The Overuse of Surgery in Respiratory Diseases: Report from Russia

This review is an update and continuation of preceding publications on invasive procedures used in Russia without sufficient indications. Among contributing factors have been partial isolation from the international scientific community, obstacles to the import of drugs and medical equipment, insufficient consideration of the principles of professional autonomy, informed consent and scientific polemics, as well as paternalistic attitude to patients. The following is discussed here: the overuse of thoracic surgery and endoscopy in bronchial asthma, supposed pulmonary malformations, infectious and other respiratory conditions with special reference to tuberculosis and alcoholism. The main conclusion is that, performing invasive procedures, the risk-to-benefit ratio must be kept as low as reasonably achievable. Patients should not undergo surgery merely to comply with doctrines. Evidence-based clinical indications must be determined individually; the patients being objectively informed on potential benefits and risks. Today, international literature is available on the Internet. The government stimulates the medical research and innovations. However, considering persisting drawbacks, measures for improvement of the healthcare in Russia must include participation of authorized foreign advisors.

The central topic of this review is invasive procedures without sufficient indications in Russian Federation (RF). Clinical recommendations are avoided here. Among others, the following has been discussed previously: the overuse of gastrectomy for peptic ulcers, overtreatment of radiation-related lesions, spleno-renal anastomosis in diabetes, overuse of renal biopsy, excessive and compulsory treatments of alcoholics, cauterisation of cervical ectopy regardless of the presence of epithelial dysplasia, Halsted and lately of Patey mastectomy with removal of pectoral muscles, overtreatment of thyroid lesions [1,2]. 

Bronchial asthma and related conditions

The lung denervation via thoracotomy as a treatment method of bronchial asthma [3-9] was presented as “the most accepted procedure” in an official instruction issued by the Health Ministry of RF [10]. As a part of this method, the “skeletonization” of bronchi with cutting of nerve branches, reimplantation of lungs, or cross-section of trachea with subsequent anastomosis, were applied [4-6]. The theoretical foundation of this method was the idea that denervation interrupts abnormal nerve impulses [3]. High efficiency was ascribed for the lung “autotransplantation” i.e., complete separation with immediate re-implantation, but surgery-related risks were acknowledged [4,6,7]. Supposedly, this latter procedure normalizes metabolic processes and neuro-humoral relations in the respiratory system, disrupting incorrect reflexive connections and the “pathological impulsation” from the nervous system [3,7,10].  Enhanced sensitivity to bronchodilators and improved blood circulation were claimed [9]. One of the recommended modalities included resection of the Truncus sympathicus [10], which has later been noticed to cause neurological complications [8]. Various adverse effects of the denervation have been reported, among them insufficient bronchial drainage, requiring therapeutic bronchoscopies, and neurologic derangements up to hemiparesis [8]. As described in detail below, it was recommended to combine the denervation with removal of chronic infectious foci, i.e. resection of pulmonary tissues, or with otorhinolaryngolical operations [10].

Histopathological descriptions exaggerating non-specific findings in the central and peripheral nervous system have been presented as a theoretical foundation of the above-mentioned procedures [3]. In particular, dystrophy of sympathetic ganglia, cell swelling, tortuosity of nerve fibers and diapedesis hemorrhages (the latter possibly caused by the operation) were presented as morphological features of asthma and justification for the denervation [3]. As mentioned below in regard to lung resections, some pathologists have supported surgical methods with questionable indications. 

The skeletonization was advocated for both steroid-dependent and infectious-allergic asthma subtypes [9,10]. It was claimed that medical therapy prior to the surgery must be temporally limited [10]. This approach, which also included pulmonary resections or pneumonectomies, was endorsed by the Health Ministry: “The widely held belief that the reason for surgery in asthma is failure of medical therapy is inaccurate. Persistent inflammatory foci in the lungs and bronchi, even if conservative treatment is effective, are indications for surgery. Delaying the procedure entails involvement of additional areas of the bronchial tree in the inflammatory process, elevates the degree of allergy, causes dystrophic changes in the nervous apparatus and endocrine glands” [10]. Such guidelines resulted in resection of viable pulmonary tissues, which was noticed by pathologists performing cutting up of surgical specimens. 

