- Email: [email protected]
Chopping and changing: long-term results of epilepsy surgery
Comment
of 1·4% (one of 74 patients) and a 1-year survival rate of 96% (71 of 74 patients). Postoperative haemodynamic improvement was also excellent. The Papworth group previously reported an in-hospital mortality of 15% in 151 patients,4 which shows the benefit of increased experience with this difficult operation. The most important finding of Vuylsteke and colleagues’ study was that continuous perfusion of the brain did not result in a difference in postoperative cerebral function compared with the absence of perfusion.3 For the primary endpoint at 12 weeks after surgery, mean differences in Z scores in cognitive function between the groups were: 0·14 (95% CI –0·14 to 0·42, p=0·33) in a test of eye–hand coordination and attention, –0·06 (–0·38 to 0·25, p=0·69) for a learning test, and 0·01 (–0·26 to 0·29, p=0·92) in a test of fine motor coordination. Perhaps more surprisingly, especially in view of some publications that have implicated cardiopulmonary bypass in a reduction of cerebral function postoperatively,6 was the finding that cognitive function was not impaired by either strategy but, if anything, improved in both groups compared with preoperative levels. This finding is particularly remarkable because the mean duration of bypass, commonly less than 2 h for most cardiac surgery, was more than 5 h in both study groups.3 This study calls into question the belief that cardiopulmonary bypass itself is associated with impairment
of cerebral function postoperatively, and also shows that hypothermic circulatory arrest without cerebral perfusion for short periods need not be harmful. It confirms that circulatory arrest is the optimum approach for the pulmonary endarterectomy operation. Any surgical treatment, of course, balances immediate harm against long-term improvement and, in these patients, cardiac output and oxygenation, particularly during exercise, would have been substantially better after surgery than before, probably contributing to the improvement in cerebral function seen postoperatively. Stuart Jamieson Division of Cardiothoracic Surgery, University of California San Diego, San Diego, CA 92103, USA [email protected] I declare that I have no conflicts of interest. 1
2 3
4
5
6
Pengo V, Lensing AW, Prins MH, et al. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med 2004; 350: 2257–64. Jamieson SW, Kapelanski DP. Pulmonary endarterectomy. Curr Probl Surg 2000; 37: 165–252. Vuylsteke A, Sharples L, Charman G, et al. Circulatory arrest versus cerebral perfusion during pulmonary endarterectomy surgery (PEACOG): a randomised controlled trial. Lancet 2011; 378: 1379–87. Thomson B, Tsui SS, Dunning J, et al. Pulmonary endarterectomy is possible and effective without the use of complete circulatory arrest—the UK experience in over 150 patients. Eur J Cardiothorac Surg 2008; 33: 157–63. Jamieson SW, Kapelanski DP, Sakakibara N, et al. Pulmonary endarterectomy: experience and lessons learned in 1,500 cases. Ann Thorac Surg 2003: 76: 1457–62. Newman MF, Kirchner JL, Phiips-Bute, et al. Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery. N Engl J Med 2001; 344: 395–402.
