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Surgical Procedures with Questionable Indications Used in Russia

Submitted:

12 January 2024

Posted:

12 January 2024

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Abstract
This review summarizes available data on invasive procedures applied with questionable indications in Russia in the recent past: mastectomy with the removal of muscles, gastrectomy for peptic ulcers, spleno-renal anastomosis for diabetes mellitus, thoracic surgery for bronchial asthma, overuse of surgery in tuberculosis, excessive and compulsory treatments of alcohol-dependent patients, etc. Among factors contributing to the use of invasive procedures with unproven efficiency have been the partial isolation from international scientific community, insufficient consideration of the principles of professional autonomy, informed consent and scientific polemics, training of medical personnel. It is known that invasive procedures can exert a placebo effect, which might have contributed to reported efficiency of some methods discussed here. However, by definition, placebo must be free of risks.
Keywords: 
Peptic ulcers
;  
gastrectomy
;  
diabetes
;  
portosystemic shunting
;  
asthma
;  
lung denervation
;  
medical ethics
Subject: 
Medicine and Pharmacology  -   Surgery

Introduction

This review is an update and continuation of papers on invasive procedures applied in the former Soviet Union (SU) with questionable clinical indications.1-3 According to the author’s estimates after a practice abroad (repeatedly during 1990-2008), an average size of malignant tumours in surgical specimens was larger in Moscow clinical centres 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 management was not followed in the former SU for some period. In the 1980s and decreasingly in the 1990s, the Halsted procedure with the removal of both Pectoralis muscles was a predominant method of breast cancer (BC) management;4-7 it was presented as the main treatment modality of BC in some textbooks and monographs published after the year 2000.8-10 The principle of informed consent was often disregarded. The surgical modality could be extended to a radical (Halsted) procedure if an intraoperative frozen section examination found e.g. an early (2 cm) BC.11 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.12 Newly developed mastectomy modalities with the muscle resection have been patented.13,14 Old age was not regarded as contraindication to a radical surgery.15 In view of complications, some experts recommended the modified radical mastectomy of Patey with resection of the smaller pectoral muscle for relatively early (T1-2) laterally located BC.16-18 Others advocated the Halsted procedure.19 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 (1995-1998) 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 tumour 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.”20 In papers dated 2015-2022, the Patey operation was still mentioned as a routine procedure;21-23 but the preservation of both pectoral muscles was finally becoming a standard. Today, the recommendations are adjusted to international patterns.

Diabetes Mellitus

The surgical spleno-renal anastomosis with the shunting of pancreatic blood into the systemic circulation was introduced by Eduard Galperin and applied for the treatment of insulin-dependent diabetes mellitus.24-31 At the same time, Galperin wrote: “Diabetic patients generally tolerate surgery very poorly.” 30 The method was applied also in type 2 diabetes.32,33 The supposed mechanism was “creating a more optimal interaction of subcutaneously injected insulin and glucagon produced in the pancreas.”24 Of note, in patients with liver cirrhosis the surgical portocaval shunting resulted in deterioration of oral glucose tolerance.34 Diabetes mellitus was even regarded to be a contraindication for portocaval anastomosis operations.35
In a series of 415 patients, early post-operative complications were observed in 28 patients including 2 cases of sepsis, 5 of pyelonephritis, 5 of pneumonia; 2 patients died in the first post-surgery week. Ketonuria was observed in 18 patients,25 which agrees with the known fact that surgical stress may trigger ketosis in diabetics. Comparable percentages of complications were given in the article.24 The patients were subdivided into groups with a strong, moderate and absent effect.26 There was no group with deterioration, so that the assessment could 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.27 Severe acidosis was designated as a typical side effect.27,28 The anti-diabetic efficiency of the shunting was reported to be 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.29 During one-year (1990) engagement in the United States, Galperin used his method on dogs and rats deploring that there was no opportunity to apply it in humans.30
By 2010, the surgical treatment of diabetes described above was still in use while a high thrombosis risk of the shunt was pointed out.28 During the operations, biopsies from the pancreas (~0.5 cm) and kidneys were taken. Histological descriptions included glomerulitis with mesangium interposition, relocation of mesangial cells to the periphery of capillary loops and formation of double-contoured basement membranes, presented by the authors as typical features of diabetic glomerulosclerosis.36 In fact, these changes are typical for membranoproliferative glomerulonephritis. This condition, if found in a diabetic patient, is regarded as a superimposed disease requiring special therapy. Kidney biopsy is generally indicated for diabetics only if a renal condition other than diabetic nephropathy is suspected. The misrepresentation of histological features of glomerulonephritis as traits of diabetic nephropathy may lead to inadequate therapy. Finally, renal and pancreatic biopsies are associated with risks. Other invasive procedures applied within the framework of the surgical treatment of diabetes included renal and splenic venography and celiac arteriography.24,25

