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Systematic Review and Meta-Analysis of Resection Sequence in Synchronous Colorectal Liver Metastasis: Primary vs.
Sofoklis Mavrantonis1, Omar Abou El-Wafa2, Sascha Vaghiri2
1General Surgery Service, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK.
Journal of Surgical Oncology
|June 15, 2026
Summary
The colorectal-first (CRf) approach shows improved disease-free survival (DFS) compared to the liver-first (Lf) strategy for synchronous colorectal liver metastases. While one-year overall survival (OS) is higher in CRf, long-term survival and other outcomes showed no significant differences.
Area of Science:
- Oncology
- Surgical Oncology
- Gastroenterology
Background:
- Synchronous colorectal liver metastases present a complex surgical challenge.
- Optimizing the sequence of resection (colorectal first vs. liver first) is crucial for patient outcomes.
Purpose of the Study:
- To compare overall survival (OS), disease-free survival (DFS), morbidity, and mortality between colorectal-first (CRf) and liver-first (Lf) resection strategies.
- To identify the optimal surgical sequence for patients with synchronous colorectal liver metastases.
Main Methods:
- Systematic review and meta-analysis of 15 studies including 8611 patients (2010-2025).
- Searches conducted in PubMed, Cochrane Central, and Google Scholar following PRISMA guidelines.
- Statistical analysis included 95% confidence intervals for OS and odds ratios for secondary outcomes, with heterogeneity assessed using Cochrane Q test.
Main Results:
- Colorectal-first (CRf) demonstrated a statistically significant survival benefit in 1-year OS compared to liver-first (Lf).
- CRf group showed significantly improved 1-, 3-, and 5-year DFS rates versus the Lf group.
- No significant differences were observed in major morbidity, 90-day mortality, or failure to proceed to the second resection stage.
Conclusions:
- Disease-free survival (DFS) is significantly increased with the CRf strategy compared to Lf.
- While 1-year OS favored CRf, this may be influenced by study heterogeneity and perioperative factors.
- This meta-analysis highlights DFS benefits of CRf, but findings should be interpreted cautiously due to the absence of randomized controlled trials.
