The main topic of this review is surgery used in Russia without sufficient indications. Among others, the following is analyzed: the overuse of gastrectomy (resection) for peptic ulcers, of thoracic surgery for tuberculosis, bronchial asthma and other respiratory diseases, spleno-renal anastomosis in diabetes, excessive treatments of alcoholics. Considering the breast cancer incidence, millions of women in the former Soviet Union underwent Halsted and lately of Patey mastectomy with removal of pectoral muscles without indications, often sans informed consent. Glioblastoma patients were routinely operated on, while it was believed by some staff that the treatment was often useless, just forcing many patients to spend the rest of their lives in bed. The training of medical personnel has been a motive, these days under the imperative of readiness for war. This topic is interconnected with certain features of Russian healthcare, namely paternalism, authoritative management style, occasional disregard for the principles of informed consent, professional autonomy and scientific polemics. In conditions of paternalism, misinformation of patients, persuasion and compulsory treatments are deemed permissible. Most importantly, the human factor has remained largely unchanged since the Soviet time. Thanks to the PubMed and other free resources, recent textbooks are partly adjusted to the international literature. However, some recommendations have been different from those used internationally. Considering shortcomings of medical practice, research and education, a simple increase in funding is unlikely to be a solution. Measures for improvement of the healthcare in Russia must include participation of authorized foreign advisers.

According to the author’s estimates after a practice abroad (repeatedly during 1990-2008), an average size of malignant tumors in surgical specimens was larger in Moscow university clinics than in hospitals of Western Europe, which reflects the timeliness of cancer diagnostics. Another difference: almost all mastectomy specimens abroad were without muscle. The worldwide tendency towards a more sparing breast cancer (BC) management was not followed in the former Soviet Union (SU) for decades. In the 1980s and decreasingly in the 1990s, the Halsted procedure with the removal of both pectoral muscles was a predominant method of BC management [1-4]; it was presented as the main treatment modality of BC in some textbooks and monographs published after the year 2000 [5-7]. The principle of informed consent was often disregarded. Patients with early cancers were subjected to mastectomies with resection of pectoral muscles without discussing potential adverse effects. A surgery could be extended to a radical procedure if an intraoperative frozen section found an early BC [8]. The latter operation is known to be associated with complications; millions of women underwent it in the former SU. Even more radical methods were recommended and applied [9]. Newly developed mastectomy modalities with the muscle resection have been patented [10,11]. Old age was not regarded as contraindication to a radical surgery [12]. In view of complications, some experts recommended the modified radical mastectomy of Patey with resection of only the smaller pectoral muscle for T1-2 laterally located BCs [13,14]. Others advocated the Halsted procedure. The Patey operation is also associated with adverse effects; nonetheless, it has been broadly used in the Russian Federation (RF) in last decades. During the author’s practice at the pathology department of the Ostroumov hospital in Moscow, incorporating the Centre for Senology (named Mammology in Russia), almost all mastectomy specimens independently of the tumor size included the smaller pectoral muscle; but the Halsted procedure was applied as well. The article dated 2007 discussed the “gradual abandonment of the Halsted operation” [15]. A study of neurologic symptoms after mastectomy [16] included 247 women who had undergone 121 (48%) operations of Patey and 73 (29%) of Halsted. In papers dated 2015-2022, the Patey operation was mentioned as a routine procedure [17-19]; but the preservation of both pectoral muscles was finally becoming a standard. Thanks to free Internet resources, the recommendations are currently adjusted to international patterns. Another extreme is observed: mastectomy without removal of pectoral muscles is called “mutilation” allegedly causing “severe moral injury” [20]. Such statements are accompanied by images of patients after reconstructive surgery, where breasts look (almost) as if not operated. Apparently, the motive is economic as the costs of plastic surgery are borne by patients. Of note, esthetic demands can be met in many cases by external prostheses.

Diabetes mellitus

The surgical spleno-renal anastomosis with the shunting of pancreatic blood into the systemic circulation was introduced by Eduard Galperin [21-23] and applied for the treatment of insulin-dependent diabetes mellitus. At the same time, Galperin wrote: “Diabetic patients generally tolerate surgery very poorly” [24]. The method was applied also in type 2 diabetes [25,26]. The supposed mechanism was “creating a more optimal interaction of subcutaneously injected insulin and glucagon produced in pancreas” [22]. Of note, in patients with liver cirrhosis the surgical portocaval shunting resulted in deterioration of oral glucose tolerance [27]. Diabetes mellitus was even regarded to be a contraindication for portocaval anastomosis operations [28].

