A glance at Quality-of-Life Post-Epilepsy Surgery: A Meta-Analysis and Systematic Review

A glance at Quality-of-Life Post-Epilepsy Surgery: A Meta-Analysis and Systematic Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review A glance at Quality-of-Life Post-Epilepsy Surgery: A Meta-Analysis and Systematic Review Ivin Thomas Jolly, Harshawardhan Dhanraj Ramteke, Sakshi Bhatia, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4857884/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : One of the most important outcomes of the epilepsy management is seizure freedom and improved quality of life (QoL). This meta-analysis and systemic review aim to compute the changes in QoL in the adults having drug resistant epilepsy further undergoing surgery. Thus, this also helps in exploring the various factors affecting the QoL with the changes in QoL. Methods : We analyzed the data using the various clinical trial medical databases and PubMed. Most of the studies had the pre- and post-operative seizure outcomes and the mean changes in pre- and post-operative QoL scores were analyzed. The literature search showed a total of 1336 studies were available after the initial search out of which 1259 were excluded. Once the abstract screening was done 77 studies were selected, going through the full text, 43 remained. We applied the language filter and also age range of the patients (19-44 years), yielded in 31 studies. Results : Four studies were included (n = 4 / 31, 12.9%) in the QOLIE-10 metanalysis. Overall preoperative QOLIE-10 score was 25.49 (19.38 – 31.60 with 95% CI) and overall postoperative QOLIE-10 score was 19.56 (12.95 – 26.16 with 95% CI). Eleven studies were included (n=11/31, 35.4%) in the QOLIE-31 metanalysis. Overall preoperative QOLIE-31 score was 43.89 (31.32 – 56.46 with 95% CI) and overall postoperative QOLIE-31 was 59.31 (45.09 – 73.54 with 95% CI). The change in QOLIE-31 was 12.28 (3.09 – 21.48 with 95% CI). Seven studies were included (n = 7/31, 22.5%) in the QOLIE-89 meta-analysis. Overall preoperative QOLIE-89 score was 49.26 (39.77 – 58.74 with 95% CI) and overall postoperative QOLIE-89 score was 58.87 (51.15 – 66.60 with 95% CI). Post operative change in QOLIE-89 was 11.04 (-0.20 – 22.27 with 95% CI). Individual studies show that better preoperative quality of life is linked to not having mood disorders before surgery, better cognitive function pre-surgery, fewer prior attempts at antiseizure medications, and higher levels of conscientiousness and openness. Additionally, being employed before and after surgery and not taking antidepressants post-surgery are associated with improved outcomes. Conclusion : This study indicates that epilepsy surgery can significantly enhance quality of life, with specific clinicodemographic factors influencing these improvements. However, the findings are limited by considerable variability between studies and a high risk of bias. Drug resistant epilepsy Epilepsy Surgery Quality of Life Deep Brain Stimulation QOLIE Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Epilepsy, affecting over 50 million people worldwide, greatly contributes to the global burden of neurological disorders. It ranks as the fifth leading cause of disability-adjusted life years (DALYs) lost, underscoring its profound impact on global health. [ 1 ] Antiseizure medications like valproic acid and phenytoin is generally first line treatment and are very effective in minimizing the episodes of epilepsy [ 2 ]. However, one third of the population will develop the resistance towards the antiseizure medications [ 3 ]. Seizures are known to affect the quality of life (QoL), catalyses into disability, causing mortality and morbidity throughout life [ 4 – 7 ]. On comparing the factor of years lived with disability (YLDs) along with other chronic neurological diseases like Parkinson, multiple sclerosis and motor neuron disease, epilepsy has more YLDs [ 8 , 9 ]. In any intervention, or clinical trials, disability caused or QoL is very important factors to be assed. Thus, it becomes very important to assess the interventions or clinical trials for its QoL, as it may help in retrospection of management pathways and patient care, and finally leading to favorable outcomes for patients and their health care. Various surgical interventions like Deep Brain Stimulation, Resective Epilepsy Surgery, Various stimulation neurosurgical procedures may be considered for the patients having drug resistant epilepsies [ 10 ]. This various surgical intervention gives the 50–70% chance of achieving of freedom from epilepsy in complying patients [ 11 ]. Some serious patients, various other palliative intracranial procedures like callosotomy may be done, with the intention of reduction of frequency. Although, it gives a very less probability towards the success of the surgery including the complete remission of the seizure or the recurrence episodes of the seizures post-surgery and improvement in QoL. Thus, it is very important to systematically study the various clinical trials and studies, to give the analysis of extent of the improved in QoL. In our search, we could possibly find one meta-analysis published meeting our exclusion and inclusion criteria, but they analysed a very limited amout of studies and from a very limited time period, which also marks our meta-analysis a perfect one. Thus, it is very important to include most of the studies from a broad time period and also include most of the matching studies. Also, in this meta-analysis we also hypothesize that “QoL increases after epilepsy surgery” Materials and Methods Search Strategy: We performed a thorough search of the mesh terms “Epilepsy Surgery” and “Quality of life” (Brief search report is available in Supplementary Material-1) in various medical clinical trial databases, various medical libraries and Pubmed till 2024. Thus, on search a deep analysis was done on the search results focusing on our inclusion and exclusion criteria. The analysis resulted in selection of 31 studies, out of which they were divided into categories based on the type of QoL questionnaire was used and were later analyzed. The search strategy is explained in Fig. 1. Inclusion and Exclusion Criteria In the metanalysis, we have included studies that focused on evaluation of QoL of patients undergoing surgical interventions. Studies having the patients having the diagnosis of epilepsy. Studies occurring between 2004–2024. We primarily focused on studies which used the standard QoL questionnaire and gave the validated data in various metrics possible to calculate the mean or change in mean before and after the epilepsy surgery. The main subjects of the study should be the adults more than 18 years having drug resistant epilepsy or have undergone the epilepsy surgery. The main exclusion criteria were studies reporting children as the subjects of their trials. Studies published in language other than English. Studies having multiple versions the latest versions were selected. Registration Details The review has been verified and was conducted according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) guidelines, and registered in PROSPERO with the number CRD42024569649 [ 12 , 13 ]. Study selection and risk of bias All the researchers did the screening on the title and abstract of the various studies and was discussed thoroughly to reach to the conclusion of adding or removing the studies. The final decided studies were screened for full texts, two studies full text could not be found, hence we used the data available in the study by Shakhatreh et. Al. [ 14 ]. The final data was extracted from each and every study in the excel sheet in the form of the table [Table 1]. The Risk of bias was checked in the ROBINS-I (Risk of Bias in Non-randomized studies of interventions (ROBINS-I) and ROB2 (Revised Cochrane Risk-of-Bias for Randomized Trials (RoB2) for randomized controlled trials (RCTs) [ 15 , 16 ]. Data Extraction and Analysis The extracted data was divided into various factors like Author, Year of publication, Country, Frequency of seizures / month (some were directly given in numbers, some were given in mean), QoL questionnaire used, Pre-surgery or Pre-operation QoL in mean and Post Surgery QoL in mean (Table 1). All the data was extracted from the full text of the papers that were selected for the study, except the two studies, Thaveepoksom-boon et. Al 2016 [ 17 ] and Togtokhjargal 2016 [ 18 ], the data was directly used from the meta-analysis of Shakhatreh et. Al. [ 14 ]. If any supplementary data was required, we contacted the relevant author for the supplementary data or from the supplementary data section of each article from their journal website. The analysis of the data was done through the JASP (V.0.18.3), a statistical software made by University of Amsterdam. For the hypothesis “Quality of life will increase after epilepsy surgery”, paired t-test was done to check the hypothesis, where the value of was set to p < 0.05 at 95% CI. Classical metanalysis was performed with the random effects with sidik-jonkman method, along with the forest plot and funnel plot for analysis of the