A comparative assessment of laser interstitial thermal therapy and open resective surgery for drug-resistant epilepsy: a meta-analysis of 3873 patients

Open resective surgery (ORS) has become the standard of care for focal drug-resistant epilepsy (DRE). However, minimally invasive surgical alternatives, such as laser interstitial thermal therapy (LITT), have also been shown to be safe and effective. A meta-analysis comparing both treatments is warranted to assess the benefits of each modality for focal DRE. A literature search was conducted until March 14, 2024, to identify studies comparing LITT and ORS in patients with DRE. The primary outcomes included seizure freedom (SF), length of hospital stay (LHS), and complication rate (CR). Subgroup analyses were performed based on age, epilepsy etiology, and propensity score-matched (PSM) studies. Of 558 articles, 15 cohort studies met the authors' inclusion criteria, encompassing 3873 patients for analysis. The rate of SF in the LITT group was 52.5% (95% CI 0.453-0.597, I2 = 47.4%) and 67.1% (95% CI 0.602-0.739, I2 = 57.4%) for the ORS group. LITT showed a significantly lower rate of SF compared to ORS (risk ratio [RR] 0.78, 95% CI 0.70-0.88, p ≤ 0.0001). However, when PSM studies (RR 0.85, 95% CI 0.63-1.15, p = 0.30) and studies on patients with temporal lobe epilepsy (TLE) (RR 0.88, 95% CI 0.67-1.14, p = 0.34) were analyzed, the SF rates were similar. Patients who underwent LITT had a significantly shorter LHS (mean difference 2.95 days, 95% CI 1.12-4.78, p < 0.00001), lower CR (RR 0.54, 95% CI 0.37-0.79, p < 0.002, I2 = 32%), lower rate of ischemic stroke (RR 0.15, 95% CI 0.04-0.65, p = 0.01), and lower rate of permanent neurological deficits (RR 0.13, 95% CI 0.05-0.36, p < 0.0001). Across unmatched studies evaluating focal DRE, ORS showed a higher rate of SF. However, pooled matched-cohort analyses showed no difference between interventions in achieving SF, a trend also noted in the authors' PSM TLE sample. LITT, however, offered significantly shorter LHS and lower CRs. Future prospective studies should match patient populations to control for confounding factors and assess key outcomes, such as postoperative neurocognitive follow-up and quality of life measurements, in order to fully evaluate the risks and benefits of each approach.