Diabetes mellitus
The surgical spleno-renal anastomosis with the
shunting of pancreatic blood into the systemic circulation was introduced by
Eduard Galperin [37-40] and applied for the treatment of insulin-dependent
diabetes mellitus. At the same time, Galperin wrote: “Diabetic patients
generally tolerate surgery very poorly” [40]. The method was applied in type 2
diabetes as well [41,42]. The supposed mechanism was “creating a more optimal
interaction of subcutaneously injected insulin and glucagon produced in pancreas”
[38]. Of note, in patients with liver cirrhosis the surgical portocaval
shunting resulted in deterioration of glucose tolerance [43]. Diabetes mellitus
was regarded as a contraindication for portocaval anastomosis [44]. 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 [45], in agreement with the known fact that surgical stress may
trigger ketosis in diabetics. Comparable percentages of complications were
quoted in another paper [38]. The patients were subdivided into groups with a
strong, moderate and absent effect [39]. There was no group with worsening, so
that the assessment was probably biased. According to another report,
thrombosis of the shunt was found by angiography in 27% of the patients within
eight months after the operation [46]. Severe acidosis was designated as a
typical complication [46,47]. The anti-diabetic efficiency of the shunting was
moderate both in humans and in experimental dogs, whereas a majority of the
animals did not survive the diabetes induction by streptozotocin or pancreatic
resection with a subsequent shunting surgery [37]. 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 [40]. By 2011,
the surgical treatment of diabetes described above was still in use while a risk
of shunt thrombosis was pointed out [47,48]. The same experts applied
renoportal venous anastomosis for the treatment of chronic hepatitis and
arterial hypertension [47,49]. In the course of the operations, wedge biopsies
from the pancreas (~0.64 cm) and core biopsies from kidney were collected.
Histological descriptions included glomerulitis with proliferation of mesangial
cells, their relocation to the periphery of capillary loops, mesangial
interposition and formation of double-contoured basement membranes. The authors
postulated that mesangioproliferative glomerulonephritis is the initial stage
of diabetic glomerulopathy [50,51]. In fact, mesangial interposition and
double-contoured basement membranes are typical for membranoproliferative
glomerulonephritis. This condition, if found in a diabetic patient, may be seen
as a superimposed disease, potentially needing immunosuppressive therapy. Renal
biopsy is generally indicated for diabetics only if a kidney condition other
than diabetic nephropathy is suspected; more details and references are in the
preceding paper [52]. The misrepresentation of histological criteria of
glomerulonephritis as features of diabetic nephropathy may lead to inadequate
therapy. Last but not least importantly, renal and pancreatic biopsies are
associated with risks. Invasive procedures applied within the framework of the
surgical treatment of diabetes included also renal and splenic venography and
celiac arteriography [38,45].
Peptic ulcers
The surgical treatment of gastro-duodenal ulcers in
the former SU has been different from the international practice. Gastrectomy
became the predominant method of peptic ulcer management after the 24th
All-Union Congress of Surgeons in 1938 [53,54]. According to the author’s
observations, gastric resections were comparatively rarely performed abroad for
peptic ulcers; their volume was more limited, often corresponding to
antrectomy. For perforations, an ulcer excision was usually performed and an
annular specimen was sent to the pathology department. 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 have been applied in
ulcer perforations [55-60]. Relapses after gastric resections or suturing of
perforated ulcers were treated by gastrectomy [61]. At the same time, adverse
effects of resections were generally known by experts [53,62]. The limited
availability of modern medical therapy was designated as a social indication
for gastrectomy [57]. The hyper-radicalism in the gastric surgery originates
from the well-known surgeon Sergei Yudin (lately also spelled Iudin), who was a
“passionate supporter of gastric resections in ulcer perforations” [63]. During
the Second World War, Yudin was one of the leading surgeons of the Red army. He
was known for his radical approach: wide resection rather than drainage of
wounds [63]. His leitmotif was: “Unhesitatingly excise muscular tissue to
access fractured bone” [64]. The former health minister B.V. Petrovsky wrote
that Yudin’s hyper-radicalism, followed by colleagues, led to hemorrhages,
extensive defects of bone and soft tissues [65,66]. According to Yudin’s
teachings, the pylorus and lesser curvature must be removed at an ulcer
surgery. His articles advocating gastrectomy for peptic ulcers were republished
with favorable editorial commentaries [67]. References to Yudin’s publications
continued until recently, quoting the fact that he performed gastrectomy in 75%
of perforated ulcers [66]. Resection of the stomach in case of perforation has
been advocated by many experts from the former SU [53,57,68-73]. The supposed
advantage of this method was ascribed to the limited availability of modern
drugs. In some articles recommending gastrectomy, it was claimed that medical
therapy does not achieve a complete recovery, so that resection should be
performed at an early date to prevent complications [69]. The definition
“complete recovery” seems to be hardly applicable to the condition after
gastrectomy. Anyway this strategy has been in disagreement with that applied in
other countries [74]. Like in many topics discussed here, recommendations are
currently adjusted to international patterns. Recent guidelines included
laparascopic treatments and ulcer excision along with the suturing and
resection as treatment options for perforated ulcers. A drastic decrease in
surgery rate among ulcer patients during last decades with almost complete
disappearance of elective resections [75-77] confirms the fact of overtreatment
in the recent past.