In a series of 415 patients, early post-operative complications were observed in 28 patients including 2 cases of sepsis, 5 pyelonephritis, 5 pneumonias; 2 patients died in the first post-surgery week. Ketonuria was observed in 18 patients [29], which agrees with the known fact that surgical stress may trigger ketosis in diabetics. Comparable percentages of complications were reported in the article [22]. The patients were subdivided into groups with a strong, moderate and absent effect [23]. There was no group with deterioration, so that the assessment must have been biased. According to another report, thrombosis of the shunt was found by angiography in 27% of the patients during eight months post-surgery [30]. Severe acidosis was designated as a typical side effect [30,31]. The anti-diabetic efficiency of the shunting was moderate both in humans and in the experiment on dogs, whereas a majority of the animals did not survive the diabetes induction by streptozotocin or pancreatic resection with a subsequent shunting surgery [21]. During his one-year-long employment in the United States in 1990, Galperin used his method on dogs and rats, deploring that there was no opportunity to apply it in humans [24]. 

By 2011, the surgical treatment of diabetes described above was still in use while a high risk of shunt thrombosis was pointed out [31,32]. During the operations, biopsies from the pancreas and kidneys were taken. Procedures applied within the framework of the surgical treatment of diabetes included celiac arteriography, renal and splenic venography [22,29]. 

Peptic ulcers

Certain surgical treatments of gastro-duodenal ulcers in the former SU have been different from the international practice [33]. According to the author’s observations, gastric resections were rarely performed abroad for peptic ulcers; their volume was smaller, being often equivalent to antrectomy. For perforated ulcers, a local excision was usually performed, while a ring-shaped specimen of the stomach wall was sent to the pathologist. Laparoscopic repair is used increasingly these days. In Russia, primary gastric resection (2/3-4/5 of the stomach), antrectomy with vagotomy, or a simple suture, depending on the patient’s condition, has been applied [34-39]. Some experts called attention to the adverse effects of resections [33,40]. The limited availability of modern medical therapy was designated as social indication for the stomach resection [33,36]. 

The hyper-radicalism in the gastric surgery originates from Sergei Iudin (in earlier papers spelled Sergey Yudin), who was a “passionate supporter of gastric resections in ulcer perforations” [41]. According to his doctrine, the pylorus and lesser curvature must be resected at an ulcer surgery [42]. During the World War II, Iudin was one of leading surgeons of the Soviet army. He was notorious for radical operations: “Total and wide resection of devitalized tissue… resection rather than drainage and removal of bone fragments in joint wounds (including knee and hip joints)” [41]; “Unhesitatingly excise muscular tissue to access fractured bone” [43]. Former health minister Boris Petrovsky [44] wrote that Iudin’s radicalism in military surgery, followed by other surgeons, led to hemorrhages, extensive defects of osseous and soft tissues. Iudin’s articles recommending stomach resection in ulcer patients were published later with approving editorial commentaries [42]; his writings are cited now as before. Resection of the stomach in case of ulcer perforation has been advocated by many experts from the former SU [33,36,45-49]. The continuous adherence to this method was explained by limited accessibility of modern drugs [33,36]. In some articles recommending resections, it was stated that the drug therapy doesn’t provide an adequate solution [46] and … doesn’t achieve a complete recovery”, so that resection should be performed early to avoid complications [45]. The notion of “complete recovery” seems to be hardly applicable to the condition after gastrectomy. Anyway, this strategy was in disagreement with that applied in other countries. 

Like in many topics discussed in this review, recommendations are currently adjusted to international patterns thanks to the PubMed and other free databases. At least a fivefold decrease in gastric resection frequency among ulcer patients during last decades has been reported from some institutions [50-52], which indicates an overuse in the recent past. However, the attitude delineated above is reappearing today, notably, from military-medical institutions [53]. The military needs trained surgeons. In recent publications, gastrectomy has been designated as the most frequent, main or singular surgical treatment of gastric ulcers [35,54,55], applicable for any ulcer location [53]. As before, appeals to “radicalism” can be heard, advantages of early surgery for uncomplicated ulcers being emphasized [35,53]. 

