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• W2802671410 abstract "To the Editor: Liu et al1 are to be congratulated for describing the largest published series of bilateral anterior capsulotomy in anorexia nervosa (AN). Their work confirms that magnetic resonance imaging-guided bilateral anterior capsulotomy represents a possible treatment for refractory AN, a life-threatening condition that can be resistant to usual care. However, certain points should be clarified. These points are: (1) the definition of inclusion criteria, (2) the definition of primary endpoint, (3) the study design, (4) the target definition and the use of anterior capsulotomy, and (5) the long-term follow-up and evaluation of the included patients. The inclusion of psychiatric patients in trials assessing invasive treatment is challenging. In the specific condition of AN, the inclusion criteria pitfalls are difficult to overcome. There are no clear and strict criteria defining “refractory” AN. In addition, the minimum duration of disease before considering resistance is not clearly defined. Lastly, the definition of resistance differs between previously published studies on invasive treatment for AN.6,7 There is therefore a need for consensual operational criteria to identify treatment-refractory patients with AN.8 Another difficulty in AN studies is the absence of a clear definition of remission. Weight restoration is a crucial component of AN recovery, but is only 1 component of it, probably consisting in a first clinical step. Mood disorders and anxiety are also involved in AN relapse. This, in turn, may explain why targeted brain areas known to regulate emotion, such as the subcallosal cingulate gyrus, represent an option chosen by many authors.6 The long-term follow-up of patients included in such experimental procedure represents the gold-standard to assess the safety and efficacy in practical conditions. Complete pre- and postoperative investigations, eventually including positron emission tomography scan, could help to determine the remission of AN patients.6 The design of the present study was a case-series, a typical design for studies on this topic. It is well-known that enrollment in a study leads to different care than “regular” patients.9 A case control study, enrolling patients in the same treatment regimen except for the invasive procedure, could partly overcome this bias. Definition of the target in AN represents another challenge for the multidisciplinary team in charge of patients. Anterior capsulotomy was performed for the first time by Jean Talairach at Sainte-Anne Hospital in 1949 and had proved to be effective in obsessive compulsive disorder.10 Nevertheless, it is an irreversible procedure and the rate of complication in this study was relatively high (17.6%). More comprehensive neuropsychological tests for their patients are recommended, as well as a long-term evaluation of complications “memory loss” and “lethargy.” The cognitive evaluation consisted in Mini Mental State Examination. Mini Mental State Examination was designed for dementia and do not detect mild cognitive impairment,20 as acknowledge by the authors. Somatic complications of undernutrition and suicide make AN the psychiatric disorder with the highest mortality rate.2 Efficient treatment is still lacking as 20% of patients experience recurrent patterns of remissions and relapses, chronicity being also a problem.3 Invasive procedures for psychiatric patients should remain exceptional but have to be considered. Multicentric studies enrolling a large number of patients, with strict inclusion criteria and clear ethic rules, could help to define which patients with AN may benefit of deep brain stimulation,4,5 but such studies are still pending. Deep brain stimulation is a minimally invasive, and almost completely reversible, surgical procedure. Stimulation parameters can be adapted to each patient making deep brain stimulation an adjustable therapy.11 However, in these severely malnourished population of patients, implantation of deep brain stimulation devices is at higher risk, requiring close collaboration with intensive care specialists. Sun et al7 reported promising results of deep brain stimulation of the nucleus accumbens for treatment resistant AN. This target is promising because of the role of nucleus accumbens in the reward system.12,13 Recent neurocognitive and neuroimaging studies or animal models incriminate reward system in development and maintenance of AN.14-19 Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article." @default.
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• W2802671410 date "2018-04-18" @default.
• W2802671410 modified "2023-10-17" @default.
• W2802671410 title "Letter: Long-Term Follow-up Study of MRI-Guided Bilateral Anterior Capsulotomy in Patients With Refractory Anorexia Nervosa" @default.
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• W2802671410 doi "https://doi.org/10.1093/neuros/nyy123" @default.
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