Metabolic dysfunction–associated steatotic liver disease (MASLD) is increasing globally and affects a growing proportion of patients with colorectal cancer (CRC). Beyond shared risk factors such as obesity and metabolic syndrome, MASLD appears to actively shape a pro-metastatic hepatic microenvironment, with important implications for colorectal liver metastases (CRLM), particularly in the surgical setting.

This narrative review synthesizes epidemiologic, mechanistic, imaging, and clinical data on the interplay between MASLD and CRC/CRLM, with a focus on hepatobiliary surgical relevance.

MASLD is associated with increased risks of colorectal adenomas and CRC. Key mechanisms contributing to a pro-metastatic hepatic niche include insulin resistance, adipokine dysregulation, gut–liver endotoxemia with TLR4/NF-κB activation, chronic inflammation, fibrosis and extracellular matrix remodeling, and oxidative stress. Clinically, steatohepatitis and fibrosis are linked to higher perioperative morbidity, postoperative liver failure, and worse short-term outcomes after hepatectomy, whereas simple steatosis shows heterogeneous associations with survival. Chemotherapy-associated liver injury frequently overlaps with MASLD. In addition, MASLD reduces CT sensitivity for small hepatic lesions, while abbreviated non-contrast MRI improves surveillance.

MASLD is a clinically relevant modifier of CRLM biology and surgical risk. Early identification, metabolic optimization, MASLD-informed perioperative planning, and MRI-based surveillance should be prioritized. Prospective phenotype-resolved studies are needed to refine risk stratification.