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

BACKGROUND: 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. METHODS: 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). RESULTS: 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. CONCLUSIONS: 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.