Chopping and changing: long-term results of epilepsy surgery See Articles page 1388
1360
Surgical management of medically refractory focal epilepsy has seen a resurgence in the past 20 years.1 Advances in structural and functional neuroimaging2 and invasive electroencephalography have increased success in identifying the ictal onset zone; and functional MRI, tractography, and cortical mapping have allowed for safe resection. Seizure freedom is the most substantial predictor of improved quality of life, and freedom rates of 60–70% are routinely reported after 1–2 years’ follow-up.3–5 However, seizure control at late follow-up is less good (table) with many studies reporting seizure freedom rates of 40–50% at 10 years. Moreover, few studies show how many patients have sustained long-term seizure freedom after surgery. Importantly, although patients who are seizure free at
2 years are likely to remain so at 7 years6 and 10 years,7 late seizure recurrence is not uncommon and little is known about its prediction, prognosis, management, or causation. In The Lancet, Jane de Tisi and colleagues8 report the largest and longest prospective study of epilepsy surgery outcome for up to 19 years (representing more than 5200 person-years of follow-up). This study is novel in its prospective analysis of seizure freedom at successive annual reviews in individual patients unlike other studies that review seizure freedom only at last follow-up. The cohort consists mainly of temporal lobe surgery, typical of adult epilepsy surgery. Similar to previous studies, de Tisi and colleagues8 report the percentage of patients remaining free of non-simple www.thelancet.com Vol 378 October 15, 2011
Comment
partial seizure to be 63% at 2 years, 52% after 5 years, and 47% after 10 years, and that an initial and longer period of seizure absence is the strongest indicator of good long-term outcome.6,9–11 Conversely, in patients with prolonged postoperative seizure activity, likelihood of remission is decreased.11,12 An analysis of seizure-freedom patterns in individual patients over time yields a key finding: although 70% of patients were seizure free for the last year at any one time, only 51% were completely seizure free throughout followup because every year there was 3–15% change within the patient groups. 73% of patients had at least 1 year of absolute seizure freedom and 82% had at least 1 year with no seizures or only simple partial seizures. Surgical procedure
What about the prediction, prognosis, and management of different patterns of seizure outcome? Another key finding is the identification of simple partial seizures within 2 years of surgery as a significant risk factor for long-term seizure recurrence (hazard ratio 2·4, 95% CI 1·5–3·9). This finding has implications for decisions to discontinue antiepileptic drugs in patients with only simple partial seizures. The outcome in patients not rendered immediately seizure free13 or suffering a short-lived relapse also allows for optimism, with 15% of the total cohort eventually gaining remission. In 3% of patients, remission occurred 2–12 years after introduction of a previously unused antiepileptic drug. A similar number of patients who had seizures when
Patients Patients seizure free at follow up (%) (N=6603) 1 year
2 years
5 years
10 years
15 years
Worthwhile No worthwhile improvement (%) improvement (%)
Engel et al, 1993
Anterior temporal lobectomy
3579
..
68% (2430)
..
..
..
92% (3289)
8% (290)
Engel et al, 1993
Amygdalohippocampectomy
413
..
69% (284)
..
..
..
91% (376)
9% (37)
Wiebe et al, 2001
Anterior temporal lobectomy
36
..
..
..
64% (23)
64% (23)
..
McIntosh et al, 2004 Anterior temporal lobectomy
325
61% (198)
55% (180)
48% (155)
41% (133)
Dupoint et al, 2006
Anterior temporal lobectomy (n=88) or Amygdalohippocampectomy (n=22)
110
75% (83)
66% (73)
54% (61)
41% (45)
Dunlea et al, 2010
Anterior temporal lobectomy (n=74), Amygdalohippocampectomy (n=62), neocorticectomy (n=34), lesionectomy (n=21), frontal lobe resection (n=4)
199
57% (113)
41% (82)
44% (88)
55% (80)
..
Salanova et al, 1999 En bloc temporal lobectomy
145
66% (96)
63% (91)
60% (87)
Elwes et al, 1991
En bloc anterior temporal lobectomy
102
56% (57)
60% (61)
67% (68)
..
..
25% (50)
.. 91% (100)
·· ·· 4% (11)
..
..
9% (10)
..
..
..
One postoperative haematoma
..
..
..
One mild hemiparesis
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
Paglioli et al, 2004
Temporal lobectomy
134
85% (114)
77% (103)
74% (99)
Keleman et al, 2006
Anterior temporal lobectomy-mixed pathology
94
72% (68)
66% (62)
59% (56)
Cohen-Gadol et al, 2006
Mixed non-lesional pathology, includling mesial temporal sclerosis
399
78% (311)
76% (303)
74% (295)
Clusmann et al, 2002
Multiple pathologies and procedures
456
..
..
..
..
..
89% (408)
11% (48)
..
Clusmann et al, 2004
Paediatric study many surgical approaches
89
..
..
..
..
..
87% (77)
13% (12)
..
