraid of worsening and insist on the operation, venturing legal causes in case of complications, at that point the surgeon – perhaps at the beginning of the career and without multidisciplinary teams behind – often decides to intervene, even without real indication “.
A few years ago, according to a study by the Eogoi (Association of Ostetrics Italian Hospital Gynecologists), 75 percent of the hysterectomies had been performed for benign pathologies and the intervention was much more widespread in the southern regions and small hospitals compared to large towns in northern Italy. Another case: as part of the operations for diverticolitis, researchers from the Washington University of Seattle have calculated that in more than half of the cases surgery is used even if the patient is at the first hospitalization and presents uncomplicated inflammations, contravening the international guidelines. In short, defensive medicine seems to have a weight also on cholecisactomie (110,800 interventions in Italy in 2023, nine thousand more than 2022), inguinal hernias, kidney calculations to be removed instead of waiting for the results of the care, or other surgical procedures for which the patients themselves ask for interventions for fear of aggravating themselves quickly.
Instead – in case of doubts we should – request a “second opinion”, That is, an opinion to other specialists perhaps of hospitals, cities or different regions: widespread practice abroad, especially in the United States, which is now also taking hold in Italy. “A classic example is the hernia of the album” explains Carlo Ruosi, national president of the Italian Society of Vertebral Surgery. «The first approach must be conservative, so we always recommend to patients, in case an intervention already on the first visit, to look for another specialist for a second opinion is proposed. This is because, especially in small hospitals, there is sometimes an excessive tendency to the operation ». When the scalpel involves the back, it can condemn patients – in case of errors – to a life of pain or disability, and also lead to very high costs for the national health service.
Moreover, the orthopedics field lends itself to many distortions, unless you turn to highly experienced centers. To mention some numbers: for the hip prostheses there were more than 131 thousand interventions in 2023 (there were 104 thousand in 2015) and for those of the knee we reached 108 thousand in 2023 against the just over 72 thousand in 2015. Numbers that could certainly be a sign of greater attention to health, but it cannot be excluded that a not indifferent percentage can be linked to excessive intervention, reimbursements and defensive practices.
Another sore note concerns the thyroid nodules, now become almost an epidemic in Italy and Europe. Well, it is estimated that the removal intervention is useless in eight out of ten cases. “Today the thyroid ultrasound is performed routine, perhaps because they are found in the analysis of the minimum alterations of the functionality of the gland functionality,” says Andrea Giustina, an ordinary of endocrinology and metabolism diseases of the Vita-Salute University of San Raffaele. “In addition, the thyroid is also displayed in non -dedicated exams, as in the carotid ECODOPPLER. During these investigations it is frequent to find even small thyroid nodules, then subjected to aspirated needle and cytological examination. At that point, if the investigations give a high probability of malignancy, surgery is appropriately resorted to. But if the probability is very low, better surveillance with ultrasound monitoring ».
Thyroid tumors, in fact, are low risk of mortality, with survival rates at 20 years of over 90 percent. The problem is that, to patients, it must be said that it is better to wait, while maybe I am in anxiety. «It is always very important to explain, before the aspirated needle, that the cytological examination cannot establish with certainty the malignancy of the lump but only to indicate its probability, and that less than 5 percent of all nodules is evil. Of course, then there is always the decision of the patients »concludes Giustina. That today are increasingly disoriented, prey to fake news, word of mouth and influencer. But if the operating table is involved (and of course if there is no urgent urgency) the choice must always be thoughtful: never stop at the first opinion, perhaps convenient because it comes from the small hospital closest to our house, but to inquire, ask for another opinion, search for the reference centers. And then, trust.
