The Evolving Role of Living Donor Liver Transplantation in the Management of Colorectal Liver Metastases

Surgical resection remains the cornerstone of curative-intent therapy for colorectal liver metastases (CRLM). However, a substantial proportion of patients present with technically unresectable diseases or develop intrahepatic recurrence, despite optimal multimodal treatment. In this setting, liver transplantation (LT) has emerged as a potential strategy for durable, cancer-free survival in selected patients. Early experience with deceased donor liver transplantation (DDLT) for CRLM showed encouraging outcomes, but broader implementation has been constrained by ethical concerns and logistical barriers related to organ scarcity. Living donor liver transplantation (LDLT) offers a fundamentally different paradigm, potentially mitigating these limitations while introducing distinct technical, ethical, and logistical considerations. In this manuscript, we delineate the technical and logistic differences between DDLT and LDLT in the context of CRLM and highlight advantages unique to LDLT-based strategies. We contrast historical data with emerging contemporary evidence, with particular emphasis on LDLT outcomes. We critically examine evolving patient selection frameworks, incorporating molecular profiling and circulating tumor DNA-based liquid biopsy. In addition, we report our institutional experience with left lobe LDLT for CRLM in a patient who remains disease-free 30 months after transplantation. We conclude with a comprehensive appraisal of the current LDLT literature in CRLM and propose directions for future research.