Resections were performed in asthma patients combined with the denervation, or as an independent procedure [11]. In one study, segment- or lobectomies were performed in approximately 10% of asthmatic patients [12]. The operations were performed in cases with bilateral inflammatory or fibrotic lesions, both during exacerbations and in remissions, claimed to be a radical therapy of asthma. This concept was advocated by the well-known surgeon Fyodor Uglov, who purported that resection of infectious foci is a radical treatment of bronchial asthma. This approach was based on his supposition that in 98% of cases, the cause of asthma is local chronic pneumonia. The supposition that allergy in asthma develops on the background of persistent infection was supported by references to the Russian scientific school, Sergei Botkin in particular [11,13]. The priority of domestic achievements in asthma surgery was pointed out [5]. Focal chronic pneumonia and deforming bronchitis were regarded as indication for lobe- or segmentectomy. In accordance with this doctrine, it was claimed that a delay of surgery would result in exacerbation of infection [11].

Bronchitis, pneumonia and congenital malformations 

Pulmonary resections with questionable indications were applied to patients with relapsing bronchitis or pneumonia. Lobe- and pneumonectomies were used, and advantages of the latter stressed both for uni- and for bilateral lesions [14]. The recommendation for progressive chronic pneumonia was “lobectomy for segmentary lesions and pneumonectomy in all other cases” [15]. Allegedly, dysontogenetic lung conditions in children were a more common reason for lobe- and pneumonectomy than acquired conditions [16]. Irina Esipova, one of the leading experts in pulmonary pathology, diagnosed malformations in 66% of resected specimens from children operated for relapsing pneumonia and/or bronchitis [17]. The same research team reported that the lesions in their specimens were not diffuse but focal, thus supporting the surgical treatment. Esipova claimed that misdiagnosis of bronchitis instead of dysontogenetic conditions led to unreasonable delay of surgery [17]. Reportedly, “dysontogenetic” lung diseases in children were a more frequent indication for pulmonary resections than acquired conditions; whereas lobe- and pneumonectomies were predominantly applied [18,19]. Certain experts advocated surgical treatment of supposed pulmonary malformations at the age of 2-6 years [20]. 

In accordance with the above concept, pathologists described in surgical specimen’s non-specific lesions: fibrous foci with black pigment, singular small cysts, uneven contours of bronchial walls, abnormal epithelial cilia, etc. [17,21]. Such descriptions of supposed congenital malformations have been partly at variance with the international literature. Several images have been reproduced and commented in the book [1]. The overdiagnosis of pulmonary malformations was subsequently noticed by colleagues [22]. In particular, histopathological changes described as congenital malformations can be observed in the normal juvenile lungs or after a resolved pneumonia. It was stressed that clinical manifestations of questionable or true malformations (e.g., bronchial diverticula) are rarely significant enough to justify resection. Scrutiny of past experience has shown that surgery is not an adequate treatment for many cases of inflammatory diseases and suspected malformations [22]. Indications for pulmonary surgery in asthma, chronic pneumonia and related lesions have been revised and narrowed. However, the present review is not outdated because mentality and motives have remained largely unchanged. One of the motives of the overuse of surgery has been personnel training under the imperative of readiness for war [23].

Pulmonary tuberculosis (Tb)

Along with development of medical treatment of Tb, the use of surgery has decreased in many countries. Priority of Russia in this field has been pointed out [24,25]. The surgery has been performed not only in specialized centers but also in peripheral hospitals. This development was associated with the name of Mikhail Perelman, who endorsed the surgical treatment [26]. Lung resections were recommended for patients with inactive post-tuberculous fibrosis including oligosymptomatic cases. On the other hand, operations were performed in florid disseminated disease. In some provinces of the Urals, Siberia and Volga regions, 25-40% of patients with destructive Tb were operated [27]. At the time of initial diagnosis, surgery is considered to be indicated in 15-20% of patients [28,29]. According to other papers, indications for surgery were found in 20-40% of patients at the time of diagnosis or in those with active Tb [30,31]. In the international literature the figures are generally lower [32]. It was pointed out that a half of lung surgeries in RF had been performed for Tb [25]. 