bias. For the whole meta-analysis value of p < 0.05 at 95% CI was set. Types of Epilepsy surgeries Patients having drug resistant epilepsy having localizable epileptogenic zone and does not affect major brain areas. Palliative surgeries may be offered to patients having multifocal epilepsy, epilepsy having epileptogenic zone and focusing one the major brain areas or having no distinguishable epileptogenic focus. We included all the major various types of the surgeries or neurosurgical procedures available, like radiofrequency thermocoagulation, laser interstitial thermal therapy, disconnection, resective intracranial surgeries, stereotactic surgeries, deep brain stimulation, vagus nerve stimulation and various other nerve stimulation. Accordingly, resective epilepsy surgeries have been divided into two groups, resections or mesial temporal structures along with anterior temporal neocortex like anterior temporal lobectomy and amygdalohippocampectomy, and selective amygdalohippocampectomy. Various other cortical resections like corticectomy, focal cortical resection, lateral temporal resection, and extratemporal resection. The outcomes of the surgery are relatively differed between various studies. Some studies reported frequency of the seizures/month, some studies reported in overall improvement in QoL, whereas others used Engels Classification [ 19 ]. In Engles classification, the seizures outcomes are divided into four categories, the first-class states that patient is free of the disabling seizure and fourth class states that there is no improvement. Thus, it is worth mentioning that change in QoL and post operative seizure outcome is recorded as favourable or unfavourable based on the ease of the physicians. Following, all the favourable outcomes were recorded in engel class I, and depending on the degree of severity, unfavourable outcomes were placed in engel II-IV classification. There are two kinds of health related QoL which can be useful to measure the various health status and do the overall assessment of the patient. These two kinds are generic and disease specific questionnaires like epilepsy QoL questionnaire [ 19 ]. The generic questionaires include short form focusing on 36 various factors (SF-36), 8-item short form (SF-8), World health organization quality of life (WHOQoL), and EuroQoL which is a five-factor based scale, which provide an overall assessment of the health status. One of the major drawbacks of using generic questionnaires is they does not focus on the specific disease or don’t evaluate the factors affecting the epilepsy or impact of the epilepsy towards QoL. Thus,epilepsy specific questionaires are Quality of Life in epilsy versions (QOLIE), this versions predominantly used are QOLIE-89, QOLIE-31,QOLIE-10 and Epilepsy surgery inventory (ESI-55) [ 20 – 22 ]. This QoL questionaires mainly focus on multiple factors evaluating anti-seizure medicines effects and side effects, impact of patient’s cognition, ability to work, socialize and cope-up with society along with seizure episodes. The QOLIE-31 is the abridged version of QOLIE-89, where the QoL is calculated using the mean of various factors, the scale of the questionnaire is 0-100, where 0 is worse and 100 is best QoL. The QOLIE-10 is the 10-factor measuring scale questionnaire, where the scale is 0-100, where 0 being best QoL and 100 is worst QoL. Metanalysis: Metanalysis was performed for the selected studies, having same questionnaires, since three major questionnaires were mostly used in our study (QOLIE-89, QOLIE-10, QOLIE-31). Thus, having same QoL questionnaire, they were taken up for random-effects with sidik-jonkman metanalysis. In this metanalysis, we compared the QoL mean scores before and after the epilepsy surgery. The Standard deviation was taken from the studies, or studies which didn’t have SD, based on the supplementary data it was calculated. The analysis of the data was done through the JASP (V.0.18.3), a statistical software made by University of Amsterdam. Heterogeneity was measured using τ 2 to check the SD in correlation, I 2 described the percentage of variability in the same effect size and heterogenicity. Value of p < 0.05 was obtained via paired t-test, to check on the hypothesis. Based on the studies that we studied, any change in QoL mean was considered to be the change, thus calculating the relative change in the QoL. Some studies having the very small number of subjects, a proper standard mean was calculated, and was added into the study. In some studies, there were two arms, one arm mainly surgical and other arm medical, so, we used surgical arm to evaluate. To visualize the analysis, Forest plotting was done in pre-surgical QoL mean, like wise Post operative QoL mean and overall change in QoL mean in QOLIE-89, QOLIE-31 and QOLIE-10. Also to visualize the presence of bias in the study, funnel plot was done in the same process. Results The literature search showed a total of 1336 studies were available after the initial search out of which 1259 were excluded. Once the abstract screening was done 77 studies were selected, going through the full text, 43 remained. We applied the language filter and also age range of the patients (19–44 years), yielded in 31 studies. Figure 1, explains the search strategy and result outcome through PRISMA flow diagram. In Table 1, major demographic points have been listed according to the 31 studies. 24 studies were done in high-income countries, where 11 studies were from USA [ 25 , 27 , 31 , 32 , 33 , 38 , 40 , 43 , 46 , 49 ], China [ 30 , 44 ], Czech Republic [ 18 ], Spain [ 47 , 50 ], Taiwan [ 39 ], Canada [ 28 , 34 , 36 ], France [ 23 ], Australia [ 26 , 51 ] and Germany [ 37 ]. Other studies were conducted in middle income countries Brazil 2 studies [ 29 , 48 ], India 1 study [ 35 ], South Africa [ 41 ], Thailand [ 17 ], Turkey [ 24 ], and Iran [ 45 ]. A multi country study was conducted which had patients from India, UK and USA [ 42 ]. In 31 studies a total of 2420 patients having drug resistant epilepsy were taken up for the surgery (Table 1). With minimum frequency per month ranging from 1 to 108, some values were also reported in mean. 29 studies used ( n = 29/31, 93.5) used epilepsy-specific health related questionnaires. Four studies used QOLIE-10 ( n = 4/31, 12.9), Eleven studies used QOLIE-31 ( n = 11/31, 35.4), Seven studies used QOLIE-89 (n = 7/31, 22.5), One study used QOLIE-36-P ( n = 1/31, 3.2), Two studies used ESI-55 ( n = 2/31, 6.45). Some studies used the generic health-related questionnaire like WHOQOL-BREF ( n = 2/31, 6.45) and SF-8 (n = 1/31, 3.2). Other various forms of questionnaire that were used were CDER (n = 1/31, 3.2), CEP Interview (n = 1/31, 3.2), and a self-customized questionnaire inspired from QOLIE-31 (n = 1/31, 3.2). All the patients whose date have been reported underwent the epilepsy surgery or interventions. The type of surgery was not mentioned in one study, but due to its clinical significance we kept it included (n = 1/31, 3.2; 16/2420, 0.66). Gamma knife surgery was performed in two surgeries ( 30/2420, 1.23%), anterior temporal lobectomy was performed in five studies (280/2420, 11.5), Vagus nerve stimulation was performed in four studies (63/2420, 2.60), Resective Epileptic surgery was performed in one study (396/2420, 16.3%), Cortico-amygdalo-hippocampectomy was performed in one study (58/2420, 2.39%), Temporal lobe epilepsy surgery was performed in one study (80/2420, 3.30%), External Trigeminal Nerve Stimulation was performed in one study (40/2420, 1.65), Deep Brain stimulation was performed in two studies (159/2420, 6.5%). In some studies, either type of surgeries were not specified, or one or more surgeries were performed ( 1175/2490, 47.1%). All the included studies the follow up period was reported in months postoperatively. The post operative period ranged from 6 months to 78 months, with median follow up of 12 months and Interquartile range of 12–39). With insufficient data in some studies, it was very unlikely to calculate or correlate the QoL scores and which was changed significantly over the post-operative time course due to long follow-up period in some [ 38 ] and short follow-up period in some [ 32 ]. In some studies, the post-operative seizure outcome was reported in Engels classification, whereas, some studies presented in just seizure present or absent basis. Most of the patients could successfully report in reduction of the seizure episodes and showed a really good improvement in QoL. The median was 66.70 (78.60–54.00), for the postoperative seizures experienced or complete seizure freedom. Most of the studies could show that QoL improved significantly post-operatively. Absence of depression postoperatively was found in several studies, some studies also suggested that there was significant improvement in the employment status and improved social behavior. Most importantly QoL was changed at all ages and thus people’s life improved significantly. Studies could not suggest any association between the improvement in QoL and also hemispheric operative site. Some factors like sex, educational attainment and duration