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Epilepsy Surgery Beats Long-Term Drug Therapy

Study: Operation for temporal-lobe form is safe, effective

WEDNESDAY, Aug. 1, 2001 (HealthDayNews) -- Surgery for one common form of epilepsy is far more effective than long-term treatment with anticonvulsant drugs, says a new study.

In the Aug. 2 issue of the New England Journal of Medicine, Canadian researchers present the first prospective study with control patients that compares surgery to drug treatment in patients with temporal-lobe epilepsy, the most common type of epilepsy associated with seizures affecting only one part of the brain.

"Having no real scientific evidence, we really did not know how big the benefit was," says Dr. Samuel Wiebe, the principal investigator and an associate professor of clinical neuroscience at the University of Western Ontario in London, Ontario.

In the study, the researchers randomly assigned 40 patients with temporal-lobe epilepsy to undergo surgery and gave another 40 control patients (who were on a surgery waiting list) with the same diagnosis antiepileptic drugs for one year, after which they were eligible for the surgery. Among the drug patients, the anticonvulsants were switched up to four times over the course of one year.

The surgeries were performed between 1996 and 2000. The anticonvulsants were typical of treatment for this form of epilepsy, consisting of such drugs as Dilantin, Tegretol, and valproic acid

Epilepsy specialists who were not told which group the patients were assigned to evaluated the best medical therapy and the patient outcome for a year after treatment. These doctors reviewed records and looked for cessation of seizures that impaired awareness, as well as reduced frequency or severity of seizures, quality of life, disability or death.

After one year, 58 percent of the surgical patients were free of seizures that impaired awareness, compared to 8 percent of the group on anticonvulsant drugs. Thirty-eight percent of the surgical patients were free of all seizures, compared to 3 percent of the medications group.

On average, the patients who received surgery also reported a significantly better quality of life. "The benefits in terms of quality of life in our patients are remarkable," says Wiebe. He described a woman who, four years after surgery, was living without medication or seizures. The changes since the surgery, she wrote to Wiebe, were "amazing," giving her freedom and the opportunity to have another child.

Ten percent of the surgery patients reported adverse effects, including sensory abnormalities in the left thigh, a wound infection, and a decline in verbal memory.

Depression occurred in 18 percent of the surgery patients and in 20 percent of the drug patients. One of the patients in the medications group suffered a sudden, unexplained death 7.5 months into the study.

Wiebe says he wasn't particularly surprised that surgery turned out to be so effective, but he was struck by how poorly the anticonvulsants performed. "Given the fact that medication is really the only other alternative [to surgery], the medication alternative is really a poor one," he adds.

He says that, until now, there has not been compelling evidence that surgery is more effective. "We could not make strong clinical practice guidelines or recommendations based on that evidence," he says.

As such, he adds, "before you agree to have anybody handle your brain, you really want to be as sure as you can that it's actually a safe procedure and it's going to have a benefit for you. To date, there was no proof of that scientifically."

Dr. Jerome Engel Jr., a professor of neurology and neurobiology at the University of California, Los Angeles, School of Medicine, says that surgical treatment for epilepsy is very under-utilized.

"It's an effective and safe treatment for epilepsy, and for some kinds of epilepsy it should be the treatment of choice," says Engel. "But. . . physicians and the general public are not using it. When they think of it at all, they think of it as a last resort."

Engel says that this study finally uses the gold standard of scientific research -- a randomized, controlled trial -- to study epilepsy surgery. Until now, he says, the people evaluating the patients afterwards are the same people who did the surgery.

"What's interesting about Dr. Wiebe's study is that the results that he obtained using a randomized, controlled experimental design and an independent investigator who interviewed the patients afterwards got exactly the same results as the studies that have published over the past two decades," says Engel. "So there's no doubt that for this particular form of epilepsy, surgery is very safe and very effective."

In fact, Engel points out, it's statistically safer to have surgery than to continue having uncontrolled seizures. Moreover, he says, people who have lived with chronic seizures for years often lack vocational and interpersonal skills and may either be living at home or be institutionalized. "But if you operate on them when the seizures begin, and you consider this the treatment of choice rather than a last resort, you can salvage them and rescue them from a lifetime of disability," he says.

According to Engel, physicians and patients need to consider the surgical option sooner. "What happens is that there's so many antiepileptic drugs now available, that it literally would take a lifetime to prove that somebody's seizures don't respond to medication, and you can't afford to wait and keep trying one drug after another," he says.

Engel hopes to see a follow-up study on early surgical intervention, and Wiebe is planning such a trial at several medical centers in the United States.

Epilepsy is a neurological disorder, affecting about 2.3 million Americans, that involves a malfunction of electrical impulses in the brain, leading to seizures.

What To Do

For more information on epilepsy surgery, check out the Web sites for the Massachusetts General Hospital, the Cedars-Sinai Neurofunctional Surgery Center, or the Johns Hopkins Epilepsy Center.

SOURCES: Interviews with Samuel Wiebe, M.D., associate professor, Department of Clinical Neurological Sciences, University of Western Ontario, London, Ontario; Jerome Engel Jr., M.D., Ph.D., professor, Neurology and Neurobiology, Reed Neurologic Research Center, University of California, Los Angeles School of Medicine, Los Angeles; Aug. 2, 2001, New England Journal of Medicine
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