Gastric Ulcers

Certain surgical treatments of gastro-duodenal ulcers in the former SU were different from the international practice.37 According to the author’s observations, gastric resections were rarely performed abroad for peptic ulcers; their volume was smaller, being usually equivalent to antrectomy. For perforated ulcers, a local excision was usually performed, while a ring-shaped specimen was sent to the pathologist. Laparoscopic repair is used increasingly often these days. In Russia, primary gastric resection (2/3-3/4 or even 4/5 of the stomach), antrectomy with vagotomy, or a simple suture (depending on the patient’s condition) was performed.38-43 Admittedly, recent guidelines included ulcer excision along with suturing and resection among treatment options for perforated ulcers. The limited availability of modern medical therapy was designated as social indication for the stomach resection.40 Certain papers called attention to the adverse effects of resections.37,44 At least a fivefold decrease in gastric resection frequency in ulcer patients during last decades has been reported from some institutions,45-47 which alone indicates an overuse in the recent past.
The hyper-radicalism in the gastric surgery originates from Sergei Iudin (the spelling is according to the PubMed; in earlier papers spelled Sergey Yudin),48 who was a “passionate supporter of gastric resections in ulcer perforations.”49 According to his doctrine, the pylorus and lesser curvature must be resected at an ulcer surgery.48 During the World War II, Iudin was a leading surgeon of the Soviet army. He was notorious for radical operations: “Total and wide resection of devitalised tissue… resection rather than drainage and removal of bone fragments in joint wounds (including knee and hip joints);”49 “Unhesitatingly excise muscular tissue to access fractured bone.”50 As per former health minister B.V. Petrovsky, Iudin’s radicalism in military surgery, followed by other surgeons, led to haemorrhages, extensive defects of osseous and soft tissues.51 Iudin’s articles recommending stomach resection in ulcer patients were published later with positive editorial commentaries;48 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.37,40,52-56 The continuous adherence to this method was explained by the limited accessibility of modern drugs.37,40 In some articles recommending resections, it was stated that the drug therapy doesn’t provide an adequate solution56 and … doesn’t achieve a complete recovery”, so that resection should be performed early enough to avoid complications.53 The definition “complete recovery” seems to be hardly applicable to the condition after gastrectomy. Anyway this strategy was in disagreement with that applied in other countries.57 Like in some other topics discussed here, recommendations are currently adjusted to international patterns. However, some questionable guidelines have remained without commentaries, so that a reversion to suboptimal practices cannot be excluded.