Chan et al, 2006
Temporal lobectomy
Schwartz et al, 2006 Many procedures for mesial temporal lobe epilepsy Lee et al, 2006
Anterior temporal lobectomy
Foldvary et al, 2000 Temporal lobectomy Sperling et al, 1996
Temporal lobectomy
Total (%)
··
66% (88)
37% (120)
36% (13)
Adverse effect
.. 72% (287)
14% (56)
12
..
..
..
..
..
67% (8)
33% (4)
..
285
..
..
..
..
..
87% (248)
13% (37)
..
51
..
79
..
89 6597
73% (37) ..
.. 52% (41)
72% (64)
68% (61)
72% (64)
70%
67%
60%
.. 45% (36)
.. ..
.. 80% (63)
.. 20% (16)
.. ..
··
··
··
··
··
52%
31%
83%
17%
··
Table: Epilepsy surgery outcomes
www.thelancet.com Vol 378 October 15, 2011
1361
Comment
these drugs were withdrawn went into long-term remission after recommencing them. Most patients who were seizure free after surgery chose to remain on an antiepileptic drug and we await further analysis of the effects of drug reduction in this cohort. Studies have been unable to make these patterns explicit and so have tended to overestimate the number of patients who had no seizure from the time of surgery. de Tisi and colleagues’ data have helped to identify these patterns and will be useful for counselling patients and guiding their physicians. This study validates the long-term effectiveness of epilepsy surgery showing that over 50% of all patients are rendered continuously long-term seizure free; it also raises important questions and challenges. Are the benefits of seizure freedom apportioned equally to the continuous and later remission groups? Can selection and resection strategies be further improved to optimise long-term seizure control? Finally, the median duration of epilepsy before surgery in this study was 20 years. In view of the long-term results of surgery shown, clinical practice needs to change with the early referral of appropriate patients.
We declare that we have no conflicts of interest. 1 2 3
4 5
6
7
8
9
10
11
12
13
Engel J Jr. Surgery for seizures. N Engl J Med 1996; 334: 647–52. Duncan JS. Imaging in the surgical treatment of epilepsy. Nat Rev Neurol 2010; 6: 537–50. Wiebe S, Blume WT, Girvin JP, Eliasziw M, for the Effectiveness and Efficiency of Surgery for Temporal Lobe Epilepsy Study Group. A randomized, controlled trial of surgery for temporal-lobe epilepsy. N Engl J Med 2001; 345: 311–18. Engel J Jr, Rasmussen TB, Ojemann LM. Surgical treatment of the epilepsies, 2nd edn. New York: Raven Press, 1993. Téllez-Zenteno JF, Dhar R, Wiebe S. Long-term seizure outcomes following epilepsy surgery: a systematic review and meta-analysis. Brain 2005; 128: 1188–98. Salanova V, Markand O, Worth R. Longitudinal follow-up in 145 patients with medically refractory temporal lobe epilepsy treated surgically between 1984 and 1995. Epilepsia 1999; 40: 1417–23. McIntosh AM, Kalnins RM, Mitchell LA, Fabinyi GC, Briellmann RS, Berkovic SF. Temporal lobectomy: long-term seizure outcome, late recurrence and risks for seizure recurrence. Brain 2004; 127: 2018–30. de Tisi J, Bell GS, Peacock JL, et al. The long-term outcome of adult epilepsy surgery, patterns of seizure remission, and relapse: a cohort study. Lancet 2011; 378: 1388–95. Lee SA, Yim SB, Lim YM, Kang JK, Lee JK. Factors predicting seizure outcome of anterior temporal lobectomy for patients with mesial temporal sclerosis. Seizure 2006; 15: 397–404. Janszky J, Pannek HW, Janszky I, et al. Failed surgery for temporal lobe epilepsy: predictors of long-term seizure-free course. Epilepsy Res 2005; 64: 35–44. Elwes RD, Dunn G, Binnie CD, Polkey CE. Outcome following resective surgery for temporal lobe epilepsy: a prospective follow up study of 102 consecutive cases. J Neurol Neurosurg Psychiatry 1991; 54: 949–52. Cohen-Gadol AA, Wilhelmi BG, Collignon F, et al. Long-term outcome of epilepsy surgery among 399 patients with nonlesional seizure foci including mesial temporal lobe sclerosis. J Neurosurg 2006; 104: 513–24. Salanova V, Andermann F, Rasmussen T, Olivier A, Quesney L. The running down phenomenon in temporal lobe epilepsy. Brain 1996; 119: 989–96.