Respiratory conditions 

Another method to be commented is thoracic surgery with the denervation of lungs as a treatment of bronchial asthma [56,57]. Among others, the “skeletonization” of pulmonary roots with transection of nerves, auto-transplantation of lungs (complete removal with immediate re-implantation) [58] or cross-section of trachea with subsequent suturing [59] were applied. The theoretical ground was the assumption that the denervation “precludes abnormal nervous impulsation” [56]. Exaggerated histological descriptions of “dystrophy” in the autonomic nervous system were presented as a theoretic basis of the denervation [56]. The surgical treatment of asthma was recommended by the Health Ministry, while thoracotomy with lung denervation was designated as “the most accepted surgical treatment” [60]. The skeletonization was advocated both for steroid-dependent and infectious-allergic asthma varieties [60]. Repeated bronchoscopies were applied post-surgery because of the bronchial drainage impairment [58]. The pulmonary denervation and lung resection were recommended also for asthma cases when drug and inhalation therapy had been efficient. It was suggested that non-invasive treatment prior to the operation must be limited in time [60]. 

Denervation was sometimes performed simultaneously with lung resection, lobectomy or bilobectomy. In this connection, a quote from the recommendations of the Health Ministry deserves attention: “The widespread idea that indication for surgery in asthma is the ineffectiveness of conservative therapy is incorrect. The presence of foci of chronic inflammation in the lungs and bronchi, even with a good effect from conservative treatment, is an indication for surgery. Delaying the operation serves to involve other parts of the bronchial tree in the inflammatory process, enhances the degree of allergy, degenerative changes in the innervation apparatus and endocrine organs” [60]. Such instructions can lead to resection of largely unchanged pulmonary tissues, which was noticed by pathologists. 

As mentioned above, the denervation surgery was sometimes combined with removal of pulmonary segments or lobes regarded to be pathologically altered [60]. Lung resections in asthma were used also without denervation, including cases when inhalation or drug therapy was efficient. Among indications for the surgical treatment were focal lesions: chronic pneumonia, bronchiectasis and bronchitis deformans [61]. Sokolov et al. stated that ≤10% of their asthma patients underwent resections [62]. The surgeries were performed also in patients with bilateral inflammatory or fibrotic lesions, both in exacerbations and in remissions, supposed to be indicated for a radical treatment of asthma. This concept was advocated by Fedor Uglov [61,63], who claimed “resection of infected foci” to be the aim of asthma management. The therapy was based on the belief that “in 98% of cases, the cause of asthma is focal chronic pneumonia” [61]. The purpose of the operation was the “removal of focal infection.” Localized chronic pneumonia with bronchial lesions was by itself regarded to be indication for lung resection. Asthma patients were transferred from internistic departments for the surgical treatment. After a course of therapeutic bronchoscopies, Uglov and co-workers performed resections of pulmonary lobes or segments regarded by them to be pathologically changed [61,63]. 

Resections were applied to children with recurrent bronchitis and/or pneumonia; while efficiency of pneumonectomy was stressed, also in cases with bilateral involvement [64]. The recommendation for progressive chronic pneumonia was “lobectomy for segmentary lesions and pneumonectomy in all other patients” [65]. Reportedly, “dysontogenetic” lung diseases in children were a more frequent indication for radical surgery than acquired conditions; whereas lobe- and pneumonectomies were predominantly applied [66]. A leading expert in pulmonary pathology Irina Esipova with co-workers found malformations in 66% and bronchial diverticulosis in 64% of resected specimens from children operated for relapsing pneumonia or bronchitis deformans [67]. The same authors reported that, contrary to preceding publications, the lesions were predominantly not diffuse but local, thus justifying resections. Contemporary international literature was referenced scarcely in suchlike papers. Furthermore, Esipova claimed that misdiagnosis of malformations as chronic bronchitis led to undue delay of surgery [67]. In accordance with this concept, pathologists described in surgical specimens’ inflammation, fibrosis, dystrophy and malformations without specifying extent and severity [67,68], whereas descriptions were at variance with the international literature [69], histological images being poor quality [70]. In some cases, the surgery could have been indicated; but the overtreatment was known to occur and noticed by other experts. It was pointed out that some histological phenomena described as malformations are common in postnatal lungs normally or after resolved pneumonia [71]. It was also noticed that diagnostics of lung malformations is difficult; the percentage of wrong diagnoses amounting to 65-75%. The patients were operated nonetheless based on the assumption that inflammatory complications are inevitable [72].