Bronchial Asthma

Another method to be commented was the thoracic surgery with denervation of lungs as a treatment of bronchial asthma58-62 referred to as “the most accepted procedure” in the Instruction by the Health Ministry of RF.59 Among others, the “skeletonisation” of pulmonary roots,59 auto-transplantation of lungs (complete removal with immediate re-implantation) 62,63 or intersection of trachea with subsequent suturing64 have been proposed. The theoretical ground was the assumption that denervation “precludes abnormal nervous impulsation.”58 In this connection, questionable morphological descriptions of degeneration in neural ganglia have been proposed to corroborate the denervation.58 The operation was officially recommended by the Health Ministry whereas thoracotomy with the lung denervation was designated as “the most accepted surgical treatment for severe bronchial asthma.”59 The skeletonisation method was patented and advocated for steroid-dependent and infectious-allergic varieties of bronchial asthma.59,65 Repeated bronchoscopies were applied post-surgery.62 Pulmonary denervation and lung resections were recommended also for asthma cases when drug and inhalation therapy had been efficient. It was suggested that non-invasive treatment prior to the surgery must be limited in time.59 One research group effectuated surgical denervations in 457 asthma patients. The following complications were recorded: in 27 patients - inflammation not otherwise specified; 12 - dysphagia, vocal fold palsy or Horner syndrome; 11 - pneumonia, empyema, pneumothorax, paraplegia and 2 cases of hemiparesis; 58 complications not otherwise specified; 6 patients died within a month after the surgery.61 By 2002, the method was still in use.60 The denervation surgery was sometimes combined with a resection of pulmonary segments or lobes deemed pathologically altered.59
Pulmonary resections were used in bronchial asthma also without denervation, even in the cases when inhalation or drug therapy were efficient. Among indications for the surgical treatment were focal lesions: chronic pneumonia, bronchiectasis, pneumocirrhosis or “bronchitis deformans.”66 Certain authors stated that ≤10% of their asthma patients underwent resections.67 The surgeries were performed also in patients with extensive 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 Uglov,66,68 who claimed a “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.”66 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. Asthmatics were transferred from internistic departments for the surgical and bronchoscopic therapy. “After a course of therapeutic bronchoscopies,”66 Uglov et al. performed lobe- and segmentectomies, resecting parts of the lung regarded by them to be pathologically altered.66,68 The surgery for pulmonary malformations in children has been commented previously.69

