Surgery for bilobar colorectal liver metastasis: from staged resections to liver transplantation. A systematic review of the outcomes of the different strategies.

BACKGROUND

The management of multiple bilobar colorectal liver metastases (BCRLMs) continues to evolve, and the optimal strategy remains controversial. This was a systematic review that analyzed the outcomes of different surgical strategies for BCRLMs.

METHODS

A systematic literature search that included MEDLINE, Embase, and the Cochrane Library was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines and registered in the International Prospective Register of Systematic Reviews. This review included studies reporting surgery for BCRLMs (January 2010 to August 2025) according to 5 strategies: two-stage hepatectomy (TSH), associated liver partitioning and portal vein ligation for staged hepatectomy (ALPPS), parenchymal-sparing hepatectomy (PSH), one-stage hepatectomy with ablation (OSHA), and liver transplantation (LT).

RESULTS

A total of 34 studies that reported the outcomes of 2756 patients were included (TSH [20 studies; 1813 patients], ALPPS [11 studies; 272 patients], PSH [2 studies; 142 patients], OSHA [3 studies; 279 patients], and LT [8 studies; 250 patients]). BCRLMs treatment has mostly synchronous presentation (82.3%). Patients who underwent ALPSS showed a higher rate of extrahepatic disease (EHD), whereas those who underwent LT had no EHD. Patients who underwent LT had the highest rate of preoperative chemotherapy (100%) and a higher median number of lesions (n = 11). However, the patients who underwent LT were less likely to be females. Mutational status (KRAS or BRAF) was reported in <40% of patients. The overall 90-day postoperative mortality rate was 4.0%. However, patients who underwent LT had a lower 90-day postoperative mortality rate (0.8%). The overall R1 resection rate was 18.9%. However, patients who underwent PSH had a higher R1 resection rate (55.7%). The median overall survival (OS) and disease-free survival (DFS) estimates were similar across strategies (TSH: 41 vs 15 months, respectively; ALPPS: 44 vs 11 months, respectively; PSH: 45 vs 9 months, respectively; OSHA: 47 vs 10 months, respectively; LT: 60 vs 19 months, respectively), but LT showed higher OS and DFS estimates.

CONCLUSION

The outcomes of patients with BCRLMs differed across surgical strategies that showed high variability across countries, centers, and eras. Therefore, there is a need for a common definition of BCRLMs and guidelines for managing patients, including a transplantation option.