Pediatric epilepsy surgery in Lebanon
In this article we review our experience in epilepsy surgery in Lebanon with the 40 pediatric patients who underwent either resective surgery (36 patients) or VNS (vagal nerve stimulation) (4 patients) procedures at the Adult and Pediatric Epilepsy Program at the American University of Beirut - Medical Center (AUB- MC) in its first 10 years. The program, which started in 1995 and included clinical studies, invasive and non-invasive video EEG monitoring, epilepsy surgery, and basic science research, was the first of its kind in Lebanon and in countries of the region. Patients underwent neurologic, and psychologic assessments, video long term monitoring (VLTM), and magnetic resonance imaging (MRI). In addition, subdural electrode monitoring, intraoperative and extraoperative cortical stimulation, positron emission tomography (PET), single-photon emission computed tomography (SPECT) and intracarotid sodium amobarbital procedure (Wada) tests were performed as needed. Average follow-up after surgery was 4.10 ± 2.61 years and the average age at surgery was 10.63 ± 5.05 years (range 2.50-18). Temporal lobectomy was the most frequent procedure (42.5%) followed by extratemporal resections (27.5%), hemispherectomy (10.0%), multilobar resections (10%) and VNS (10%). In the resective surgery group, 30 out of 36 patients (83.3%) had Engel class I outcome. Age at surgery, age at epilepsy onset, pre-operative seizure frequency, type of surgery, and tumor etiology were not found to be predictive of resective surgery outcome. Of the patients who were evaluated as outpatients and who qualified for inpatient evaluation for epilepsy surgery, many more could not be admitted for financial reasons than those who could be admitted. This occurred, despite the presence of substantial financial and philanthropic aid. Patients were often denied coverage by their third party payers due to the presumed "congenital" nature of epilepsy or other financial reasons. We conclude that advanced epilepsy presurgical workups and surgical procedures and outcomes comparable to those achieved in the West, are possible in non-developed countries, but financial coverage issues limit the number of patients that can benefit from this therapy and, thus, still need to be addressed.