Bronchial asthma and
respiratory diseases
Another method to be commented is the thoracic surgery
with the denervation of lungs as a treatment of bronchial asthma [78-80]
depicted as “the most accepted procedure” in the Guidelines by the Ministry of
Health [81]. Among others, the “skeletonization” of pulmonary roots with
transection of nerves, auto-transplantation of lungs (complete separation with
immediate re-implantation) or cross-section of trachea with subsequent suturing
were applied [80,82,83]. The theoretical ground was the hypothesis that
denervation “prevents abnormal nervous impulsation” [78]. Such argumentation
was usual at that time, when the so-called ideas of nervism, based on the
concept of trophic function of nerves, were officially promoted. Exaggerated
histological descriptions of “dystrophy” or degeneration in the structures of
the autonomic nervous system, claimed to be irreversible, were presented as a
theoretic basis of the denervation [78,84]. Stepan Babichev, the main
protagonist of the asthma surgery, was a first generation military surgeon,
later the chancellor of Moscow Medical Stomatological Institute (currently
named University) and assistant of the Health Minister. The surgical treatment
of asthma was officially recommended by the Ministry of Health; whereas
thoracotomy with lung denervation was designated as “the most accepted surgical
treatment” [81]. The skeletonization was advocated for steroid-dependent and
infectious-allergic asthma forms [81,85]. Repeated bronchoscopies were applied
post-surgery because of the bronchial drainage impairment [80]. The overuse of
bronchoscopy in children and adults has been discussed elsewhere [86]. The
pulmonary denervation and lung resections were recommended also for asthma
cases when drug and inhalation therapy had been efficient. It was suggested
that medical treatment prior to the operation must be limited in time [81]. In
one study, indications for surgery were found in 41.7% of 986 asthma patients;
457 operations were performed with complications recorded in 58 (12.3%) of the
cases. The following adverse effects were observed: in 27 patients –
inflammatory complications; 12 – neurological symptoms including dysphagia,
vocal fold palsy or Horner syndrome; 11 – pulmonary complications such as
pneumonia, empyema, pneumothorax, 8 – bleeding and/or local circulatory
derangements; 2 cases of paraplegia and hemiparesis; 6 patients died within 32
days after the operation [87].
In 2002, the surgical modality was still in use [79].
Denervation was sometimes performed simultaneously with lung resection,
lobectomy or bilobectomy [88]. In this connection, a quote from the
recommendations of the Health Ministry deserves attention: “The widespread
concept 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 medical 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” [81].
Such instructions could lead to resections without sufficient indications. As mentioned
above, the denervation surgery was sometimes combined with removal of pulmonary
segments or lobes regarded by the operators as pathologically altered [81].