The recommendation to remove tuberculoma originated from Lev Bogush [33]. Stable tuberculoma has been regarded as indication for surgery in adults and children [34-36]. The lesions ≥1 cm was routinely operated [37]. Another indication in children and adolescents is the “absence of positive dynamics” after 6 months of medical therapy or earlier in case of drug resistance [35]. The irreversibility was regarded as indication for surgery. Of note, tuberculoma is a stable lesion; and neither progression nor involution should be generally expected. Now as before, tuberculoma is among the forms of Tb that are most often operated [28]. It was the most frequent indication for lung surgery in Tb patients at the leading institution - the I.M. Sechenov Medical Academy (MMA, later renamed University): 44.2% of all patients and 40.7% in children [25,38]. At some phthisiological hospitals this percentage was as high as 50-80% [39]. Bilateral resections were performed in various forms of Tb including tuberculomas on both sides. Research from MMA reported 771 operations, including 168 pneumonectomies, 181 lobectomies, 180 other lung resections, performed in 700 Tb patients, up to 4 operations per patient. Postoperative complications were recorded in 100(12.9%) and lethal outcomes in 12(1.5%) of the cases [40]. Another example from MMA: among 60 operated Tb patients, the complication rate was 37%, mortality - 5%; 18.3% of the patients were released from the hospital with persisting complications [41]. Limited follow-up causes undercount of complications, especially those developing at a later date. 

Out of 1,311 Tb cases operated at the Phthisiopulmonology Institute in St. Petersburg, 241 had recurrences and 203 were re-operated [42]. Postoperative recurrences were regarded as indications for repeated surgeries up to a concluding pneumonectomy and resections of the remaining sole lung [43]. Bilateral lobectomies or pneumonectomy plus contralateral “sparing” resection were regarded to be indicated for patients with a Tb lesion on one side and non-specific inflammatory or fibrotic lesions in the contralateral lung. Bilateral resections and bilobectomies were performed in various lesions including tuberculomas. According to a recent monograph, among 420 patients operated for tuberculoma, bilateral operations were performed in 130(31%) [44]. Resections were regarded to be applicable also in cases with severe respiratory insufficiency. More references are in [32]. 

Resections in Tb were performed by some surgeons without preceding attempt of medical treatment or within one month after the diagnosis, when medical therapy could have been effective. One of the arguments in favor of the early surgery was non-compliance increasing with time [37], as the patient’s collected information and advice about their disease. Lung operations were performed and recommended also for aged patients with comorbidities. Sokolov found indications for surgery in 210 from 289(72.6%) Tb patients over 50 years old and operated 180 (62.2%) of them, 144 operations being lung resections. Among the latter 144 patients, 93(66.4%) had cavitating lesions and 43(30.8%) tuberculoma [45]. 

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 [46]. Statements of this kind can be found in recent publications e.g.: “Surgery in patients with tuberculomas is recommended to reduce their infectiousness” [47]. According to Giller, a reduction of Tb incidence can be achieved through a “radical sanitation” of contagious patients including those without destructive pulmonary lesions [48], the surgery being important as it impedes infection of other people [25]. “Reduction of M. tuberculosis circulation in society” has been declared as a goal of surgical treatment [28]. Of note, tuberculoma is usually not contagious. Broadened indications for surgery have been applied to patients with comorbidity of Tb and alcoholism because of supposedly “high epidemiological danger” associated with them [36]. One more citation: “Active surgical sanitation of infectiously dangerous patients with pulmonary Tb contributes to the rapid improvement of epidemiological statistics” [49]. No mention of informed consent has been found in the context. According to medical and common ethics, potential contagiosity does not justify a thoracic surgery without sufficient clinical indications. 