of epilepsy at the surgical time and also the location of epileptogenic zone, and mood personality disorders are not significant. Metanalysis QOLIE-10 Four studies were included (n = 4 / 31, 12.9%) in the QOLIE-10 metanalysis [ 31 , 35 , 46 , 49 ]. Overall preoperative QOLIE-10 score was 25.49 (19.38–31.60 with 95% CI) and overall postoperative QOLIE-10 score was 19.56 (12.95–26.16 with 95% CI). The change in the QOLIE-10 postoperative was 5.60 ( -2.79, 14.46 with 95% CI). All the scores were statistically significant as value of p < 0.001 and clinically meaningful. Although three cohort and one randomized control trial (RCT) were combined in meta-analysis, they have very less heterogenicity showing consistency in the trials (I 2 = 8.7 x 10 − 6 %). This indicates substantial changes in the post-operative QoL. The forest plot is given in Fig. 2. Metanalysis QOL-31 Eleven studies were included (n = 11/31, 35.4%) in the QOLIE-31 metanalysis [ 18 , 33 , 34 , 36 , 38 , 43 , 44 , 47 , 48 , 50 , 51 ]. Overall preoperative QOLIE-31 score was 43.89 (31.32–56.46 with 95% CI) and overall postoperative QOLIE-31 was 59.31 (45.09–73.54 with 95% CI). The change in QOLIE-31 was 12.28 (3.09–21.48 with 95% CI). All the scores were statistically significant as value of p < 0.001 and clinically meaningful. Although six cohort and five RCTs were combined in meta-analysis, they have very moderate heterogenicity showing consistency in the trials (I 2 = 35.45%). This indicates substantial changes in the post-operative QoL. The forest plot is given in Fig. 3. Metanalysis QOL-89 Seven studies were included (n = 7/31, 22.5%) in the QOLIE-89 meta-analysis [ 27 , 28 , 32 , 39 , 40 , 41 , 42 ]. Overall preoperative QOLIE-89 score was 49.26 (39.77–58.74 with 95% CI) and overall postoperative QOLIE-89 score was 58.87 (51.15–66.60 with 95% CI). Post operative change in QOLIE-89 was 11.04 (-0.20–22.27 with 95% CI). All the scores were statistically significant as value of p < 0.001 and clinically meaningful. Although two cohort and five RCTs were combined in meta-analysis, they have very less heterogenicity showing consistency in the trials (I 2 = 0.92%). This indicates substantial changes in the post-operative QoL. The forest plot is given in Fig. 4. Risk of bias assessment ROBINS-I was used as a primary tool to measure the bias in measurement of outcome. Robins I was used in total of 13 studies [ 35 , 46 , 49 , 33 , 43 , 44 , 47 , 48 , 50 , 18 , 39 , 41 ]. Mostly there was high bias in the most of the factors, but low bias was seen in the selection of patients and nature of intervention. Thus, overall bias was low to moderate, possessing potential risk in the included studies. On the other hand, robs 2 was as a primary tool to measure the bias in the RCTs. Robs 2 was used in total of 18 studies [ 17 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 34 , 37 , 38 , 40 , 42 , 45 , 51 ]. Overall bias result was low to moderate, some factors were high, potentially affecting the studies. Visual representation of ROBINS-I and Robs 2, have been given in supplementary material 1 and 2 respectively. Funnel plot for risk of bias has been plotted for QOLIE-10, QOLIE-31 and QOLIE-89 have been plotted against the forest plots in Figs. 2, 3 and 4 respectively. Discussion This metanalysis and systemic review clearly demonstrates that the surgery significantly improves the Quality-of-life functions. In addition, this study has been found to focus on the various other outcomes like the post-operative outcome, frequency of seizure pre- and post-surgery, absence of psychiatric illness, social skills, and various related treatments. This systemic review is consistent with the favorable outcomes regarding the improvement of quality of life post epileptic surgery. The findings presented in the systemic review and meta-analysis, combined with various other literature available supports the evidence that epilepsy surgery is safe and has a high efficacy rate of survival and can be considered as one of the best managements for the patients having drug-resistant epilepsy. An extremely important goal for all patients suffering from epilepsy is to minimize the seizure or maintain a freedom from seizures. Many studies showed strong association with the favorable seizure outcome after surgery [ 52 ]. The heterogenicity factor showed that there is substantial change in postoperative QoL. We saw numerous patients who improved well from preoperative DRE to a favorable postoperative seizure state. However, this proportion was seen in QOLIE-31 and not in QOLIE-10 and QOLIE-89. This might be due to bias in patient selection or sample size bias; moreover, one should note that QOLIE-89 is a strong questionnaire and has so much sensitivity. A broad discussion could be considered toward the question, "Why there is not a significant improvement in QoL in relation to the improved seizure state". First, Quality of life (QoL) may be affected by the presence of neurocognitive issues that are pre-existing and stable, not expected to improve with surgery. Neurocognitive function may even worsen postoperatively following procedures such as anterior temporal lobectomy. This decline can have a negative impact on QoL, especially when seizure control is suboptimal [ 53 ]. Early postoperative follow-up does not provide enough time for improvements in QoL with lifestyle changes like work productivity, driving, and ability to form stable relationships. Also, less common postoperative outcomes, including surgical complications and "the burden of normality," might determine the QoL early postoperative [ 54 ]. This is referring to the transition from illness chronicity to a state of wellness along with anxiety, guilt, and increased expectations and assuming responsibilities to regain normalcy. These may temporarily dampen QoL; in addition, patients may experience an identity change, often leading to a foreclosed identity; that is, relatively little exploration of other alternatives and difficulty in embracing the change in the long term [ 55 ]. As an example, a number of studies have demonstrated that attaining Engel class I (the broad "seizure freedom" category that contains multiple subcategories of different seizure states) results in a lower QoL; however, this does not occur for those who have attained the subclass Engel 1a ("completely seizure-free since surgery"). To include confounders that consist of unmet pre-surgery expectations of wanting to be "cured" and to discontinue anti-seizure medications (ASMs) and needing to change the number or dose of ASMs, and their side effects [ 56 ], the QoL of the larger Engel class I decreased. In addition to disabling seizures, depression and anxiety are well-known to impact the QoL of individuals living with epilepsy. It has been reported in literature that lack of preoperative mood disorders is related to a better postoperative QoL. Besides disabling seizures, people with epilepsy widely recognize depression and anxiety as factors that influence their QoL. Patients without preoperative mood disorders tend to have a better QoL after surgery. An explanation for this is that patients with pre-existing psychiatric disorders may experience a temporary worsening of symptoms after surgery, which in turn lowers their QoL [ 57 ]. Another study found that patients on antidepressants at the time of their postsurgical QoL evaluation reported a small decline in their overall "health perception," rating their health as somewhat worse than when they completed their preoperative assessment. On the other hand, patients who were not on antidepressants at the time of postsurgical QoL reported slight improvement in health perception in overall [ 58 ]. Moreover, links between QoL and depression are generally stronger in the postoperative period, as more significant improvements were seen in patients whose depression got better after epilepsy surgery [ 59 ]. On the other hand, another study documented postoperative improvement in QoL even in the presence of mood disorders [ 60 ]. Even when there were not enough data to reach a conclusion in meta-analysis, comorbid mood disorders are clearly part of the big picture of comorbidities in epilepsy. Their presence alone does not seem to be an influencing factor in postoperative QoL, but they most certainly are modifiable conditions and should be actively taken care of from a pre- as well as postoperative point of view. This review also finds that personality traits protect QoL; for example, it is found that conscientiousness and openness to experience protect against a reduction in QoL. Patients with those characteristics seem to evoke adaptive methods of coping, which tends to be the associated factor for improving QoL after surgery compared to having higher neuroticism. Other factors significantly related to improved postoperative QoL were better pre-surgical cognition, lower preoperative ASM testing trials, and employment for pay. All these factors are related to each other. More favorable presurgical cognitive function would suggest a higher functional reserve, in predicting better postsurgery cognition and thus improved employment