Ahmed-Ramadan Sadek, *William Peter Gray Wessex Neurological Centre, Southampton University Hospitals NHS Trust, Southampton, UK; and Division of Clinical Neurosciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK (ARS, WPG) [email protected]
Patient blood management is key before elective surgery Published Online October 6, 2011 DOI:10.1016/S01406736(11)61552-3 See Articles page 1396
1362
Writing in The Lancet, Khaled Musallam and colleagues address an important topic through their analysis of the American College of Surgeons’ National Surgical Quality Improvement Program database;1 namely, what is the prevalence of preoperative anaemia in patients undergoing major non-cardiac surgery and what are the implications? Moreover, by removal of data for allogeneic red-blood-cell transfusions in their analysis (and thus in the absence of treatment for anaemia) the independent and natural course of preoperative anaemia is shown. The main finding of their study1 was that preoperative anaemia—even to a mild degree— was significantly and independently associated with increased postoperative morbidity and mortality.
This association might be aggravated by concomitant perisurgical blood loss2 and (frequently unnecessary) allogeneic transfusions.3 I believe that Musallam and colleagues’ findings could have an enormous effect on health-care systems worldwide because preoperative diagnosis and treatment of anaemia (apart from transfusions of red blood cells) has almost never been undertaken routinely before surgery.3 Anaemia is a serious but easily treatable condition. Treatment is less costly than is transfusion and would possibly improve outcomes, not only by increased tolerance of perioperative blood loss and avoidance of allogeneic transfusions but also through elimination of the risk of anaemia by maintaining increased www.thelancet.com Vol 378 October 15, 2011
of 1·4% (one of 74 patients) and a 1-year survival rate of 96% (71 of 74 patients). Postoperative haemodynamic improvement was also excellent. The Papworth group previously reported an in-hospital mortality of 15% in 151 patients,4 which shows the benefit of increased experience with this difficult operation. The most important finding of Vuylsteke and colleagues’ study was that continuous perfusion of the brain did not result in a difference in postoperative cerebral function compared with the absence of perfusion.3 For the primary endpoint at 12 weeks after surgery, mean differences in Z scores in cognitive function between the groups were: 0·14 (95% CI –0·14 to 0·42, p=0·33) in a test of eye–hand coordination and attention, –0·06 (–0·38 to 0·25, p=0·69) for a learning test, and 0·01 (–0·26 to 0·29, p=0·92) in a test of fine motor coordination. Perhaps more surprisingly, especially in view of some publications that have implicated cardiopulmonary bypass in a reduction of cerebral function postoperatively,6 was the finding that cognitive function was not impaired by either strategy but, if anything, improved in both groups compared with preoperative levels. This finding is particularly remarkable because the mean duration of bypass, commonly less than 2 h for most cardiac surgery, was more than 5 h in both study groups.3 This study calls into question the belief that cardiopulmonary bypass itself is associated with impairment
of cerebral function postoperatively, and also shows that hypothermic circulatory arrest without cerebral perfusion for short periods need not be harmful. It confirms that circulatory arrest is the optimum approach for the pulmonary endarterectomy operation. Any surgical treatment, of course, balances immediate harm against long-term improvement and, in these patients, cardiac output and oxygenation, particularly during exercise, would have been substantially better after surgery than before, probably contributing to the improvement in cerebral function seen postoperatively. Stuart Jamieson Division of Cardiothoracic Surgery, University of California San Diego, San Diego, CA 92103, USA [email protected] I declare that I have no conflicts of interest. 1
2 3
4
5
6
Pengo V, Lensing AW, Prins MH, et al. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med 2004; 350: 2257–64. Jamieson SW, Kapelanski DP. Pulmonary endarterectomy. Curr Probl Surg 2000; 37: 165–252. Vuylsteke A, Sharples L, Charman G, et al. Circulatory arrest versus cerebral perfusion during pulmonary endarterectomy surgery (PEACOG): a randomised controlled trial. Lancet 2011; 378: 1379–87. Thomson B, Tsui SS, Dunning J, et al. Pulmonary endarterectomy is possible and effective without the use of complete circulatory arrest—the UK experience in over 150 patients. Eur J Cardiothorac Surg 2008; 33: 157–63. Jamieson SW, Kapelanski DP, Sakakibara N, et al. Pulmonary endarterectomy: experience and lessons learned in 1,500 cases. Ann Thorac Surg 2003: 76: 1457–62. Newman MF, Kirchner JL, Phiips-Bute, et al. Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery. N Engl J Med 2001; 344: 395–402.
