Reoperation

Re-operation is the use of a further surgical procedure intended to relieve a patient's drug-resistant epilepsy when a previous procedure for the same purpose has failed. The procedures do not necessarily have to be of the same kind.

There are two broad indications for reoperation, which, by their nature, define the candidates. The first is when a lesser procedure does not produce the expected result or is unsatisfactory to the patient or their relatives. The second is when seizures persist and there is reasonable evidence that further operation, usually a resection and often at the same site as the original surgery, will bring further benefit. The evaluation criteria must be the same as those used in assessing surgical candidates de novo.

In passing from a functional operation such as callosotomy to a resective procedure, the same principles should apply. The goals of surgery should be similar to those expressed at a first operation but modified by a realistic reassessment of the situation. The most important element is a proper assessment of the underlying pathology. It is clear that, except in special circumstances, the complete removal of discrete pathology is most likely to produce complete freedom from seizures. The use of acute ECoG at re-operation is not clear.

The overall results of re-operation, as it affects seizure frequency, can be gleaned from the published papers. Three very crude groups were used: "seizure free", corresponding to Engel's group 1A; "significantly improved", corresponding to Engel groups 1B-1D, 2 and 3A; and "not improved", corresponding to Engel group 3B and worse. Overall, 44.3% were seizure free, 30.5% significantly improved and 25.2% were not improved. Temporal lobe resections tended to do better, with 55.7% seizure free and 16.5% not improved, whereas for other resections, only 24.5% were seizure free and 40% were not improved. When there is a structural lesion which has been missed or incompletely removed, then the seizure-free proportion rises to 80-90% [25]. A recent paper suggests that magnetic source imaging may aid selection for re-operation and showed epileptogenicity around the margin of a previous resection in ten patients. Five of these patients were selected for re-operation and three were rendered seizure free.

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