prospects – all likely enhancing QoL [ 61 ]. In the contrary, in drug-resistant epilepsy (DRE) populations, "cognitive dysfunction" probably results from inadequately controlled seizures as well as ASM-related side effects, with significant deleterious impact on the QoL and work opportunities [ 62 ]. Fewer preoperative ASM trials were associated with better postoperative QoL in one of the studies in this review. This argues in favor of prompt identification and referral of eligible DRE surgical candidates to comprehensive epilepsy centers [ 63 ]. Limitations exist within this study that pertain to both the source data and the systematic review itself. The most important one is concerned with the fact that some original studies used generic health-related QoL instruments, such as WHOQOL, not specific to epilepsy patients, for example, the QOLIE-31. The use of generic instruments tends not to adequately capture the full range of epilepsy related burdens, such as "seizure worry," and they can be limited by "ceiling" or "floor" effects that limit the extent to which epilepsy related impact can be fully measured across a variety of QoL domains [ 64 ]. The second limitation was that non-English language studies were excluded. Evidence would suggest this would not have led to a systematic bias [ 65 ]. All nonrandomized clinical trials had a high risk of bias, reducing evidence quality to a low level; this factor does not allow these studies to be removed from meta-analysis. However, it may compromise the reliability of the results. Yet another limitation is that the individual studies presented substantial heterogeneity, as clearly shown by wide prediction intervals, which limit the feasibility of making accurate predictions of the outcomes in future research. This variability may be due to different time points for measuring postsurgical QoL, variations in the type of epilepsy surgery, and differences in the proportions of patients with favorable postoperative seizure outcomes [ 66 ]. We could not, however, convert other QOL instruments to QOLIE-31 and pool them into a single meta-analysis, because raw individual patient data were not available. Thirdly, publication bias remains a possibility with a tendency for studies reporting more favorable results on post-operative QoL to be published. Fourthly, heterogeneity of clinicodemographic variables and outcome measures is impeding the prospect of wider meta-analytic pooling of data from studies; Fifth, the site of epilepsy surgery was only noted in the reports of half of the cases reviewed, though over half were treated by temporal lobe resections [ 67 ]. Thus, the meta-analysis results reflect mostly the temporal lobe epilepsy cohort. In addition, the seizure outcomes have been reported at varying postoperative follow-up periods; for some studies, the follow-ups have been small (< 12 months) that perhaps do not capture long-term outcomes. The seizure outcomes and QoL changes were not consistently reported in all patients, and therefore the meta-regression will just look for trends but will not say the exact QoL change with respect to the postoperative seizure state. While it is tempting to infer that those with the greatest QoL improvements are the same subjects who have experienced the most favorable postoperative seizure outcomes, this cannot be confirmed without individual-level data [ 68 ]. Conclusion To conclude, in systemic review and meta-analysis it was found that half of all patients have improved the quality of life and experienced a significant reduction in seizure episodes. Various factors affecting QoL were studied and disabling the recurrence of seizure episodes was one the major impacting factor. As the studies included in the metanalysis are prone to have a high risk of bias, thus the findings of the metanalysis should be carefully interpreted. Thus, this meta-analysis has overcome all the limitations that other meta-analyses had and this creates the requirement of more prospective studies that target modifiable clinical risk. Future prospectives include various risk factors like mood disorders and processing it with post-operative QoL. A suggestive note can be taken is, researcher in future studies may use a very specific health related QoL instruments, rather than the traditional or generic ones, as the main instrument for measure for studies related to epilepsy. To end, patients who achieve Engel class II or have good seizure freedom post operation or those living with epilepsy. Declarations Author Contribution Harshawardhan Dhanraj Ramteke - Prepared the manuscript and Extarcted DataIvin Thomas Jolly - Guided the topic and also helped in data extractionSakshi Bhatia - Made the figuresManish Juneja - Guided the topic and meta-analysis performKomuroju Pooja Mrinmai - Writting, proofreading and figures assembly. 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BMC Public Health 24(1):1529. 10.1186/s12889-024-19018-3 PMID: 38844872; PMCID: PMC11157882 Chen H, Modur PN, Barot N, Van Ness PC, Agostini MA, Ding K, Gupta P, Hays R, Mickey B (2016) Predictors of Postoperative Seizure Recurrence: A Longitudinal Study of Temporal and Extratemporal Resections. Epilepsy Res Treat 2016:7982494. 10.1155/2016/7982494 Epub 2016 Mar 16. PMID: 27069682; PMCID: PMC4812270 Tables Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table.png SupplementaryMaterial.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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17:53:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4857884/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4857884/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":63126957,"identity":"2fa899c9-e29e-422c-b8c5-f4995f9e9622","added_by":"auto","created_at":"2024-08-23 12:26:11","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":162734,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4857884/v1/ddf0888076784625bd17189a.png"},{"id":63126953,"identity":"160e2e11-d3d4-4fb1-be59-77376f561528","added_by":"auto","created_at":"2024-08-23 12:26:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":805090,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4857884/v1/684049e72be023002e69542d.png"},{"id":63126956,"identity":"30cf8979-65b8-405c-be34-8566d745131f","added_by":"auto","created_at":"2024-08-23 12:26:11","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1542338,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4857884/v1/d376a1706206520a2e6ff535.png"},{"id":63126952,"identity":"a0a9c3f9-705d-4259-887b-27eddf374068","added_by":"auto","created_at":"2024-08-23 12:26:07","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1188361,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-4857884/v1/4f6ac4bc6359daa2ec897827.png"},{"id":63879635,"identity":"1aa53ae5-ef43-4fce-8929-430ff455d4af","added_by":"auto","created_at":"2024-09-03 10:02:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4279110,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4857884/v1/101a72b6-eb9f-4352-9d7b-f8a45f1ead7e.pdf"},{"id":63126955,"identity":"74d38ecd-6497-4ed1-8dc0-4254070799e8","added_by":"auto","created_at":"2024-08-23 12:26:11","extension":"png","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":653504,"visible":true,"origin":"","legend":"","description":"","filename":"Table.png","url":"https://assets-eu.researchsquare.com/files/rs-4857884/v1/1bb730bba4a5c0c908aaa7ce.png"},{"id":63126954,"identity":"3dd7be3f-aa34-40d0-b44f-16e9e0cbaf1a","added_by":"auto","created_at":"2024-08-23 12:26:10","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":769990,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-4857884/v1/91e7d56af4725b0c44e63c44.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"A glance at Quality-of-Life Post-Epilepsy Surgery: A Meta-Analysis and Systematic Review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEpilepsy, affecting over 50\u0026nbsp;million people worldwide, greatly contributes to the global burden of neurological disorders. It ranks as the fifth leading cause of disability-adjusted life years (DALYs) lost, underscoring its profound impact on global health. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Antiseizure medications like valproic acid and phenytoin is generally first line treatment and are very effective in minimizing the episodes of epilepsy [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, one third of the population will develop the resistance towards the antiseizure medications [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Seizures are known to affect the quality of life (QoL), catalyses into disability, causing mortality and morbidity throughout life [\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. On comparing the factor of years lived with disability (YLDs) along with other chronic neurological diseases like Parkinson, multiple sclerosis and motor neuron disease, epilepsy has more YLDs [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In any intervention, or clinical trials, disability caused or QoL is very important factors to be assed. Thus, it becomes very important to assess the interventions or clinical trials for its QoL, as it may help in retrospection of management pathways and patient care, and finally leading to favorable outcomes for patients and their health care.