Chopping and changing: long-term results of epilepsy surgery See Articles page 1388
1360
Surgical management of medically refractory focal epilepsy has seen a resurgence in the past 20 years.1 Advances in structural and functional neuroimaging2 and invasive electroencephalography have increased success in identifying the ictal onset zone; and functional MRI, tractography, and cortical mapping have allowed for safe resection. Seizure freedom is the most substantial predictor of improved quality of life, and freedom rates of 60–70% are routinely reported after 1–2 years’ follow-up.3–5 However, seizure control at late follow-up is less good (table) with many studies reporting seizure freedom rates of 40–50% at 10 years. Moreover, few studies show how many patients have sustained long-term seizure freedom after surgery. Importantly, although patients who are seizure free at
2 years are likely to remain so at 7 years6 and 10 years,7 late seizure recurrence is not uncommon and little is known about its prediction, prognosis, management, or causation. In The Lancet, Jane de Tisi and colleagues8 report the largest and longest prospective study of epilepsy surgery outcome for up to 19 years (representing more than 5200 person-years of follow-up). This study is novel in its prospective analysis of seizure freedom at successive annual reviews in individual patients unlike other studies that review seizure freedom only at last follow-up. The cohort consists mainly of temporal lobe surgery, typical of adult epilepsy surgery. Similar to previous studies, de Tisi and colleagues8 report the percentage of patients remaining free of non-simple www.thelancet.com Vol 378 October 15, 2011
Comment
partial seizure to be 63% at 2 years, 52% after 5 years, and 47% after 10 years, and that an initial and longer period of seizure absence is the strongest indicator of good long-term outcome.6,9–11 Conversely, in patients with prolonged postoperative seizure activity, likelihood of remission is decreased.11,12 An analysis of seizure-freedom patterns in individual patients over time yields a key finding: although 70% of patients were seizure free for the last year at any one time, only 51% were completely seizure free throughout followup because every year there was 3–15% change within the patient groups. 73% of patients had at least 1 year of absolute seizure freedom and 82% had at least 1 year with no seizures or only simple partial seizures. Surgical procedure
What about the prediction, prognosis, and management of different patterns of seizure outcome? Another key finding is the identification of simple partial seizures within 2 years of surgery as a significant risk factor for long-term seizure recurrence (hazard ratio 2·4, 95% CI 1·5–3·9). This finding has implications for decisions to discontinue antiepileptic drugs in patients with only simple partial seizures. The outcome in patients not rendered immediately seizure free13 or suffering a short-lived relapse also allows for optimism, with 15% of the total cohort eventually gaining remission. In 3% of patients, remission occurred 2–12 years after introduction of a previously unused antiepileptic drug. A similar number of patients who had seizures when
Patients Patients seizure free at follow up (%) (N=6603) 1 year
2 years
5 years
10 years
15 years
Worthwhile No worthwhile improvement (%) improvement (%)
Engel et al, 1993
Anterior temporal lobectomy
3579
..
68% (2430)
..
..
..
