Colorectal Gastrointestinal stromal tumor ( GIST ) is a common mesenchymal tissue-derived tumor of the digestive system, and surgery is the treatment of choice for resectable GIST. However, 40% to 90% of patients eventually experience recurrence and metastasis after resection of the primary tumor [1, 2], with the most common sites of metastasis being the liver (65%) and omentum (21%), and more than 50% of patients have simple liver metastases [1]. Statistically, GIST heterochronic liver metastases are more frequent than simultaneous ones, with a median time to occur of about 12 months; therefore, liver changes should be closely monitored within 1 year after resection of the primary tumor [3]. However, there are case reports of liver metastases occurring 11 or 17 years after resection of the primary tumor [4, 5], so it is necessary to implement long-term follow-up of GIST patients. prior to 2000, surgical resection was the only effective means of treating liver metastases from GIST, with a 5-year survival rate of about 30% after surgery; for those who could not be surgically resected, the median survival was only 18 months, and rarely survived more than 5 years [6]. With the improved understanding of the pathogenesis of GIST and the clinical application of targeted drugs such as imatinib and sunitinib, the treatment strategy for GIST liver metastases has been “revolutionized”, and imatinib alone can achieve a median survival of 48 months for GIST liver metastases [7]. Therefore, surgery in combination with targeted drugs has become the principle of GIST treatment for clinicians today, especially for progressive and advanced (recurrent metastases) GIST treatment. I. Combining targeted drugs to create R0 resection and improve survival prognosis Although imatinib has become the first-line treatment option for patients with advanced GIST, and more than 80% of patients can benefit from treatment, cases of complete remission (CR) with the help of imatinib are extremely rare, and tumor cell remnants can still be found on pathological examination even when imaging shows inactive tissue [8]. Even if imaging shows CR, once imatinib is discontinued, tumors can erupt in a short period of time. Not only that, with secondary tumor cell mutations, most patients with effective initial therapy develop imatinib resistance in about 2 years. Once resistance occurs, the majority of patients will have poor outcomes, either by increasing their imatinib dose or switching to second-line treatment with sunitinib. There is a consensus that surgery combined with imatinib reduces recurrent metastases and improves survival in patients with intermediate- and high-risk GIST; also, imatinib combined with surgery creates an opportunity for R0 resection in patients with GIST liver metastases, which in turn provides the possibility of long-term survival. Radkani et al [10] treated a case of small bowel mesenchymal tumor with concurrent large liver metastases, which was effectively reduced by preoperative imatinib and increased by portal embolization, resulting in R0 resection with no tumor recurrence at 14 months of follow-up. In a study by Xia et al [11], 39 patients with liver metastases who had undergone primary resection were randomly assigned and 19 patients enrolled in preoperative imatinib treatment + surgery + postoperative imatinib adjuvant chemotherapy had R0 resection with 1-year and 3-year survival rates of 100% and 89.5%, respectively, which was significantly different from the group receiving imatinib chemotherapy alone (1-year and 3-year survival rates of 85% and 60%, respectively), especially in the preoperative The benefit of surgery was even greater in patients with poor treatment outcome (SD+PD). For patients with advanced GIST who cannot be surgically resected at R0, tyrosine kinase inhibitors (TKI) such as imatinib and sunitinib are the main treatments, however, secondary drug resistance limits the further survival benefit of patients. It has been reported that a patient with liver metastases from GIST disappeared from the primary lesion while the metastatic lesion progressed after long-term treatment with imatinib, suggesting that drug resistance varies between lesions even in the same patient [12]. the greater the likelihood of drug resistance. Therefore, timely surgical excision of drug-resistant lesions seems to be a feasible remedy. Kikuchi et al [14] treated a patient with multiple metastatic GIST secondary to imatinib resistance, and after 1 year of sunitinib treatment, some of the lesions progressed, and because of the lack of effective third-line drugs, an enlarged left hepatectomy + peritoneal reduction was performed to remove as much of the visible tumor as possible, and sunitinib treatment was continued after surgery, and no tumor recurrence was observed at 13 months of follow-up. 15] classified patients after TKI treatment into three categories according to their efficacy: stable, locally progressive, and extensively progressive. A retrospective analysis found that patients with stable and locally progressive disease could benefit from tumor reduction surgery, with 1-year progression-free survival rates of 80% and 33%, respectively, and 1-year overall survival rates of 95% and 86% after surgery. Similar results were obtained in a study by DeMatteo [16], in which 20 patients with effective TKI therapy had a 2-year progression-free survival and an overall survival rate of 61% and 100%, respectively; 13 patients with focal resistance had a median time to disease progression of 12 months after surgery and an overall 2-year survival rate of 36%; and 7 patients with multiple progression had a median time to disease progression of 36%. The median time to disease progression after surgery was 12 months in 13 patients with focal drug resistance, and the 2-year overall survival rate was 36%; while the median time to disease progression after surgery was only 3 months in 7 patients with multi-drug resistance, and the 1-year overall survival rate was 36%. This shows that a significant proportion of patients with recurrent metastatic GIST can still benefit from tumor reduction surgery by strictly grasping the indications. Third, palliative resection of high-risk lesions reduces treatment complications Patients with GIST liver metastases mostly require long-term TKI maintenance, and complications during treatment affect the long-term benefit of patients. For those lesions with obstruction, chronic bleeding, and prone to perforation or rupture, palliative resection when the patient’s underlying condition still allows is much less risky than emergency surgery in terms of surgical and perioperative mortality.Pantaleo et al [17] presented a case of gastric mesenchymal tumor with multiple metastases to the liver and peritoneum, and despite no progression on second-line sunitinib maintenance therapy, long-term chronic hemorrhage resulted in moderate anemia. The patient subsequently underwent elective primary + partial liver metastases and palliative resection of peritoneal nodes, after which the patient recovered uneventfully and continued to receive sotane-based therapy and remained alive at 10 months of follow-up. Thus, the timely resort to surgery and reduction of acute complications in patients can lead to better long-term maintenance with TKI and thus survival benefit for patients with GIST liver metastases. Thus, although the survival of patients with GIST liver metastases has been greatly improved with the clinical application of TKI such as imatinib and sunitinib, the presence of drug resistance and secondary mutations limits their efficacy. In contrast, surgery remains the only important treatment that may provide long-term survival for both resectable GIST and patients with progressive and advanced GIST (especially liver metastases), and thus the combination of surgery and targeted drugs has ushered in a new era of GIST treatment. Also timely surgical intervention during palliative care has positive implications for improving TKI efficacy and reducing complications. The best treatment plan relies on multidisciplinary (MDT) specialists to work together to obtain the best outcome based on the patient’s specific condition.