\u003c/p\u003e \u003cp\u003eVarious surgical interventions like Deep Brain Stimulation, Resective Epilepsy Surgery, Various stimulation neurosurgical procedures may be considered for the patients having drug resistant epilepsies [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This various surgical intervention gives the 50\u0026ndash;70% chance of achieving of freedom from epilepsy in complying patients [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Some serious patients, various other palliative intracranial procedures like callosotomy may be done, with the intention of reduction of frequency. Although, it gives a very less probability towards the success of the surgery including the complete remission of the seizure or the recurrence episodes of the seizures post-surgery and improvement in QoL.\u003c/p\u003e \u003cp\u003eThus, it is very important to systematically study the various clinical trials and studies, to give the analysis of extent of the improved in QoL. In our search, we could possibly find one meta-analysis published meeting our exclusion and inclusion criteria, but they analysed a very limited amout of studies and from a very limited time period, which also marks our meta-analysis a perfect one. Thus, it is very important to include most of the studies from a broad time period and also include most of the matching studies. Also, in this meta-analysis we also hypothesize that \u0026ldquo;QoL increases after epilepsy surgery\u0026rdquo;\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSearch Strategy:\u003c/h2\u003e \u003cp\u003eWe performed a thorough search of the mesh terms \u0026ldquo;Epilepsy Surgery\u0026rdquo; and \u0026ldquo;Quality of life\u0026rdquo; (Brief search report is available in Supplementary Material-1) in various medical clinical trial databases, various medical libraries and Pubmed till 2024. Thus, on search a deep analysis was done on the search results focusing on our inclusion and exclusion criteria. The analysis resulted in selection of 31 studies, out of which they were divided into categories based on the type of QoL questionnaire was used and were later analyzed. The search strategy is explained in Fig.\u0026nbsp;1.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and Exclusion Criteria\u003c/h2\u003e \u003cp\u003eIn the metanalysis, we have included studies that focused on evaluation of QoL of patients undergoing surgical interventions. Studies having the patients having the diagnosis of epilepsy. Studies occurring between 2004\u0026ndash;2024. We primarily focused on studies which used the standard QoL questionnaire and gave the validated data in various metrics possible to calculate the mean or change in mean before and after the epilepsy surgery. The main subjects of the study should be the adults more than 18 years having drug resistant epilepsy or have undergone the epilepsy surgery. The main exclusion criteria were studies reporting children as the subjects of their trials. Studies published in language other than English. Studies having multiple versions the latest versions were selected.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eRegistration Details\u003c/h2\u003e \u003cp\u003eThe review has been verified and was conducted according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) guidelines, and registered in PROSPERO with the number CRD42024569649 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStudy selection and risk of bias\u003c/h2\u003e \u003cp\u003eAll the researchers did the screening on the title and abstract of the various studies and was discussed thoroughly to reach to the conclusion of adding or removing the studies. The final decided studies were screened for full texts, two studies full text could not be found, hence we used the data available in the study by Shakhatreh et. Al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The final data was extracted from each and every study in the excel sheet in the form of the table [Table\u0026nbsp;1]. The Risk of bias was checked in the ROBINS-I (Risk of Bias in Non-randomized studies of interventions (ROBINS-I) and ROB2 (Revised Cochrane Risk-of-Bias for Randomized Trials (RoB2) for randomized controlled trials (RCTs) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Extraction and Analysis\u003c/h2\u003e \u003cp\u003eThe extracted data was divided into various factors like Author, Year of publication, Country, Frequency of seizures / month (some were directly given in numbers, some were given in mean), QoL questionnaire used, Pre-surgery or Pre-operation QoL in mean and Post Surgery QoL in mean (Table\u0026nbsp;1). All the data was extracted from the full text of the papers that were selected for the study, except the two studies, Thaveepoksom-boon et. Al 2016 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and Togtokhjargal 2016 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], the data was directly used from the meta-analysis of Shakhatreh et. Al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. If any supplementary data was required, we contacted the relevant author for the supplementary data or from the supplementary data section of each article from their journal website.\u003c/p\u003e \u003cp\u003eThe analysis of the data was done through the JASP (V.0.18.3), a statistical software made by University of Amsterdam. For the hypothesis \u0026ldquo;Quality of life will increase after epilepsy surgery\u0026rdquo;, paired t-test was done to check the hypothesis, where the value of was set to p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 at 95% CI. Classical metanalysis was performed with the random effects with sidik-jonkman method, along with the forest plot and funnel plot for analysis of the bias. For the whole meta-analysis value of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 at 95% CI was set.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTypes of Epilepsy surgeries\u003c/h2\u003e \u003cp\u003ePatients having drug resistant epilepsy having localizable epileptogenic zone and does not affect major brain areas. Palliative surgeries may be offered to patients having multifocal epilepsy, epilepsy having epileptogenic zone and focusing one the major brain areas or having no distinguishable epileptogenic focus. We included all the major various types of the surgeries or neurosurgical procedures available, like radiofrequency thermocoagulation, laser interstitial thermal therapy, disconnection, resective intracranial surgeries, stereotactic surgeries, deep brain stimulation, vagus nerve stimulation and various other nerve stimulation. Accordingly, resective epilepsy surgeries have been divided into two groups, resections or mesial temporal structures along with anterior temporal neocortex like anterior temporal lobectomy and amygdalohippocampectomy, and selective amygdalohippocampectomy. Various other cortical resections like corticectomy, focal cortical resection, lateral temporal resection, and extratemporal resection.\u003c/p\u003e \u003cp\u003eThe outcomes of the surgery are relatively differed between various studies. Some studies reported frequency of the seizures/month, some studies reported in overall improvement in QoL, whereas others used Engels Classification [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In Engles classification, the seizures outcomes are divided into four categories, the first-class states that patient is free of the disabling seizure and fourth class states that there is no improvement. Thus, it is worth mentioning that change in QoL and post operative seizure outcome is recorded as favourable or unfavourable based on the ease of the physicians. Following, all the favourable outcomes were recorded in engel class I, and depending on the degree of severity, unfavourable outcomes were placed in engel II-IV classification.\u003c/p\u003e \u003cp\u003eThere are two kinds of health related QoL which can be useful to measure the various health status and do the overall assessment of the patient. These two kinds are generic and disease specific questionnaires like epilepsy QoL questionnaire [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The generic questionaires include short form focusing on 36 various factors (SF-36), 8-item short form (SF-8), World health organization quality of life (WHOQoL), and EuroQoL which is a five-factor based scale, which provide an overall assessment of the health status. One of the major drawbacks of using generic questionnaires is they does not focus on the specific disease or don\u0026rsquo;t evaluate the factors affecting the epilepsy or impact of the epilepsy towards QoL. Thus,epilepsy specific questionaires are Quality of Life in epilsy versions (QOLIE), this versions predominantly used are QOLIE-89, QOLIE-31,QOLIE-10 and Epilepsy surgery inventory (ESI-55) [\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This QoL questionaires mainly focus on multiple factors evaluating anti-seizure medicines effects and side effects, impact of patient\u0026rsquo;s cognition, ability to work, socialize and cope-up with society along with seizure episodes. The QOLIE-31 is the abridged version of QOLIE-89, where the QoL is calculated using the mean of various factors, the scale of the questionnaire is 0-100, where 0 is worse and 100 is best QoL. The QOLIE-10 is the 10-factor measuring scale questionnaire, where the scale is 0-100, where 0 being best QoL and 100 is worst QoL.