Background Resection of primary and liver lesions is the optimal management of Stage IV rectal cancer with liver metastases. For patients with extensive liver metastases, FOLFOX and FOLFIRI have improved resection rates and survival. We compared survival outcomes in patients with Stage IV rectal cancer with liver metastases undergoing staged or synchronous resection with those undergoing primary rectal resection only or no resection at all. Methods Patients with metastatic rectal cancer to liver were identified from a colorectal cancer database from 2002 to 2008. Patients received neoadjuvant chemoradiation and adjuvant FOLFOX or FOLFIRI therapy. The outcomes for patients who underwent synchronous resection, staged resection, resection of rectal tumor only, and no resection with chemotherapy only were compared. Statistical analysis was determined by ANOVA. Survival was determined using the Kaplan-Meier method. Results Seventy-four patients were identified: 30 synchronous resections, 13 staged resections, 22 primary resection only, and 9 no resection. Median follow-up was 23 months (range = 4-58 months). Sixty-five percent of patients underwent liver resection with 26% rendered eligible for resection after adjuvant therapy. Those who underwent primary resection only had shorter median survival than those who underwent either staged or synchronous liver resection (31 vs. 47 vs. 46 months, respectively; P = 0.17). Survival was no different for synchronous versus staged resection (P = 0.6). Volume of liver disease predicted resectability (P = 0.001). Without liver resection, 2-year survival was approximately 60%. Palliative surgery was required in six of nine patients who did not undergo resection of their primary tumor. Conclusions Current chemotherapeutic regimens lead to improved survival in patients with unresectable liver metastases. Upfront chemotherapy in the asymptomatic patient compared with resection of the primary tumor does not appear to significantly affect survival. However, given that 60% of patients were alive after 2 years, resection of the primary lesion for palliative reasons and local control must be considered.