Epilepsy surgery in low- and middle-income countries: A scoping review

Abstract

Background: Epilepsy surgery is an important treatment option for people with drug resistant epilepsy. Although surgical procedures are under-utilized worldwide, it is far worse in Low-and Middle-Income Countries (LMIC) and it is less clear to what extent people with drug resistant epilepsy receive such treatment at all. Here we review the existing evidence for the availability and outcome of epilepsy surgery in LMIC, and discuss some challenges and priority. Methods: We used the six stage methodological framework developed by Arskey and O'Malley as a guide. We searched PubMed, Embase, Global Health Archives, Index Medicus for South East Asia Region (IMSEAR), Index Medicus for Eastern Mediterranean Region (IMEMR), Latin American & Caribbean Health Sciences Literature (LILACS), African Journal Online (AJOL), and African Index Medicus (AIM) to identify the relevant literature. Results: We retrieved 148 articles on epilepsy surgery from 31 countries representing 22% of the 143 LMIC. Epilepsy surgery appears established in some of these centers in Asia and Latin America, while some are in their embryonic stage reporting procedures in a small cohort performed mostly by motivated neurosurgeons. The commonest surgical procedure reported was temporal lobectomies. The post-operative seizure-free rates and quality of life are comparable to those in the high-income countries (HIC). Some models have shown that epilepsy surgery can be performed within a resourcelimited setting through collaboration with international partners and through the use of information and communication technology. The cost of surgery is a fraction of what is available in HIC. Conclusion: This review has demonstrated the availability of epilepsy surgery in few LMIC. The information available is inadequate to make any reasonable conclusion of its existence as routine practice. Collaborations with international partners can provide an opportunity to bring high-quality academic training and technological transfer directly to surgeons working in these regions and should be encouraged.

Trends in pediatric epilepsy surgery: A lower‐middle‐income country perspective

“…Viewing the evolution of epilepsy surgery over the years from an LMIC perspective, a study by Wieser et al in 2000 revealed that only 26 (18.3%) of 142 LMICs reported epilepsy surgery 33 . More recently, a scoping review showed a marginal increase—31 countries (21.7%) of the 143 LMIC reported epilepsy surgery; however, the bulk of publications were from three countries—India, China, and Brazil 17 . While the utilization of epilepsy surgery seems to be on an upward trend in these three countries, it is important to note the gross under‐representation of other LMICs particularly in Africa.…”

“…In the past, access to advanced epilepsy care and facilities for epilepsy surgery was deemed inadequate 16 . However, recent years have seen a change for the better with increasing availability of epilepsy surgery 17 . Analyzing the trends and patterns related to epilepsy surgery and referral would help to identify potential areas that require more attention and help devise strategies aimed at better epilepsy care and utilization of services.…”

Missed opportunities for epilepsy surgery referrals in Bhutan: A cohort study

“…With the average price of epilepsy surgery in India ranging from USD $1500 to $3400, any potential referrals may require an extension of Bhutan's universal healthcare coverage plan to foreign hospital visits as well, with the Bhutanese government offsetting the cost of surgery instead of the individual patient (Watila et al 2019). Such policies would require forward-thinking negotiations between relevant governments and ideally lead to capacitybuilding of Bhutanese health care workers to recognize, treat, and triage cases of epilepsy to the best available care.…”

“…Barriers to epilepsy surgery are usually even greater in LMICs due to the lack of organized care, health infrastructure, shortage of specialists, and the cost of surgery, which contribute to the underutilization of evidence-based surgical treatments (Watila et al 2019). A global review conducted in 2000 found that only 26 of 142 LMICs conducted epilepsy surgery; despite advances in recent years, epilepsy surgery nevertheless remains a rare practice, making it difficult for PWE in LMICs to consider surgery as a viable treatment option (Watila et al 2019;Weiser et al 2000).…”

Budget Impact Analysis of Treatment Flow Optimization in Epilepsy Patients: Estimating Potential Impacts with Increased Referral Rate to Specialized Care

“…One study demonstrated that epilepsy surgery could be performed within a resource-limited setting in low-to middle-income countries with the same quality as in high-income countries, so transfer of skills and expertise from high-income countries should be encouraged. 9 Based on the National Database Open Data, the rate of epilepsy surgeries in patients with drug-resistant epilepsy in Japan is estimated at approximately half of that in the United States. 10 The problem with Japan's medical care system is that no medical department plays an initiative role in epilepsy care.…”