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eMetanalysis:\u003c/h2\u003e \u003cp\u003eMetanalysis was performed for the selected studies, having same questionnaires, since three major questionnaires were mostly used in our study (QOLIE-89, QOLIE-10, QOLIE-31). Thus, having same QoL questionnaire, they were taken up for random-effects with sidik-jonkman metanalysis. In this metanalysis, we compared the QoL mean scores before and after the epilepsy surgery. The Standard deviation was taken from the studies, or studies which didn\u0026rsquo;t have SD, based on the supplementary data it was calculated. The analysis of the data was done through the JASP (V.0.18.3), a statistical software made by University of Amsterdam. Heterogeneity was measured using τ\u003csup\u003e2\u003c/sup\u003e to check the SD in correlation, I\u003csup\u003e2\u003c/sup\u003e described the percentage of variability in the same effect size and heterogenicity. Value of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was obtained via paired t-test, to check on the hypothesis. Based on the studies that we studied, any change in QoL mean was considered to be the change, thus calculating the relative change in the QoL. Some studies having the very small number of subjects, a proper standard mean was calculated, and was added into the study. In some studies, there were two arms, one arm mainly surgical and other arm medical, so, we used surgical arm to evaluate. To visualize the analysis, Forest plotting was done in pre-surgical QoL mean, like wise Post operative QoL mean and overall change in QoL mean in QOLIE-89, QOLIE-31 and QOLIE-10. Also to visualize the presence of bias in the study, funnel plot was done in the same process.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe literature search showed a total of 1336 studies were available after the initial search out of which 1259 were excluded. Once the abstract screening was done 77 studies were selected, going through the full text, 43 remained. We applied the language filter and also age range of the patients (19\u0026ndash;44 years), yielded in 31 studies. Figure\u0026nbsp;1, explains the search strategy and result outcome through PRISMA flow diagram.\u003c/p\u003e \u003cp\u003eIn Table\u0026nbsp;1, major demographic points have been listed according to the 31 studies. 24 studies were done in high-income countries, where 11 studies were from USA [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], China [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], Czech Republic [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], Spain [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], Taiwan [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], Canada [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], France [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], Australia [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e] and Germany [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Other studies were conducted in middle income countries Brazil 2 studies [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], India 1 study [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], South Africa [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], Thailand [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], Turkey [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], and Iran [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. A multi country study was conducted which had patients from India, UK and USA [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. In 31 studies a total of 2420 patients having drug resistant epilepsy were taken up for the surgery (Table\u0026nbsp;1). With minimum frequency per month ranging from 1 to 108, some values were also reported in mean. 29 studies used ( n\u0026thinsp;=\u0026thinsp;29/31, 93.5) used epilepsy-specific health related questionnaires. Four studies used QOLIE-10 ( n\u0026thinsp;=\u0026thinsp;4/31, 12.9), Eleven studies used QOLIE-31 ( n\u0026thinsp;=\u0026thinsp;11/31, 35.4), Seven studies used QOLIE-89 (n\u0026thinsp;=\u0026thinsp;7/31, 22.5), One study used QOLIE-36-P ( n\u0026thinsp;=\u0026thinsp;1/31, 3.2), Two studies used ESI-55 ( n\u0026thinsp;=\u0026thinsp;2/31, 6.45). Some studies used the generic health-related questionnaire like WHOQOL-BREF ( n\u0026thinsp;=\u0026thinsp;2/31, 6.45) and SF-8 (n\u0026thinsp;=\u0026thinsp;1/31, 3.2). Other various forms of questionnaire that were used were CDER (n\u0026thinsp;=\u0026thinsp;1/31, 3.2), CEP Interview (n\u0026thinsp;=\u0026thinsp;1/31, 3.2), and a self-customized questionnaire inspired from QOLIE-31 (n\u0026thinsp;=\u0026thinsp;1/31, 3.2).\u003c/p\u003e \u003cp\u003eAll the patients whose date have been reported underwent the epilepsy surgery or interventions. The type of surgery was not mentioned in one study, but due to its clinical significance we kept it included (n\u0026thinsp;=\u0026thinsp;1/31, 3.2; 16/2420, 0.66). Gamma knife surgery was performed in two surgeries ( 30/2420, 1.23%), anterior temporal lobectomy was performed in five studies (280/2420, 11.5), Vagus nerve stimulation was performed in four studies (63/2420, 2.60), Resective Epileptic surgery was performed in one study (396/2420, 16.3%), Cortico-amygdalo-hippocampectomy was performed in one study (58/2420, 2.39%), Temporal lobe epilepsy surgery was performed in one study (80/2420, 3.30%), External Trigeminal Nerve Stimulation was performed in one study (40/2420, 1.65), Deep Brain stimulation was performed in two studies (159/2420, 6.5%). In some studies, either type of surgeries were not specified, or one or more surgeries were performed ( 1175/2490, 47.1%).\u003c/p\u003e \u003cp\u003eAll the included studies the follow up period was reported in months postoperatively. The post operative period ranged from 6 months to 78 months, with median follow up of 12 months and Interquartile range of 12\u0026ndash;39). With insufficient data in some studies, it was very unlikely to calculate or correlate the QoL scores and which was changed significantly over the post-operative time course due to long follow-up period in some [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] and short follow-up period in some [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In some studies, the post-operative seizure outcome was reported in Engels classification, whereas, some studies presented in just seizure present or absent basis. Most of the patients could successfully report in reduction of the seizure episodes and showed a really good improvement in QoL. The median was 66.70 (78.60\u0026ndash;54.00), for the postoperative seizures experienced or complete seizure freedom. Most of the studies could show that QoL improved significantly post-operatively. Absence of depression postoperatively was found in several studies, some studies also suggested that there was significant improvement in the employment status and improved social behavior. Most importantly QoL was changed at all ages and thus people\u0026rsquo;s life improved significantly. Studies could not suggest any association between the improvement in QoL and also hemispheric operative site. Some factors like sex, educational attainment and duration of epilepsy at the surgical time and also the location of epileptogenic zone, and mood personality disorders are not significant.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eMetanalysis QOLIE-10\u003c/h2\u003e \u003cp\u003eFour studies were included (n\u0026thinsp;=\u0026thinsp;4 / 31, 12.9%) in the QOLIE-10 metanalysis [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Overall preoperative QOLIE-10 score was 25.49 (19.38\u0026ndash;31.60 with 95% CI) and overall postoperative QOLIE-10 score was 19.56 (12.95\u0026ndash;26.16 with 95% CI). The change in the QOLIE-10 postoperative was 5.60 ( -2.79, 14.46 with 95% CI). All the scores were statistically significant as value of p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and clinically meaningful. Although three cohort and one randomized control trial (RCT) were combined in meta-analysis, they have very less heterogenicity showing consistency in the trials (I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;8.7 x 10\u003csup\u003e\u0026minus;\u0026thinsp;6\u003c/sup\u003e%). This indicates substantial changes in the post-operative QoL. The forest plot is given in Fig.\u0026nbsp;2.