Lung resections in asthma were applied also without denervation, even in the
cases where drug and inhalation therapy were effective. Among indications for
the surgical treatment have been focal lesions: chronic pneumonia,
bronchiectasis and “bronchitis deformans” [89]. Sokolov and co-workers reported
that ?10% of their asthma patients had been operated on [90]. The operations
were performed also in patients with bilateral inflammatory or fibrous lesions,
both in exacerbations and in remissions, supposed to be indicated for a radical
treatment of asthma. This concept was propagated by Fedor Uglov, who claimed a
“resection of infected foci” to be the aim of asthma management [89,91]. The
therapy was based on his belief that “in 98% of cases, the cause of asthma is
focal chronic pneumonia” [89]. Asthma patients were transferred from medical
departments for the surgical and endoscopic treatment. “After a course of
therapeutic bronchoscopies”, Uglov and co-workers performed resections of the
parts of lungs regarded by them to be pathologically changed [89,91].
Resections were applied to children with recurrent bronchitis and/or pneumonia;
while particular efficiency of pneumonectomy was stressed, also in bilateral
chronic pneumonia [92]. The recommendation for progressive chronic pneumonia
was “lobectomy for segmentary lesions and pneumonectomy in all other patients”
[93]. The claimed 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 [89,91]. Reportedly, “dysontogenetic” lung
diseases in children were a more frequent indication for radical surgery than
acquired conditions; whereas lobe- and pneumonectomies were predominantly
applied [94]. Irina Esipova and co-workers found malformations in 66% (including bronchial diverticulosis in
64%) of resected specimens from children operated on for relapsing pneumonia or
“bronchitis deformans” [95] (Figure1). The same authors claimed that, contrary
to preceding publications, the changes in the lungs were not diffuse but local,
thus justifying resections. Professor Esipova, a well-known expert often cited
in Russia, contended that misdiagnosis of malformations as chronic bronchitis
led to undue postponements of lung resections [95]. In accordance with this
doctrine, pathologists described in resected lobes and segments inflammatory
infiltration, fibrosis, dystrophy and malformations without specifying their
extent and severity, while descriptions deviated from those in standard
editions on pulmonary pathology, histological specimens being poor quality (Figure
1) [95,96]. Contemporary international literature was referenced scarcely in
suchlike papers.
Histological images described as lung malformations in
children: top adapted from [95], middle and bottom from [96], commented in the
text. The nature, extension and clinical significance of these lesions are
unclear. Some proposed criteria of malformations were formulated and
illustrated unconvincingly: large bronchi with uneven, serrated (jagged)
contours, bush-like aggregations of small bronchi and bronchioles, variously
differentiated mesenchyme with lymphoid infiltration, rhythmic muscular
fascicles, local agenesis of alveoli represented by connective tissue, abnormal
tissues alternating with normal structures, etc. (Figure 1) [96]. Reading
descriptions by Esipova and co-workers, it is evident an ex-Soviet pathologist
that some resected pulmonary lobes or segments were not significantly abnormal:
macroscopically whitish foci and coal pigment, singular cysts 2-3 mm;
microscopically atypical bronchial branching, lack of a bronchus narrowing from
the center to periphery, “nudity” of bronchi, hypoplasia of bronchial walls,
abnormal epithelial cilia, and so forth [95]. Descriptions of this kind were
sometimes used for largely normal specimens; clinical significance of the
findings being unclear. However, such reports from pathology departments were
suitable to justify resections. Undoubtedly, in some cases the surgery was
indicated; but there has been an overtreatment tendency. It was rightly noted
that many authors made no distinction between congenital malformations and
developmental variants [97]. In a more recent publication an opinion was
expressed that some histological phenomena described as malformations are
common in postnatal lungs normally or after resolved pneumonia [98]. It was
also noticed that diagnostics of lung malformations was difficult; the
percentage of wrong diagnoses amounting to 65-75% [99]. Nevertheless, the
patients were operated based on the assumption that inflammatory complications
are inevitable in future [99]. Concluding their articles, some pathologists
generalized that the “disease that affects children in the first year of life,
against the background of morpho-functional immaturity of the lungs, intense
metabolic processes and imperfection of local nonspecific and immunological
defense, is accompanied by a breakdown of typical protective reactions,
impaired regeneration and postnatal development of the lungs, excessive
expression and rapid depletion of compensatory and adaptive processes. The
latter underlies the alterative-exudative changes, the impossibility to delimit
inflammation, determines the progressive course of bronchiectasis and requires
surgical treatment at the age of 2-6 years (emphasis added)” [100]. An overuse
of surgery in tuberculosis and/or alcoholism has been discussed elsewhere
[12,101].