92% (3289)
8% (290)
Engel et al, 1993
Amygdalohippocampectomy
413
..
69% (284)
..
..
..
91% (376)
9% (37)
Wiebe et al, 2001
Anterior temporal lobectomy
36
..
..
..
64% (23)
64% (23)
..
McIntosh et al, 2004 Anterior temporal lobectomy
325
61% (198)
55% (180)
48% (155)
41% (133)
Dupoint et al, 2006
Anterior temporal lobectomy (n=88) or Amygdalohippocampectomy (n=22)
110
75% (83)
66% (73)
54% (61)
41% (45)
Dunlea et al, 2010
Anterior temporal lobectomy (n=74), Amygdalohippocampectomy (n=62), neocorticectomy (n=34), lesionectomy (n=21), frontal lobe resection (n=4)
199
57% (113)
41% (82)
44% (88)
55% (80)
..
Salanova et al, 1999 En bloc temporal lobectomy
145
66% (96)
63% (91)
60% (87)
Elwes et al, 1991
En bloc anterior temporal lobectomy
102
56% (57)
60% (61)
67% (68)
..
..
25% (50)
.. 91% (100)
·· ·· 4% (11)
..
..
9% (10)
..
..
..
One postoperative haematoma
..
..
..
One mild hemiparesis
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
Paglioli et al, 2004
Temporal lobectomy
134
85% (114)
77% (103)
74% (99)
Keleman et al, 2006
Anterior temporal lobectomy-mixed pathology
94
72% (68)
66% (62)
59% (56)
Cohen-Gadol et al, 2006
Mixed non-lesional pathology, includling mesial temporal sclerosis
399
78% (311)
76% (303)
74% (295)
Clusmann et al, 2002
Multiple pathologies and procedures
456
..
..
..
..
..
89% (408)
11% (48)
..
Clusmann et al, 2004
Paediatric study many surgical approaches
89
..
..
..
..
..
87% (77)
13% (12)
..
Chan et al, 2006
Temporal lobectomy
Schwartz et al, 2006 Many procedures for mesial temporal lobe epilepsy Lee et al, 2006
Anterior temporal lobectomy
Foldvary et al, 2000 Temporal lobectomy Sperling et al, 1996
Temporal lobectomy
Total (%)
··
66% (88)
37% (120)
36% (13)
Adverse effect
.. 72% (287)
14% (56)
12
..
..
..
..
..
67% (8)
33% (4)
..
285
..
..
..
..
..
87% (248)
13% (37)
..
51
..
79
..
89 6597
73% (37) ..
.. 52% (41)
72% (64)
68% (61)
72% (64)
70%
67%
60%
.. 45% (36)
.. ..
.. 80% (63)
.. 20% (16)
.. ..
··
··
··
··
··
52%
31%
83%
17%
··
Table: Epilepsy surgery outcomes
www.thelancet.com Vol 378 October 15, 2011
1361
Comment
these drugs were withdrawn went into long-term remission after recommencing them. Most patients who were seizure free after surgery chose to remain on an antiepileptic drug and we await further analysis of the effects of drug reduction in this cohort. Studies have been unable to make these patterns explicit and so have tended to overestimate the number of patients who had no seizure from the time of surgery. de Tisi and colleagues’ data have helped to identify these patterns and will be useful for counselling patients and guiding their physicians. This study validates the long-term effectiveness of epilepsy surgery showing that over 50% of all patients are rendered continuously long-term seizure free; it also raises important questions and challenges. Are the benefits of seizure freedom apportioned equally to the continuous and later remission groups? Can selection and resection strategies be further improved to optimise long-term seizure control? Finally, the median duration of epilepsy before surgery in this study was 20 years. In view of the long-term results of surgery shown, clinical practice needs to change with the early referral of appropriate patients.
