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Surgery seems more beneficial than continued drug treatment in eligible patients with pharmacoresistant epilepsy, analysis suggests

Monday, December 15 2008 | Comments
Evidence Grade 0 What's This?
A new decision analysis model indicates that anterior temporal lobe resection would generally provide substantial life expectancy improvements relative to medication therapy in surgically eligible patients with pharmacoresistant temporal lobe epilepsy.

The study authors explained that epilepsy surgery is underused, even though as many as 40% of patients with epilepsy are refractory to antiepileptic drugs. A randomized trial to evaluate the 2 treatments would be unlikely, so they created a Monte Carlo simulation model to compare the potential survival benefit of anterior temporal lobe resection versus continued medical management.

The model considered patients (assumed mean age, 35 yrs) with partial seizures that were refractory to >=2 drugs. Medical literature and U.S. life tables provided data on 1-year and long-term seizure outcomes and mortality and long- and short-term surgical complications. Real patients who had undergone surgery provided preference-based quality-of-life values, so the researchers could calculate quality-adjusted life expectancy.

In prototypical patients eligible for surgery, surgery would increase survival by 5.0 years (95% CI, 2.1-9.2 yrs) compared with drug therapy, with surgery preferred in 100% of simulations.

Similarly, according to the model, surgery would increase quality-adjusted life expectancy by 7.5 quality-adjusted life-years (95% CI, -0.8 to +17.4 quality-adjusted life-years); surgery was preferred in 96.5% of quality-of-life simulations.

These results were robust in sensitivity analyses.

Additional data suggested that a 35-year-old patient would experience 15 more seizure-free years (95% CI, 9.6-24.6 yrs) and a 15% reduction in the lifetime absolute risk of seizure-related death (95% CI, 4%-35%) with surgery.

"The quality-of-life and mortality benefit from being seizure-free with surgery outweighed the risk of long-term surgical complications," the investigators summarized.

"Referral to a specialized epilepsy surgery program should be considered when at least 2 appropriate antiepileptic drugs have been tried at maximum tolerable doses and when patients are experiencing disabling partial-onset seizures," they further advised. (Choi H, et al. JAMA 2008;300:2497-2505.)

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