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eMetanalysis QOL-31\u003c/h2\u003e \u003cp\u003eEleven studies were included (n\u0026thinsp;=\u0026thinsp;11/31, 35.4%) in the QOLIE-31 metanalysis [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Overall preoperative QOLIE-31 score was 43.89 (31.32\u0026ndash;56.46 with 95% CI) and overall postoperative QOLIE-31 was 59.31 (45.09\u0026ndash;73.54 with 95% CI). The change in QOLIE-31 was 12.28 (3.09\u0026ndash;21.48 with 95% CI). All the scores were statistically significant as value of p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and clinically meaningful. Although six cohort and five RCTs were combined in meta-analysis, they have very moderate heterogenicity showing consistency in the trials (I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;35.45%). This indicates substantial changes in the post-operative QoL. The forest plot is given in Fig.\u0026nbsp;3.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eMetanalysis QOL-89\u003c/h2\u003e \u003cp\u003eSeven studies were included (n\u0026thinsp;=\u0026thinsp;7/31, 22.5%) in the QOLIE-89 meta-analysis [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Overall preoperative QOLIE-89 score was 49.26 (39.77\u0026ndash;58.74 with 95% CI) and overall postoperative QOLIE-89 score was 58.87 (51.15\u0026ndash;66.60 with 95% CI). Post operative change in QOLIE-89 was 11.04 (-0.20\u0026ndash;22.27 with 95% CI). All the scores were statistically significant as value of p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and clinically meaningful. Although two cohort and five RCTs were combined in meta-analysis, they have very less heterogenicity showing consistency in the trials (I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.92%). This indicates substantial changes in the post-operative QoL. The forest plot is given in Fig.\u0026nbsp;4.\u003c/p\u003e \u003cp\u003eRisk of bias assessment\u003c/p\u003e \u003cp\u003eROBINS-I was used as a primary tool to measure the bias in measurement of outcome. Robins I was used in total of 13 studies [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Mostly there was high bias in the most of the factors, but low bias was seen in the selection of patients and nature of intervention. Thus, overall bias was low to moderate, possessing potential risk in the included studies. On the other hand, robs 2 was as a primary tool to measure the bias in the RCTs. Robs 2 was used in total of 18 studies [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Overall bias result was low to moderate, some factors were high, potentially affecting the studies. Visual representation of ROBINS-I and Robs 2, have been given in supplementary material 1 and 2 respectively. Funnel plot for risk of bias has been plotted for QOLIE-10, QOLIE-31 and QOLIE-89 have been plotted against the forest plots in Figs.\u0026nbsp;2, 3 and 4 respectively.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis metanalysis and systemic review clearly demonstrates that the surgery significantly improves the Quality-of-life functions. In addition, this study has been found to focus on the various other outcomes like the post-operative outcome, frequency of seizure pre- and post-surgery, absence of psychiatric illness, social skills, and various related treatments. This systemic review is consistent with the favorable outcomes regarding the improvement of quality of life post epileptic surgery. The findings presented in the systemic review and meta-analysis, combined with various other literature available supports the evidence that epilepsy surgery is safe and has a high efficacy rate of survival and can be considered as one of the best managements for the patients having drug-resistant epilepsy. An extremely important goal for all patients suffering from epilepsy is to minimize the seizure or maintain a freedom from seizures. Many studies showed strong association with the favorable seizure outcome after surgery [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. The heterogenicity factor showed that there is substantial change in postoperative QoL. We saw numerous patients who improved well from preoperative DRE to a favorable postoperative seizure state. However, this proportion was seen in QOLIE-31 and not in QOLIE-10 and QOLIE-89. This might be due to bias in patient selection or sample size bias; moreover, one should note that QOLIE-89 is a strong questionnaire and has so much sensitivity.\u003c/p\u003e \u003cp\u003eA broad discussion could be considered toward the question, \"Why there is not a significant improvement in QoL in relation to the improved seizure state\". First, Quality of life (QoL) may be affected by the presence of neurocognitive issues that are pre-existing and stable, not expected to improve with surgery. Neurocognitive function may even worsen postoperatively following procedures such as anterior temporal lobectomy. This decline can have a negative impact on QoL, especially when seizure control is suboptimal [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Early postoperative follow-up does not provide enough time for improvements in QoL with lifestyle changes like work productivity, driving, and ability to form stable relationships. Also, less common postoperative outcomes, including surgical complications and \"the burden of normality,\" might determine the QoL early postoperative [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. This is referring to the transition from illness chronicity to a state of wellness along with anxiety, guilt, and increased expectations and assuming responsibilities to regain normalcy. These may temporarily dampen QoL; in addition, patients may experience an identity change, often leading to a foreclosed identity; that is, relatively little exploration of other alternatives and difficulty in embracing the change in the long term [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. As an example, a number of studies have demonstrated that attaining Engel class I (the broad \"seizure freedom\" category that contains multiple subcategories of different seizure states) results in a lower QoL; however, this does not occur for those who have attained the subclass Engel 1a (\"completely seizure-free since surgery\"). To include confounders that consist of unmet pre-surgery expectations of wanting to be \"cured\" and to discontinue anti-seizure medications (ASMs) and needing to change the number or dose of ASMs, and their side effects [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e], the QoL of the larger Engel class I decreased. In addition to disabling seizures, depression and anxiety are well-known to impact the QoL of individuals living with epilepsy. It has been reported in literature that lack of preoperative mood disorders is related to a better postoperative QoL. Besides disabling seizures, people with epilepsy widely recognize depression and anxiety as factors that influence their QoL. Patients without preoperative mood disorders tend to have a better QoL after surgery. An explanation for this is that patients with pre-existing psychiatric disorders may experience a temporary worsening of symptoms after surgery, which in turn lowers their QoL [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Another study found that patients on antidepressants at the time of their postsurgical QoL evaluation reported a small decline in their overall \"health perception,\" rating their health as somewhat worse than when they completed their preoperative assessment. On the other hand, patients who were not on antidepressants at the time of postsurgical QoL reported slight improvement in health perception in overall [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. Moreover, links between QoL and depression are generally stronger in the postoperative period, as more significant improvements were seen in patients whose depression got better after epilepsy surgery [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. On the other hand, another study documented postoperative improvement in QoL even in the presence of mood disorders [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Even when there were not enough data to reach a conclusion in meta-analysis, comorbid mood disorders are clearly part of the big picture of comorbidities in epilepsy. Their presence alone does not seem to be an influencing factor in postoperative QoL, but they most certainly are modifiable conditions and should be actively taken care of from a pre- as well as postoperative point of view. This review also finds that personality traits protect QoL; for example, it is found that conscientiousness and openness to experience protect against a reduction in QoL. Patients with those characteristics seem to evoke adaptive methods of coping, which tends to be the associated factor for improving QoL after surgery compared to having higher neuroticism. Other factors significantly related to improved postoperative QoL were better pre-surgical cognition, lower preoperative ASM testing trials, and employment for pay. All these factors are related to each other. More favorable presurgical cognitive function would suggest a higher functional reserve, in predicting better postsurgery cognition and thus improved employment prospects \u0026ndash; all likely enhancing QoL [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. In