Real-life decision making in use of hypertrophy techniques: agreement in clinical choices based on diagnosis

Liver hypertrophy techniques have expanded resectability for major hepatectomy, yet real-world indication remains heterogeneous. We assessed agreement among hepatobiliary surgeons regarding indications and hypertrophy strategies choice across standardized clinical scenarios and explored discrepancies by tumor diagnosis and center experience.

We conducted a multicenter, cross-sectional, internet-based survey via the IGROWtoH network. The questionnaire included thirteen imaging-based cases with nine questions on multidisciplinary setting, indication, rescue strategies, and surgical approach. Modal response, pairwise agreement, and free-marginal multirater kappa (κ_free) were evaluated, with stratification by center volume (>50 vs ≤ 50 resections/year).

Seventy-four surgeons participated, mostly working in high-volume centers. Agreement was near-unanimous for multidisciplinary discussion (>90%), but low for key domains as the choice of hypertrophy-inducing procedure (κ_free = 0.16) and the preferred surgical approach (open vs minimally invasive). Discrepancies varied by diagnosis: agreement on hypertrophy need and right hemiliver management was lowest in colorectal liver metastases (pairwise agreement ∼50%), whereas cholangiocarcinoma cases showed higher concordance (60-75%). High-volume centers demonstrated greater consistency, though procedure selection remained variable.

Real-life decision-making on liver hypertrophy strategies is highly variable, influenced by diagnosis and partially mitigated by center volume. These findings support the need for standardized preoperative assessment, multidisciplinary-driven pathways, and prospective registry-based evidence.