Tuberculosis (Tb)

After the successful development of medical treatment of Tb in the 1950s, the use of surgery has decreased in many countries. The priority of the former SU in this field was claimed [73-75]. The surgery of Tb has been performed not only in specialized centers but also in peripheral hospitals [73,76]. This development was associated with the name of Mikhail Perelman, who criticized the Directly Observed Treatment, Short Course (DOTS) Program by the World Health Organization and endorsed the surgical treatment [77].

In the period 1973-1987, 285,000 patients with pulmonary Tb were operated in the former SU, in 1987 - 26,000, while 85% of the surgeries were lung resections [78]. In 1986-1988, ~17,500 operations for lung Tb were performed annually in RF only in specialized institutions [75]. The incidence of Tb in 1986 and 1988 was, respectively, 43.8 and 40.8 per 100,000 [79]. More than 29% of new Tb cases were operated at that time. In 2003, 10,479 surgeries (~9% of newly diagnosed cases) were carried out, deemed insufficient [80]. In the foreign literature, corresponding figures are usually below 5% [81-83]. In the same period, the incidence of Tb in Russia increased from 34.0 in 1991 to 90.4 per 100,000 in the year 2000 [79]. Similarly, to other diseases [84,85], this drastic increase could have been partly caused by an underestimation during the Soviet period. In the year 2006, 12,286 operations were performed in RF for pulmonary Tb, including 9300 (75.7%) resections and 399 (3.2%) pneumonectomies [74]. According to another report, the forms of Tb most frequently treated by resections were cavitary Tb (52.2%) and tuberculoma (43.9%) [86]. For example, Perelman reported a series of 578 operations in 502 patients including those with fibro-cavernous Tb (196 cases) and tuberculomas (161 cases). The most frequent procedures were resection (280 cases) and pneumonectomy. The authors concluded that “indications for surgical management of pulmonary Tb should be generally expanded” [87]. Tuberculoma was the form of Tb most often operated by Giller and co-workers: 81 from 179 cases in one series [88].

Resections were recommended also for patients with inactive post-Tb fibrosis including oligosymptomatic cases [89]. On the other hand, surgeries were performed in florid disseminated Tb [90]. In some provinces of the Urals, Siberia and Volga regions, 25-40% of patients with destructive Tb were operated on [91]. At the time of initial Tb diagnosis, surgery is as before considered to be indicated in 15-20% of patients [75,92,93]. According to another paper, indications for surgery were ascertained in 20-30% of patients at the time of diagnosis and/or in those with active Tb [94]. In Ekaterinburg and surrounding province (years 2006-2008), indications for surgery were found in 1784 from 4402 (40.5%) patients with pulmonary Tb, while ‘only’ 1079 (24.5%) were operated as some patients were unavailable [95]. According to the recent handbook, ~6.4% of Tb patients are operated in RF; but “in some provinces, which cooperated with the Perelman’s Institute… the percentage has been much higher” [96]. Despite the lack of clinical trial data on efficacy of adjunctive surgical therapy of Tb, some countries of the former SU have continued performing many lung surgeries, predominantly resections [88,97,98].