the contrary, in drug-resistant epilepsy (DRE) populations, \"cognitive dysfunction\" probably results from inadequately controlled seizures as well as ASM-related side effects, with significant deleterious impact on the QoL and work opportunities [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. Fewer preoperative ASM trials were associated with better postoperative QoL in one of the studies in this review. This argues in favor of prompt identification and referral of eligible DRE surgical candidates to comprehensive epilepsy centers [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. Limitations exist within this study that pertain to both the source data and the systematic review itself. The most important one is concerned with the fact that some original studies used generic health-related QoL instruments, such as WHOQOL, not specific to epilepsy patients, for example, the QOLIE-31. The use of generic instruments tends not to adequately capture the full range of epilepsy related burdens, such as \"seizure worry,\" and they can be limited by \"ceiling\" or \"floor\" effects that limit the extent to which epilepsy related impact can be fully measured across a variety of QoL domains [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. The second limitation was that non-English language studies were excluded. Evidence would suggest this would not have led to a systematic bias [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. All nonrandomized clinical trials had a high risk of bias, reducing evidence quality to a low level; this factor does not allow these studies to be removed from meta-analysis. However, it may compromise the reliability of the results. Yet another limitation is that the individual studies presented substantial heterogeneity, as clearly shown by wide prediction intervals, which limit the feasibility of making accurate predictions of the outcomes in future research. This variability may be due to different time points for measuring postsurgical QoL, variations in the type of epilepsy surgery, and differences in the proportions of patients with favorable postoperative seizure outcomes [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. We could not, however, convert other QOL instruments to QOLIE-31 and pool them into a single meta-analysis, because raw individual patient data were not available. Thirdly, publication bias remains a possibility with a tendency for studies reporting more favorable results on post-operative QoL to be published. Fourthly, heterogeneity of clinicodemographic variables and outcome measures is impeding the prospect of wider meta-analytic pooling of data from studies; Fifth, the site of epilepsy surgery was only noted in the reports of half of the cases reviewed, though over half were treated by temporal lobe resections [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. Thus, the meta-analysis results reflect mostly the temporal lobe epilepsy cohort. In addition, the seizure outcomes have been reported at varying postoperative follow-up periods; for some studies, the follow-ups have been small (\u0026lt;\u0026thinsp;12 months) that perhaps do not capture long-term outcomes. The seizure outcomes and QoL changes were not consistently reported in all patients, and therefore the meta-regression will just look for trends but will not say the exact QoL change with respect to the postoperative seizure state. While it is tempting to infer that those with the greatest QoL improvements are the same subjects who have experienced the most favorable postoperative seizure outcomes, this cannot be confirmed without individual-level data [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTo conclude, in systemic review and meta-analysis it was found that half of all patients have improved the quality of life and experienced a significant reduction in seizure episodes. Various factors affecting QoL were studied and disabling the recurrence of seizure episodes was one the major impacting factor. As the studies included in the metanalysis are prone to have a high risk of bias, thus the findings of the metanalysis should be carefully interpreted. Thus, this meta-analysis has overcome all the limitations that other meta-analyses had and this creates the requirement of more prospective studies that target modifiable clinical risk. Future prospectives include various risk factors like mood disorders and processing it with post-operative QoL. A suggestive note can be taken is, researcher in future studies may use a very specific health related QoL instruments, rather than the traditional or generic ones, as the main instrument for measure for studies related to epilepsy. To end, patients who achieve Engel class II or have good seizure freedom post operation or those living with epilepsy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eHarshawardhan Dhanraj Ramteke - Prepared the manuscript and Extarcted DataIvin Thomas Jolly - Guided the topic and also helped in data extractionSakshi Bhatia - Made the figuresManish Juneja - Guided the topic and meta-analysis performKomuroju Pooja Mrinmai - Writting, proofreading and figures assembly.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003ehttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024569649\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSafeer VSM, Sahu JK, Madaan P, Winter SF, Baker GA, Bansal D (2024) Estimating the active and lifetime prevalence and incidence of epilepsy in Asian Countries: A systematic review and meta-analysis. 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PMID: 27069682; PMCID: PMC4812270\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Drug resistant epilepsy, Epilepsy Surgery, Quality of Life, Deep Brain Stimulation, QOLIE","lastPublishedDoi":"10.21203/rs.3.rs-4857884/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4857884/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eOne of the most important outcomes of the epilepsy management is seizure freedom and improved quality of life (QoL). This meta-analysis and systemic review aim to compute the changes in QoL in the adults having drug resistant epilepsy further undergoing surgery. Thus, this also helps in exploring the various factors affecting the QoL with the changes in QoL.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eWe analyzed the data using the various clinical trial medical databases and PubMed. Most of the studies had the pre- and post-operative seizure outcomes and the mean changes in pre- and post-operative QoL scores were analyzed. The literature search showed a total of 1336 studies were available after the initial search out of which 1259 were excluded. Once the abstract screening was done 77 studies were selected, going through the full text, 43 remained. We applied the language filter and also age range of the patients (19-44 years), yielded in 31 studies. \u003cstrong\u003eResults\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eFour studies were included (n = 4 / 31, 12.9%) in the QOLIE-10 metanalysis. Overall preoperative QOLIE-10 score was 25.49 (19.38 – 31.60 with 95% CI) and overall postoperative QOLIE-10 score was 19.56 (12.95 – 26.16 with 95% CI). Eleven studies were included (n=11/31, 35.4%) in the QOLIE-31 metanalysis. Overall preoperative QOLIE-31 score was 43.89 (31.32 – 56.46 with 95% CI) and overall postoperative QOLIE-31 was 59.31 (45.09 – 73.54 with 95% CI). The change in QOLIE-31 was 12.28 (3.09 – 21.48 with 95% CI). Seven studies were included (n = 7/31, 22.5%) in the QOLIE-89 meta-analysis. Overall preoperative QOLIE-89 score was 49.26 (39.77 – 58.74 with 95% CI) and overall postoperative QOLIE-89 score was 58.87 (51.15 – 66.60 with 95% CI). Post operative change in QOLIE-89 was 11.04 (-0.20 – 22.27 with 95% CI). Individual studies show that better preoperative quality of life is linked to not having mood disorders before surgery, better cognitive function pre-surgery, fewer prior attempts at antiseizure medications, and higher levels of conscientiousness and openness. Additionally, being employed before and after surgery and not taking antidepressants post-surgery are associated with improved outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study indicates that epilepsy surgery can significantly enhance quality of life, with specific clinicodemographic factors influencing these improvements. However, the findings are limited by considerable variability between studies and a high risk of bias.\u003c/p\u003e","manuscriptTitle":"A glance at Quality-of-Life Post-Epilepsy Surgery: A Meta-Analysis and Systematic Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-23 12:25:56","doi":"10.21203/rs.3.rs-4857884/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6afea3e5-bc4f-40e1-bd28-f0c81d3808f5","owner":[],"postedDate":"August 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-03T09:53:46+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-23 12:25:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4857884","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4857884","identity":"rs-4857884","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}