According to official instructions and textbooks, indications for surgery have been broader in alcohol-dependent than in other patients with Tb [36]. In case of alcoholism, the surgical treatment was recommended to be implemented earlier, after a shorter period of medical therapy. Perelman insisted on early surgery in patients with alcohol dependence, and operated them also in the absence of demonstrable M. Tuberculosis. At the same time, he noticed that alcoholics have more frequent post-surgery complications [50]. Bronchoscopy (Bsc) was applied in cases with bronchitis, the latter being frequent among Russian alcoholics due to cigarette smoking and the risk to sleep down in a cold place. Along with other complications, vocal cord injuries were observed after repeated Bsc sometimes performed in conditions of insufficient procedural quality. It was noticed that vomiting triggered by apomorphine within the scope of aversive therapy of alcohol dependence provoked hemoptysis and pneumothorax in patients with Tb [51]. Certain anti-Tb drugs (cycloserine, rifampicin and other) exacerbated hepatic and neural derangements in alcoholism. Nevertheless, rifampicin was officially recommended for patients with comorbidity of Tb and alcohol use disorder [52]. The overtreatment of alcoholics has been discussed elsewhere [53,54].

Compulsory hospitalisation and treatment

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 77-FZ “Prevention of Tb spread” of June 18, 2001 (amended 2013), “patients with contagious Tb, repeatedly violating the anti-epidemic regime, and those evading examinations or (emphasis added) 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 the patients must undergo prescribed examination and therapy. The non-observance of this law may lead to a criminal prosecution. A survey found more than 6000 legal proceedings; whereas 3163 Tb patients were compulsorily hospitalized [55]. In one series, 463 court cases resulted in 421 decisions to hospitalize Tb patients [56]. All legal actions of that kind initiated by medical authorities are satisfied by courts in the Moscow region. 

It was reported that ~60% patients of a “phthisio-narcological” institution for compulsory treatment escaped; ≥50% of them were brought back by the police [57]. The duration of stay in such institutions was a year or longer [51]. The compulsory treatment has been endorsed by laws and regulations. Early compulsory hospitalization has been recommended [58,59]. There is a legal mechanism enabling compulsory treatment of prison inmates diagnosed with open form of Tb (Article 18 of the Criminal Executive Code of RF). The implementation of compulsory examinations and treatments is increasingly efficient these days. Reportedly, 100% of persons excreting M. tuberculosis in Moscow region had been hospitalized since 2019 [60]. Compulsory treatments are generally at variance with the international practice and regulations. According to the World Medical Association (WMA), 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 [61]. let alone thoracic surgery. The presence of Tb or alcohol use disorder does not interfere with a person’s right to refuse the treatment. The consent for invasive procedures is of particular importance in conditions where an overtreatment may occur.

Endoscopy and biopsy

Asthma patients were transferred from medical departments for the surgical and endoscopic treatment. Repeated bronchoscopies (Bsc) were recommended and performed in children and adults both in hospitals and the outpatient settings [11]. Fyodor Uglov asserted that Bsc is essential for the diagnostics of almost all pulmonary diseases also at early stages. After a series of therapeutic Bsc, Uglov and co-workers resected parts of the lungs regarded by them as pathologically changed (discussed above) [11,13]. Certain pathologists supported the modus operandi, exaggerating incidental findings such as focal inflammation and fibrosis.

