Survey of the attitudes of hepatopancreatobiliary surgeons in northern Europe to resection of choledochal cysts in asymptomatic Western adults

Background Todani type 1 and 4 choledochal cysts are associated with a risk of developing cholangiocarcinoma. Resection is usually recommended, but data for asymptomatic Western adults are sparse. The aim of this study was to investigate diagnostic interpretation and attitudes towards resection of bile ducts for choledochal cysts in this subgroup of patients across northern European centres. Methods Thirty hepatopancreatobiliary centres were provided with magnetic resonance cholangiopancreatograms and asked to discuss the management of six cases: asymptomatic non-Asian women, aged 30 or 60 years, with variable common bile duct (CBD) dilatations and different risk factors in the setting of a multidisciplinary team (MDT). The Fleiss kappa value was calculated to estimate overall inter-rater agreement. Results For all case scenarios combined, 83 center dot 3 and 86 center dot 7 per cent recommended resection for a CBD of 20 and 26 mm respectively, compared with 19 center dot 4 per cent for a CBD of 13 mm (P < 0 center dot 001). For patients aged 30 and 60 years, resection was recommended in 68 center dot 5 and 57 center dot 8 per cent respectively (P = 0 center dot 010). There was a trend towards recommending resection in the presence of a common channel, most pronounced in the 60-year-old patient. High amylase levels in the CBD aspirate led to recommendations to resect, but only for the 13-mm CBD dilatation. There were no differences related to centre size or region. MDT discussion was associated with recommendations to resect. Inter-rater agreement was 73 center dot 3 per cent (kappa = 0 center dot 43, 95 per cent c.i. 0 center dot 38 to 0 center dot 48). Conclusion The inter-rater agreement to resect was intermediate, and the recommendation was dependent mainly on the diameter of the CBD dilatation.