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

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. 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). 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. 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.