Tuberculosis

After the successful development of medical treatment of tuberculosis (Tb) in the 1950s, the use of surgery has decreased in many countries. The priority of the former SU in this field was claimed.70-72 The surgery of Tb has been performed not only in specialized centres but also in peripheral hospitals.72,73 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.74
In the period 1973-87, 285,000 patients with pulmonary Tb were operated on in the former SU, in 1987 - 26,000, while 85% of the surgeries were lung resections.75 In 1986-88, ~17,500 surgeries for lung Tb were performed annually in RF only in specialized institutions.70 The incidence of Tb in 1986 and 1988 was, respectively, 43.8 and 40.8 per 100,000.76 More than 29% of new Tb cases were operated at that time. In 2003, only 10,479 surgeries (~9% of newly diagnosed cases) were carried out, deemed insufficient.”77 In the foreign literature, corresponding figures are usually below 5%.78-80 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 2000.76 Similarly to other diseases,81,82 this drastic increase could have been partly caused by an underestimation during the Soviet period. In the year 2006, 12,286 surgeries were performed in RF for pulmonary Tb including 9300 (75.7%) resections and 399 (3.2%) pneumonectomies.71 According to another report, the forms of Tb most frequently treated by resections and pneumonectomies were cavitary Tb (52.2%) and tuberculoma (43.9%).83 For example, Perelman et al. 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 (80). The authors concluded that “indications for surgical management of pulmonary Tb should be generally expanded.”84 Tuberculoma was the form of Tb most often operated by Giller et al. (2013): 81 from 179 cases in one series.85
Resections were recommended also for patients with inactive post-Tb fibrosis including oligosymptomatic cases.86 On the other hand, surgeries were performed in active disseminated Tb.87 In some provinces of the Urals, Siberia and Volga region, 25–40% of patients with destructive Tb were operated on.88 At the time of initial Tb diagnosis, surgery was considered to be indicated in 15-20% of patients.70 According to another paper, indications for surgery were ascertained in 20-30% of patients at the time of diagnosis and/or among cases of active Tb.89 In Ekaterinburg and surrounding province (years 2006-2008), indications for surgery were found in 1784 from 4402 (40.5%) patients with pulmonary Tb, while 1079 (24.5%) were operated. Among reasons of the allegedly low surgery rate were the patients’ non-compliance and unavailability.90 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.”91 The topic of Tb surgery may come to light globally because of the developing multidrug resistance.92 As per the estimate from Russia, the need for surgery has increased up to 15% over the last 20 years.93 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.85,94,95
Tuberculoma (>2 cm, also in children) has been generally regarded in Russia as an indication for surgery.91,96 The same experts designated fibrocavitary Tb as an absolute indication for resection.91 Tuberculomas >1 cm were routinely operated on,97-99 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 (44.2%) indication for lung surgery in Tb patients at the leading institution - Sechenov Medical Academy in Moscow;71 while at some hospitals this percentage was 50-80%.100 Tuberculoma has been a frequent indication for surgery in children and adolescents with Tb.96,101 The surgical treatment of tuberculoma was recommended also for cases with extensive lesions in remaining pulmonary tissues.102 Bilateral resections were performed for various forms of Tb including tuberculomas on both sides.103-105 A study from the Sechenov Academy reported 771 lung operations, including 168 pneumonectomies, 181 lobectomies, 180 smaller 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%).106 Another example from the same Academy: among 60 operated Tb patients the complication rate was 37%, mortality - 5%; 18.3% of the patients were dehospitalised with persisting complications.107
Resections 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.98,108 One of the arguments in favour of the early surgery was the non-compliance increasing with time,98 as the patients collected knowledge and advice. Apparently, the frequency of adverse effects has been underestimated due to the limited follow-up. Lung operations for Tb were performed and recommended also for aged patients with comorbidities.109-112 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. Among the latter 144 patients, 93 (66.4%) had cavitating disease and 43 (30.8%) - 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.109 In the monograph based on 233 lung resections in Tb patients older than 50 years (mortality - 5.4%), Sokolov et al. reasonably concluded: “It is important that a surgery doesn’t provoke an unfavourable outcome.”110 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 favour of the surgical treatment.112 Statements of this kind can be found also in recent papers e.g.: “Surgery in patients with tuberculomas is recommended to reduce their infectiousness.”93 According to Giller et al., 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.85 Note that tuberculoma is usually not contagious. It seems to be evident that potential contagiosity does not justify a thoracic surgery.
Out of 1311 Tb cases operated at the Phthisiopulmonology Institute in St. Petersburg during the period 1989-2001, 241 had Tb recurrences and 203 underwent repeated interventions.113 Postoperative recurrences were regarded as indications for repeated surgeries up to a “concluding pneumonectomy”104 and resections of the remaining sole lung.114 For example, repeated resections on both sides with a concluding pneumonectomy along with 52 bronchoscopies were described in one case report.115 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.116 Bilateral resections and bilobectomies were performed in various forms of Tb including tuberculomas.92,103-105,114,116,117 Resections were deemed applicable also in cases with severe respiratory insufficiency.73,114,118,119
