Summary: The authors present the results of a series of corpus callosotomies (CCS) in 97 patients performed from 1989 to 1997 at the Hospital Neurologico of the Liga Colombiana Contra La Epilepsia, Cartagena, Colombia. This study demonstrates the feasibility of performing these procedures in the developing world and analyzes the outcome and cost of treatment. Patients with medically intractable secondarily generalized epilepsy, bilateral nonfocal epileptic electroencephalogram (EEG), and absence of progressive encephalopathy were accepted as candidates (patients aged 0–30 years; 62 children, 19 girls and 43 boys, with mean age at surgery of 7·9 years; 35 adults, 19 women and 16 men, with mean age at surgery of 25·8 years). Preoperatively, the mean seizure frequency was 12·1 per day, or 364 per month (range, 0·06–200 per day, 1·8–6000 per‐month). Before surgery, 40% of patients were classified with generalized tonic‐clonic seizures of different etiologies, or cryptogenic seizures; 36% had mixed seizures; 19% had Lennox‐Gastaut Syndrome; and 5% had West Syndrome. Usually, routine EEG, computed tomography, and clinical findings sufficed for the surgical decision. The standard microsurgical technique performed was an anterior two‐thirds CCS by the same surgeon under general anesthesia. In five cases, an additional frontal lobe excision after electrocorticography and subdural electrode monitoring was carried out in the same session. The results were evaluated after a mean follow‐up of 35 months (range, 12–28). Two thirds of patients became seizure‐free or were left with none or some disabling seizures. AED medication was eased slightly after surgery. The complication rate was low. The patients underwent postoperative psychosocial studies and neuropsychological rehabilitation and showed tendencies toward improvement. The direct cost of CCS in U.S. dollars (US$) ranged between 3,137 and 3,995 depending on the preoperative studies. Thus, CCS is well suited for selected patients in developing countries. Thus far, implantation of a vagus nerve stimulator has exceeded our economic possibilities in treating similar patients. Some reflections on care and research among epilepsy patients in developing countries are discussed.
Summary: The organization, financing, productivity, quality of work, and cost‐effectiveness of the Epilepsy Center in Cartagena, Colombia, were studied and compared with the epilepsy surgery program at the University Hospital Zürich, Switzerland. During a 2‐month visit, one of the authors (I.T.) evaluated the center in Cartagena as a welfare institution and evaluated its epilepsy surgery program. The postoperative results of the Cartagena program were compared with those reported at the Second International Palm Desert Conference 1992, which revealed a similar rate of postoperative seizure control in temporal lobe epilepsy, slightly inferior results with hemispherectomy, and slightly better results with anterior callosotomy. A comparison between the two epilepsy centers showed that pre‐and postoperative antiepileptic drug treatment is more restricted in Colombia because of high costs. Although important diagnostic tools such as electroencephalography, seizure monitoring, neuropsychology, computed tomography, and magnetic resonance imaging are available in both centers, the Zürich program also has access to positron emission tomography, single photon emission computed tomography, magnetic resonance spectroscopy, and intracarotid and selective amobarbital tests. The postoperative seizure outcome is similar in surgical temporal lobe epilepsy patients (temporal lobectomy series, Cartagena; selective amygdalohippocampectomy series, Zürich). The comparison of direct costs of epilepsy surgery in Cartagena and Zürich showed that for the average patient undergoing epilepsy surgery in Cartagena, the cost is 5·5% of that in Zürich. This study presents evidence that epilepsy surgery is an inexpensive and efficient treatment option for epilepsy patients in developing countries. Epilepsy surgery in developing countries may even be considered at an early stage in patients who cannot afford the costs of lifetime medical treatment but can afford the one‐time cost of a surgical treatment.
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