Twenty years of frontal lobe surgery: Clinical outcomes and lessons from the frontier.

Background: Frontal lobe epilepsy (FLE) surgery often requires complex presurgical evaluations and intraoperative monitoring, which may not be readily available in resource-limited settings. We report our experience establishing FLE surgical services in Indonesia to develop strategies for a simple but reliable service in low- and middle-income countries. Methods: We included patients who underwent FLE surgery between 2003 and 2023 in Semarang, Indonesia. These patients underwent surgery with at least 12 months of follow-up. Univariate and multivariate Firth penalized logistic regression analyses were performed to identify factors associated with surgical outcome, stratified by follow-up duration. Kaplan-Meier survival analysis and log-rank tests were performed to assess time-to-seizure recurrence across subgroups. Results: 87 FLE surgeries were performed over a period of 20 years. Approximately 60% of the patients were pediatric. Most patients (63.2%) showed visible focal cortical dysplasia on imaging. At the ≥5-year follow-up group, 56.8% of the patients had Engel Class I disease, with 79.3% have favorable (productive) functional outcomes. Among factors associated with postoperative outcomes, the number of anti-seizure medicines ≥3 was a significant seizure-free predictor at ≥5-year follow-up (odds ratio 0.18, 95% confidence interval 0.04-0.87, Conclusion: Despite several limitations, this research suggests that establishing routine FLE services in countries with limited resources is feasible. To maintain a simple but reliable service, a streamlined surgery pathway should be introduced, together with strengthening national capacity and adopting cost-efficient technology.