According to internationally used textbooks, indications for Bsc in asthma include persisting wheeze unresponsive to bronchodilators and other medical therapy. The rationale is a search for alternative causes of the symptoms. There are also alternative diagnostic methods such as imaging. Some recent Russian-language textbooks are based on the international literature available on the Internet. However, earlier guidelines were partly at variance with recommendations prevailing in other countries. The aim of Bsc in asthma was claimed to be the characterization of inflammatory lesions and search for infectious foci [62-64]. At the same time, it was noticed that Bsc may provoke bronchospasm in asthmatics [64]. Ample expectoration or mucopurulent sputum in children was presented as an indication for Bsc “for assessment of the endobronchial inflammation” [65]. It was stated in a monograph that in children Bsc is recommended “almost in all subacute and chronic respiratory diseases” [66]. Asthma, Tb (including suspected), bronchitis (including atrophic), protracted pulmonary and bronchial conditions were presented as indications for Bsc in children and adults [64-74] e.g. 1478 procedures in 977 conscripts 19,5±0,1 year old with suspected pneumonia [75]. Some experts performed Bsc repeatedly every 4-5 days in children diagnosed with diffuse catarrhal-purulent endobronchitis [76]. Laser treatment through the bronchoscope was applied in asthma, chronic pneumonia and bronchitis, including cases with mucosal atrophy [77,78]. It should be mentioned that laser causes warming and, if excessive, can damage atrophic tissues. 

As mentioned above, bronchial biopsy has been used for research, some specimens being suboptimal quality. Certain histological descriptions were doubtful, for example, atrophy of bronchial mucosa in asthmatic children increasing with time: atrophic changes were reported in 79.5% of asthmatic children ~12 years old [79]. It would be unusual to encounter mucosal atrophy so often at a young age. Biopsies were taken for research from large bronchi of patients with known lung cancer; the quality of histological and ultrastructural images being suboptimal [80], which implies discomfort with no consequences for the treatment. Biopsy of internal organs performed with questionable indications have been commented in a recent paper [81].

Scrutiny of past experience has shown that surgery is not an adequate treatment for some conditions mentioned in this review. Indications for pulmonary surgery in asthma and chronic pneumonia have been revised. However, the present review is not outdated because the attitudes and motives have remained largely unchanged. One of the motives of the overuse of surgery has been personnel training under the imperative of readiness for war. This attitude is reappearing nowadays, notably, in publications from military-medical institutions [82]. Obviously, the military needs trained surgeons. For example, gastrectomy (resection) has been designated as the most frequent, main or singular surgical treatment of gastric ulcers [82-85], applicable for any ulcer location [82]. As before, appeals to “radicalism” can be heard, advantages of early surgery for uncomplicated ulcers being emphasized [82,83]. Other examples are in the book [1].

The Soviet period brought about an expansion of admission numbers to universities, often with insufficient attention to the quality of education [86,87]. Some surgical and other methods with doubtful indications were proposed by military surgeons. The training of personnel has probably been one of the motives. Furthermore, lacking professional autonomy has contributed to the persistence of outdated methods [88]. In conditions of paternalism, misinformation of patients, persuasion and compulsory treatments are regarded to be permissible [89]. Finally, the obstacles to the import of drugs and medical equipment should be mentioned. Domestic products are promoted sometimes despite questionable quality and possible counterfeiting. 

Today, the economic upturn enables acquisition of modern equipment; and scientific research is on the rise. Under these circumstances, the purpose of this review was to remind that, performing surgical or other invasive procedures, the risk-to-benefit ratio must be kept as low as reasonably achievable. Patients should not undergo invasive procedures merely to comply with doctrines. Evidence-based clinical indications must be determined individually; the patients being objectively informed on potential benefits and risks.

Insufficient coordination of medical studies and partial isolation from the international scientific community may result in parallelism in research, unnecessary experimentation, and application of invasive procedures without sufficient indications. Ethical and legal basis of medical practice and research has not been sufficiently known and observed in the former SU [81]. Today, international literature is broadly available on the Internet. The government stimulates medical research and innovations. Despite the economic upturn, it will be naive to think that matters would improve spontaneously in the near future. Considering the shortcomings of medical research and education, and insufficient adherence to the medical ethics by some healthcare organizers and medical professionals, a simple increase in funding is unlikely to be a solution. Measures for improvement of the public health system in RF must include the invitation of authorized foreign advisers and managers.

Conflicts of Interest

The author declares that he has no conflict of interest.