The role of surgery in Tb remains controversial. The message of this article is that patients should not undergo operations to merely comply with doctrines. Evidence-based clinical indications should be determined individually. The patients must obtain objective information on potential benefits and risks to be able to make their own decisions. The informed consent began to be mentioned only recently in papers from the former SU reporting research using invasive methods, for example in a bronchoscopic study of paediatric asthma, where a consent of parents was regarded to be sufficient.120 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, was supposed to be hardly applicable in RF.121 According to the governmental Regulation #378 of the June 16, 2006, patients with contagious Tb are not permitted to reside in one apartment with other people. As per the Federal Law #77 “Prevention of the Tb spread” of the June 18, 2001 (amended in 2013), “patients with contagious Tb, repeatedly violating the anti-epidemic regime, and those evading examinations for Tb or 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 chemotherapy. The non-observance of this law may lead to a criminal persecution. A survey in Russian hospitals found more than 6000 legal proceedings in the period 2004-2008 whereas 3163 Tb patients were compulsorily hospitalized.122 In one series, 463 judicial cases resulted in 421 decisions to hospitalize Tb patients.123 Compulsory treatments are generally in disagreement 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.124 The consent for invasive procedures and chemotherapy is of particular importance in conditions where an overtreatment may occur.3
According to official instructions, indications for surgery were more frequent in alcohol-dependent than in other Tb patients.125 In case of alcoholism, the surgical treatment was recommended to be implemented earlier, after a shorter period of medical therapy.99 Perelman et al. insisted on early surgery in Tb patients with alcohol dependence, and operated them also in the absence of demonstrable Tb infection (e.g. a series of 49 patients with tuberculoma plus 41 with cavernous Tb, whereas micobacteria were demonstrated in 55). At the same time, it was noticed that alcoholics have more frequent post-surgery complications.126 Bronchoscopy was applied in cases with bronchitis,127 the latter being frequent among alcoholics in Russia due to smoking and the risk to sleep down at a cold place. Along with other complications, vocal cord injuries were observed after repeated bronchoscopies sometimes performed in conditions of insufficient procedural quality. It was noticed that vomiting triggered by apomorphine as aversive therapy of alcohol dependence provoked hemoptysis in patients with Tb.127
The following treatments were applied to alcoholics: prolonged intravenous drip infusions, sorbent haemoperfusion, pyrotherapy with sulfozine, endoscopic and surgical biopsies of internal organs without clear indications, also for research.127-133 Infusions for the purpose of detoxification were generally recommended for patients with alcoholism including moderately severe withdrawal syndrome: 7-10 infusions daily, sometimes combined with intramuscular injections.132-136 The detoxification was regarded to be “indicated to nearly all alcohol-depended patients, especially to those with prolonged withdrawal syndrome.”127 Analogous recommendations were found in recent instructive publications.137,138 Some methods were patented e.g. infusion therapy and transcerebral electrophoresis of magnesium as a treatment of alcohol withdrawal syndrome.135,139-141 Of note, as per the Cochrane review, there is no sufficient evidence to decide whether or not magnesium is useful for the therapy of alcohol withdrawal syndrome.142 Excessive intravenous supply of magnesium can cause adverse effects. Fatal intravenous overdoses of magnesium in alcoholic patients were recorded.143 Besides, various intramuscular injections were recommended: magnesium sulphate, sodium bromide and thiosulphate, Unithiol, Dimercaprol; subcutaneous infusions of saline and insufflations of oxygen; extracorporeal ultraviolet irradiation of blood, sorbent hemo- and lymphoperfusion, etc.125,128,136,144-146
The recommended duration of the detoxifying treatment including intravenous infusions was 5-12 days, or even 14-21 days according to some instructions.126,127,147 This is generally at variance with the international practice. Alcohol and its metabolites are eliminated spontaneously while rehydration can be usually attained per os. Long-lasting intravenous infusions are associated with discomfort. It was known that the attitude to alcoholics was less responsible with lower procedural quality assurance. Repeated infusions, endovascular and endoscopic manipulations lead to a transmission of viral hepatitis, unfavourable especially if combined with alcohol-related liver damage. Rudoi et al. (1994) reported that ~60% patients of one “phthisio-narcological” institution for compulsory treatment broke out; over 50% of them were returned by the police.148 The duration of stay in such institutions was a year or longer.127 The compulsory treatment has been rooted in laws and regulations.127,149 In 1974, chronic alcoholism was officially declared to be a ground for enforced treatment; the regulations were made stricter in 1985, making compulsory hospitalization and therapy of chronic alcoholics independent of their anti-social behaviour. This practice was found in the 1990s to be against the human rights.149 Nonetheless, some writers recommended restoration and further expansion of the compulsory treatment system.122 According to a survey, 62.6% of specialists in addiction medicine supported compulsory treatment of alcoholism.150 Enforced therapy of socially dangerous alcoholics is stipulated by Articles 97 and 98 of the Criminal Code of RF; besides, there is a legal mechanism enabling compulsory treatment of alcoholics in prisons.151

