gms | German Medical Science

Objective: The objective of surgery in pharmacologically intractable epilepsy is seizure control. Postoperative persistence of seizures despite medical treatment should be considered as surgical failures. The aim of this report is a detailed analysis of re-operations in children with pre-planned re-resections after failed surgery.

Methods: Among 311 patients undergoing surgical treatment for epilepsy between September 1, 1998 and November 30, 2010, re-operations were performed in 34 children. Etiologies included: malformations of cortical development: n = 23; tumor: n = 4; infarction/gliosis: n = 3; Sturge-Weber-disease: n = 1. Fibertracking-guided resection and functional neuronavigation were implemented into a setup for pediatric epilepsy surgery. The vertical parasagittal hemispherotomy-technique was used. Callosotomies, vertical parasagittal hemispherotomies, subtotal hemispherectomies, multilobar resections, frontal-, temporal and parietal resections were performed.

Results: 4 children underwent pre-planned hemispherotomies as second step after multilobar resections, 9 underwent repeated surgical procedures after persistent seizures, and 21 corrective procedures were performed in addition to a first or second operation. In 4 children, a third microsurgical approach was carried out. In this group 3 disconnections and 1 amygdalon and anterior commissure re-resection were performed. The following final results were ascertained: Engel I = “seizure free” n = 15, Engel II = “almost seizure free” = > 50% seizure reduction n = 5, Engel III = “worthwile improvement” = > 50% seizure reduction n = 7, Engel IV = “no worthwhile improvement” n = 3. The follow-up was 45 ± 3 months (4.6–112).

Conclusions: Individualized re-operations can be safe and effective and may provide another chance for seizure control in selected cases. Elucidating the pathoetiologic mechanisms of surgical failure will guide epileptologists and epilepsy surgeons toward improved patient selection and more effective primary surgical procedures in the future. Further studies about the natural history of recurrent seizures, causes of operative failure, and long-term results of re-operations are required. The preliminary results are clearly encouraging.