Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada.
Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada.
Stereotact Funct Neurosurg. 2022;100(5-6):300-313. doi: 10.1159/000526000. Epub 2022 Aug 16.
Ablative lesion procedures remain as the last option in treatment of refractory depression. Contemporary ablative psychosurgeries involve producing lesions in the anterior limb of the internal capsule (bilateral anterior capsulotomy - BAC), the supragenual anterior cingulate gyrus and cingulum (bilateral anterior cingulotomy - BACING), and subgenual anterior cingulate gyrus and subcortical orbitofrontal white matter (bilateral subcaudate tractotomy - BST). A combination of BACING and BST is known as limbic leukotomy (bilateral limbic leukotomy - BLL). All procedures claim some success, but cohorts are small, depression assessment instruments differ, and inclusion and outcome criteria and follow-up duration vary. In some cohorts, more than one type of surgery was performed in several patients, further confounding interpreting the available data. Current evidence is equivocal on which surgical target works best. Method and Aim: This systematic review and meta-analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) standard on published cohorts was conducted to review and identify which is the best standalone ablative procedure for treatment-resistant depression (TRD) based on response rate (event rate) and adverse-effect profile using the Comprehensive Meta-Analysis software.
As a standalone neurosurgical procedure, we found that BAC appears to be the most effective and safest of all the ablative targets for TRD. A major limitation of this conclusion is the paucity of published case series where sample sizes are small and all are open label.
消融性损伤手术仍然是治疗难治性抑郁症的最后选择。当代的消融性精神外科手术包括在内囊前肢（双侧前囊切开术-BAC）、扣带回前上部和扣带（双侧前扣带切开术-BACING）以及扣带回前下部和皮质下眶额白质（双侧尾状核下束切开术-BST）中产生损伤。BACING 和 BST 的组合被称为边缘脑白质切开术（双侧边缘脑白质切开术-BLL）。所有手术都声称有一定的疗效，但队列规模较小，抑郁评估工具不同，纳入和结果标准以及随访时间也不同。在一些队列中，多名患者接受了不止一种类型的手术，这进一步增加了解释现有数据的难度。目前的证据表明，哪种手术靶点效果最好还存在争议。方法和目的：本研究采用系统评价和荟萃分析（PRISMA）标准，对已发表的队列进行了系统回顾和分析，旨在根据反应率（事件率）和使用综合荟萃分析软件的不良事件谱，确定哪种是治疗难治性抑郁症（TRD）的最佳独立消融性手术。结果与结论：作为一种独立的神经外科手术，我们发现 BAC 似乎是所有消融靶点中治疗 TRD 最有效和最安全的。这个结论的一个主要局限性是发表的病例系列数量较少，且所有病例均为开放标签，样本量较小。