We declare that we have no conflicts of interest. 1 2 3
4 5
6
7
8
9
10
11
12
13
Engel J Jr. Surgery for seizures. N Engl J Med 1996; 334: 647–52. Duncan JS. Imaging in the surgical treatment of epilepsy. Nat Rev Neurol 2010; 6: 537–50. Wiebe S, Blume WT, Girvin JP, Eliasziw M, for the Effectiveness and Efficiency of Surgery for Temporal Lobe Epilepsy Study Group. A randomized, controlled trial of surgery for temporal-lobe epilepsy. N Engl J Med 2001; 345: 311–18. Engel J Jr, Rasmussen TB, Ojemann LM. Surgical treatment of the epilepsies, 2nd edn. New York: Raven Press, 1993. Téllez-Zenteno JF, Dhar R, Wiebe S. Long-term seizure outcomes following epilepsy surgery: a systematic review and meta-analysis. Brain 2005; 128: 1188–98. Salanova V, Markand O, Worth R. Longitudinal follow-up in 145 patients with medically refractory temporal lobe epilepsy treated surgically between 1984 and 1995. Epilepsia 1999; 40: 1417–23. McIntosh AM, Kalnins RM, Mitchell LA, Fabinyi GC, Briellmann RS, Berkovic SF. Temporal lobectomy: long-term seizure outcome, late recurrence and risks for seizure recurrence. Brain 2004; 127: 2018–30. de Tisi J, Bell GS, Peacock JL, et al. The long-term outcome of adult epilepsy surgery, patterns of seizure remission, and relapse: a cohort study. Lancet 2011; 378: 1388–95. Lee SA, Yim SB, Lim YM, Kang JK, Lee JK. Factors predicting seizure outcome of anterior temporal lobectomy for patients with mesial temporal sclerosis. Seizure 2006; 15: 397–404. Janszky J, Pannek HW, Janszky I, et al. Failed surgery for temporal lobe epilepsy: predictors of long-term seizure-free course. Epilepsy Res 2005; 64: 35–44. Elwes RD, Dunn G, Binnie CD, Polkey CE. Outcome following resective surgery for temporal lobe epilepsy: a prospective follow up study of 102 consecutive cases. J Neurol Neurosurg Psychiatry 1991; 54: 949–52. Cohen-Gadol AA, Wilhelmi BG, Collignon F, et al. Long-term outcome of epilepsy surgery among 399 patients with nonlesional seizure foci including mesial temporal lobe sclerosis. J Neurosurg 2006; 104: 513–24. Salanova V, Andermann F, Rasmussen T, Olivier A, Quesney L. The running down phenomenon in temporal lobe epilepsy. Brain 1996; 119: 989–96.
Ahmed-Ramadan Sadek, *William Peter Gray Wessex Neurological Centre, Southampton University Hospitals NHS Trust, Southampton, UK; and Division of Clinical Neurosciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK (ARS, WPG) [email protected]
Patient blood management is key before elective surgery Published Online October 6, 2011 DOI:10.1016/S01406736(11)61552-3 See Articles page 1396
1362
Writing in The Lancet, Khaled Musallam and colleagues address an important topic through their analysis of the American College of Surgeons’ National Surgical Quality Improvement Program database;1 namely, what is the prevalence of preoperative anaemia in patients undergoing major non-cardiac surgery and what are the implications? Moreover, by removal of data for allogeneic red-blood-cell transfusions in their analysis (and thus in the absence of treatment for anaemia) the independent and natural course of preoperative anaemia is shown. The main finding of their study1 was that preoperative anaemia—even to a mild degree— was significantly and independently associated with increased postoperative morbidity and mortality.
This association might be aggravated by concomitant perisurgical blood loss2 and (frequently unnecessary) allogeneic transfusions.3 I believe that Musallam and colleagues’ findings could have an enormous effect on health-care systems worldwide because preoperative diagnosis and treatment of anaemia (apart from transfusions of red blood cells) has almost never been undertaken routinely before surgery.3 Anaemia is a serious but easily treatable condition. Treatment is less costly than is transfusion and would possibly improve outcomes, not only by increased tolerance of perioperative blood loss and avoidance of allogeneic transfusions but also through elimination of the risk of anaemia by maintaining increased www.thelancet.com Vol 378 October 15, 2011