Radical surgery is the gold standard in the treatment of synchronous colorectal liver metastases. It prolongs patient survival and is potentially curative in some cases. Simultaneous colorectal and liver resection can be safely performed if minor hepatectomy is planned, whereas for major hepatectomy the results of simultaneous resection are controversial. Neoadjuvant chemotherapy helps to better select candidates for surgery, but there is no evidence in favour of its systematic application. In selected patients, such as those with more than three metastases, neoadjuvant chemotherapy may be beneficial. In patients with unresectable synchronous liver metastases, chemotherapy is the treatment of choice. In asymptomatic patients, chemotherapy should be immediately started with the primary tumor still in place. The risk of occlusion is low, especially if modern chemotherapy regimens are administered. In case of symptomatic primary tumor, chemotherapy must be preceded by symptoms treatment. Endoscopic metallic stents may represent an effective alternative to surgery in the treatment of occlusive symptoms. A multidisciplinary approach is mandatory in patients with primary colorectal cancer and synchronous liver metastases in order to define the optimal treatment strategy, which must be tailored to every single patient.
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