Tuberculoma (>2 cm, also in children) has been generally regarded in Russia as an indication for surgery. Fibrocavitary Tb was designated as an absolute indication. Tuberculoma has been a frequent indication in children and adolescents with Tb [96,99]. Tuberculomas >1 cm was routinely operated on [100-102], which is contradicting to the international practice. There is an opinion that potential instability of tuberculoma does not justify thoracic surgery and that asymptomatic patients with stable solid lesions do not require therapy. Nonetheless, tuberculoma was the most frequent indication for lung surgery in Tb patients (44.2%; in children - 40.7%) at the leading institution – Sechenov Medical University in Moscow [74,103]; while at some hospitals this percentage reached 50-80% [104]. Now as before, tuberculoma occupies first places among Tb forms that are operated on [92]. The surgical treatment of tuberculoma was recommended also for cases with extensive lesions in remaining pulmonary tissues [105]. Bilateral resections were performed for various forms of Tb including tuberculomas on both sides [106-108]. A study from the Sechenov University reported 771 lung operations, including 168 pneumonectomies, 181 lobectomies, 180 other resections, performed in 700 Tb patients, up to 4 operations/patient. Postoperative complications were recorded in 100 (12.9%) patients and lethal outcomes - in 12 (1.5%) [109]. Another example from the same Institution: among 60 operated Tb patients the complication rate was 37%, mortality - 5%; 18.3% of the patients were released from hospital with persisting complications [110]. The tendency to underestimate complications due to limited follow-up and other reasons is known.

Resections for Tb were performed by some experts without preceding attempt of medical treatment or within one month after the diagnosis, when medical therapy could have been efficient [100,111]. One of the arguments in favor of the early surgery was non-compliance increasing with time [100] as the patients gathered knowledge and advice. Lung operations were performed and recommended also for aged patients with comorbidities [112-115]. Sokolov found indications for surgery in 210 from 289 (72.6%) Tb patients 50-73 years old and operated 180 (62.2%) of them, 144 operations being lung resections [114]. Among the latter 144 patients, 93 (66.4%) had cavitating disease and 43 (30.8%) - tuberculoma. Indications for lobectomy are questionable especially for aged patients with tuberculoma. A post-surgery reactivation of Tb was recorded in 8.6% of the cases, fistula - in 27.2%, atelectasis - 20%, pneumonia - 5.7%, pleural empyema - 3.6%, other complications - 12.9%; 8 (5.7%) patients died after the operations. In the monograph based on 233 lung resections in Tb patients older than 50 years (mortality - 5.4%), Gorovenko et al. reasonably concluded: “It is important that a surgery doesn’t provoke an unfavorable outcome” [112]. According to another report, tuberculoma was the most common indication, and lobectomy - the most frequent operation in elderly Tb patients, whereas potential contagiosity was among arguments in favor of the surgical treatment [115]. Statements of this kind can be found also in recent papers e.g.: “Surgery in patients with tuberculomas is recommended to reduce their infectiousness” [116]. According to Giller, a reduction of Tb incidence and mortality can be achieved only by means of a “radical sanitation” of contagious patients also without destructive pulmonary lesions [88]. Note that tuberculoma is usually not contagious. Obviously, potential contagiosity does not justify a thoracic surgery. Tendentious citation is sometimes used to corroborate radical surgical tactics; references are in [117]. One more citation: “Active surgical sanitation of infectiously dangerous patients with pulmonary Tb contributes to the rapid improvement of epidemiological indicators” [118]. No mentions of informed consent have been found in this connection. It is not surprising that some patients are hiding their symptoms. 

Out of 1,311 Tb cases operated at the Phthisiopulmonology Institute in St. Petersburg, 241 had Tb recurrences and 203 underwent repeated surgeries [119]. Postoperative recurrences were regarded as indications for repeated operations up to concluding pneumonectomy [108] and resections of the remaining sole lung [120]. For example, repeated resections on both sides with a concluding pneumonectomy along with 52 bronchoscopies were performed in one case [121]. Bilateral lobectomies or pneumonectomy plus contralateral “sparing” resection were deemed indicated for patients with a Tb lesion on one side and non-specific inflammatory or fibrotic lesions in the contralateral lung [122]. Bilateral resections and bilobectomies were performed in various forms of Tb including tuberculoma [106-108,120,122,123]. Resections were deemed applicable also in cases with severe respiratory insufficiency [76,120,124,125].

It is recommended to explain to patients with tuberculoma “in popular form” that surgery is necessary [126] instead of objective depiction of pros and cons. The role of surgery in Tb remains controversial. Patients should not undergo operations to merely comply with doctrines. Evidence-based clinical indications must be determined individually. The informed consent started to be mentioned relatively recently in papers from Russia reporting research using invasive methods, for example in a bronchoscopic study of pediatric asthma, where a consent of caregivers was regarded to be sufficient [127]. Some caregivers could have been misinformed about indications. Of note, the principle of informed consent or assent is applicable also to adolescents and children. 