Glioblastoma

Around 1980 the author worked as a nurse at the neurosurgery of the Botkin hospital in Moscow. Patients with glioblastoma (Gb) were routinely operated on, while it was believed by some staff that the treatment was generally useless, just forcing many patients to spend the rest of their lives in bed. The directive to apply for gliomas the largest possible radical operations was issued at the 1966 Moscow Conference of Neurosurgeons.152 Advanced age was not regarded to be an obstacle to the radicalism.153 Since then, admittedly, microsurgery and other technical advances lead to a reduction in the surgical morbidity. Arguments against resection stem from the invasiveness of Gb, which cannot be totally removed; in addition, there might be a tumor cell migration due to the operation, new neurological deficits and other complications.154 Surgical excision is not curative of Gb; recurrences occur reportedly after a median of ~13 months.155 Maximum resection using microsurgical techniques as safely feasible is considered standard of care, although the role of surgery has been difficult to define in controlled clinical trials.156 The retrospective design of studies has raised concerns about selection bias; that is, some tumours are more resectable than others, and these tumours also may be inherently less aggressive, the impact of surgery being partly an epiphenomenon.157 It is often argued that a prerequisite of glioma diagnosis is resection or biopsy, both methods being associated with risk. Of note, intracranial malignancy can be diagnosed in some cases by imaging and “liquid biopsy”.158 Improvements of preoperative diagnostics must limit indications for the trepanation.
The volume of residual tumour after surgery negatively correlates with the outcome; however, it has remained unclear whether extent of resection improves the outcome or whether tumours amenable to gross total resection have a different, on average less malignant course.156 If even surgical outcomes are deemed good, some patients remain with neurocognitive decline or otherwise deterioration of the life quality [6].159 Although evidence suggests that surgical excision improves the outcome in most cases, it is often associated with morbidity [1].155 There are indications that standard therapy including surgery may be not in a patient’s best interests [7].160 Without surgery, receiving symptomatic palliative therapy, some patients could use the remaining months to complete their tasks. This letter does not question existing methods of glioma management. It is important that patients (or caregivers if the patient’s thinking capacity is impaired) must be objectively informed about potential benefits and adverse effects of different treatments to enable their own decisions. Signed informed consent is mandatory for all surgical candidates [Manrique].161 Tacit consent must not be supposed, in particular, regarding end-of-life decisions [8].162 All the above is of importance especially for the elderly. For aged patients with newly diagnosed Gb, current recommendations include surgery; however, the survival is significantly worse than that in younger people [9].163
Many patients and their relatives access information on the Internet. The information available online is not monitored [10].164 In Russia, the media tend to trivialize risks and discomfort associated with surgeries and other invasive procedures. Some medical men on YouTube claim that new techniques enable to remove deep tumours radically without damaging brain structures.165,166 Unlike other countries, public libraries are rarely used by people and usually contain no professional medical literature. Scientific and especially medical libraries are hindered from using by the general public, including even retired doctors, by unfriendly staff and technical difficulties [11].167 Some professional publications recommending invasive procedures apply misquoting, for example: “The average life expectancy for malignant gliomas in patients receiving only conservative therapy was 9 weeks – 6.6 months”168 with references.169-171 However, in the cited sources169-171 larger figures are given. Other relevant examples of misquoting were discussed elsewhere.3,172,173 A propaganda is recognizable, whereas surgeries are often presented e.g. by popular TV series as something a priori beneficial and even as a status symbol, conductive to good convalescence; while side effects, risks and procedural quality are not mentioned. It has been reasonably recommended that medical institutions and professionals must work to produce more reliable content in order to improve the availability of credible health information for patients [10].164

Discussion and Conclusion

Factors contributing to the persistence of suboptimal practices include a partial isolation from the international scientific community, insufficient use of the foreign literature, unavailability of many internationally used handbooks,167 insufficient attention to the needs of some patients e.g. alcohol-dependent and/or elderly, training of medical personnel.173 Thanks to the Internet, foreign literature is largely available in Russia these days, guidelines being adjusted to international patterns. However, some published instructions have remained without due commentaries, so that a comeback to suboptimal practices is not excluded. The lacking professional autonomy has contributed to the persistence of suboptimal and outdated methods in the healthcare.173,174 Certain colleagues encountered impediments to their careers when they did not collaborate in dubious research and practice. Trimming of statistics has been not unusual.173 In conditions of paternalism, misinformation of patients and compulsory treatments are deemed permissible.175 Suboptimal practices have been used as per instructions by healthcare authorities and leading experts’ publications. Numerous examples were discussed previously.1-3,69,173,176 The following should be mentioned in addition to the topics delineated above: routine cauterization of cervical ectropions without cyto- or histological check for precancerous changes, parabulbar injections of placebos, overuse of bronchoscopy2 e.g. in conscripts with supposed pneumonia (1478 procedures in 977 patients in one series).177,178 As mentioned in the Introduction, millions of women in the former SU underwent Halsted mastectomy with removal of Pectoralis muscles without evidence-based indications, often without informed consent. Some authors wrote about fascism in oncology [lebedev]. Justifications of surgical hyper-radicalism, described in this review, could be heard in private conversations among medics, for example: “the fatally ill are dangerous” i.e. may commit reckless acts undesirable by the totalitarian state. The training of medical personnel under the imperative of readiness for war has been another motive. 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.173,179 Today, the economical upturn enables acquisition of modern equipment; and scientific research is encouraged by authorities. Under these circumstances, the purpose of this article was to remind that, performing surgical or other invasive procedures, the risk-to-benefit ratio must be kept as low as reasonably achievable.

Conflicts of Interest

The author declares that he has no conflict of interest.

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