Redefining Curative-Intent Treatment for Colorectal Liver Metastases: Surgical and Multidisciplinary Decision-Making—A Systematic Review

Background: Treatment of colorectal liver metastases (CRLM) has shifted from a surgery-centered to a multidisciplinary, biology-driven approach, and surgical decisions have become more individualized. Methods: Following PRISMA 2020, PubMed/MEDLINE was searched (January 1995–September 2026), supplemented by citation and guideline searching, for randomized trials, systematic reviews, guidelines, and large prospective or registry studies of adults with CRLM; findings were synthesized narratively by review question. Results: Of 1072 database records screened and 76 reports from other sources, 102 studies were included. Thermal ablation was non-inferior to resection for metastases ≤ 3 cm in the randomized COLLISION trial, with fewer adverse events (19% versus 46%). Parenchymal-sparing and minimally invasive hepatectomy, liver-remnant modulation (portal vein embolization, ALPPS), and repeat local treatment widened surgical eligibility, and sidedness- and genotype-guided conversion therapy increased secondary resection. Simultaneous, staged, and liver-first sequencing achieved similar survival in selected patients. Transplantation improved survival over chemotherapy alone in permanently unresectable, liver-confined disease. Certainty of evidence was lowest for surgical technique and patient selection. Conclusions: Curative-intent treatment should be planned lesion by lesion by a multidisciplinary team, combining resection and ablation according to tumor biology, anatomy, liver reserve, and patient fitness. Patient-reported outcomes and equitable access remain poorly studied.