The outpatient treatment of Tb, usual in other countries, is supposed to be hardly applicable in RF [128]. According to the governmental Regulation No. 378 of June 16, 2006, patients with contagious Tb are not permitted to reside in one apartment with other people. As per the Federal Law No. 77 “Prevention of the Tb spread” of June 18, 2001 (amended 2013), “patients with contagious Tb, repeatedly violating the anti-epidemic regime, and those evading examinations for Tb or [emphasis added] the therapy, are hospitalized for obligatory examination and treatment.” It is specified by the same law that the principle of informed consent is not applicable under these circumstances, and that Tb patients must undergo prescribed examination and therapy. The non-observance of this law may lead to a criminal persecution. A survey found more than 6000 legal proceedings whereas 3163 Tb patients were compulsorily hospitalized [129]. In one series, 463 judicial cases resulted in 421 court decisions to hospitalize Tb patients [130]. Compulsory treatments are generally at variance with the international practice and regulations. According to The World Medical Association, neither the statutory exceptions to the principle of informed consent nor the conditions of required care allow legally binding measures against patients refusing a treatment or hospitalization [131]. The consent for invasive procedures and chemotherapy is of particular importance in conditions where overtreatment may occur. 

As far as we know, the Soviet and present rulers, the party and military nomenklatura [132], did not allow the use of invasive procedures without indications on themselves and their relatives. Functionaries’ sons did not treat gonorrhea by tamponade and bougienage of the urethra [133]; alcoholics from their milieu have not been compulsorily treated by drip infusions days on end, being infected with viral hepatitis, neither did they drink technical ethanol sold in vodka bottles through legally operating shops [134]. As for the medical personnel, it is unlikely that they applied dry cutting and poor-quality fillings to discolored pits and fissures in their children [70], cauterized cervical ectopies without preceding Pap-smears [135], or performed Halstead mastectomies on their family members. This implies that there has been an extensive deliberate infliction of bodily harm. Military functionaries and their relatives will become more dominant thanks to the armed conflict. Those participating in it, factually or on paper, are obtaining the veteran status and hence privileges over fellow-citizens. Some of them will occupy leading positions in universities without adequate preparation and selection. War veterans enjoy advantages in healthcare and everyday life; there are, however, misgivings that the status has been awarded gratuitously to some individuals from the privileged milieu. At the same time, relatives of superior officers evaded conscription under various pretexts. In particular, many institutions of higher education grant exemption from military service. Being not accustomed to hard and meticulous work, some of the functionaries’ protégées have been involved in professional misconduct of a different kind [136].

Some invasive methods with questionable indications were introduced or advocated by first generation military surgeons. The Soviet period brought about an expansion of admission numbers to universities and medical educational institutions, sometimes with little regard for the quality of the academic preparation of students [137]. One of the motives to overuse invasive procedures was personnel training, among others, with the objective of readiness for war. Note that military and medical ethics are not the same. The comparatively short life expectancy in Russia is a strategic advantage as it necessitates less healthcare investments and pensions. Malignancies are diagnosed in Russia relatively late. Furthermore, among factors contributing to the use of invasive procedures with questionable indications have been the partial isolation from international scientific community, insufficient consideration of the principles of professional autonomy, informed consent and scientific polemics, as well as a paternalistic attitude to patients. Most importantly, the human factor has not sufficiently changed since the Soviet time. The ethical and legal basis of medical practice and research has not been sufficiently known and observed in Russia. The term “deontology” is often used for medical ethics in this country. Textbooks and monographs on deontology explained the matter somewhat vaguely, with truisms and generalities, but not much practical guidance. Today, the growing economy enables the acquisition of modern equipment; and medical research is on the increase. Under these circumstances, the purpose of this review was to remind us that, performing surgical or other invasive procedures, the risk-to-benefit ratio must be kept as low as possible. Insufficient coordination of medical studies and partial isolation from the international community can result in parallelism in research, unnecessary experimentation, and application of invasive procedures without sufficient indications. Considering shortcomings of medical practice, research and education, governmental directives and the increase in funding are unlikely to be a solution. Measures for improvement of the healthcare in Russia must include the participation of authorized foreign advisors.