Background: Stage IV gastric cancer is a disease with poor survival. The goal of our study was to determine if there is a curative advantage to surgical resection compared to palliative procedures such as bypass or no surgical intervention. Method: The Surveillance, Epidemiology and End Results (SEER 1973-2003) database was used to evaluate all distant gastric cancers including distant metastases and those requiring en-bloc resection of adjacent organs (T4NxMx;Stage4, included in SEER before 2000), but patients with T1-3N3M0 (Stage 4) disease were excluded. Those who had total/subtotal gastrectomies or debulking procedures were considered to have cancer-directed surgery while patients with biopsies or intestinal bypass were considered palliative only Cox regression was performed for survival analysis. Results: 18,372 cases of metastatic gastric cancer were identified with 64.6% males, 69.5% adenocarcinomas and 64% of tumors were poorly-differentiated. Median age at diagnosis was 68 years. Median survival was 4 months. Cancer-directed surgery was performed in 30.4% (n=5,248) of patients. Median survival for those undergoing cancer-directed surgery was 7 months vs. 3 months for patients not undergoing surgery (P<0.001). On logistic regression, people with undifferentiated carcinomas were less likely to get surgery (OR=0.33, 95%CI=0.21-0.51, P<0.001) whereas patients with linitis plastica (OR=1.67, 95%CI=1.29-2.17, P<0.001) were more likely to have surgery compared to adenocarcinoma patients. Females were more likely to have surgery (OR=1.16, 95%CI=1.06-1.28, P=0.001). African-Americans (OR=1.16, 95%CI=1.02-1.32, P=0.021), Japanese (OR=1.45, 95%CI=1.22-1.72, P<0.001) and people of other Asian backgrounds (OR=1.46, 95%CI=1.17-1.83, P=0.001) were more likely to have surgery compared to Whites. On survival analysis, African-Americans and Native Americans had an increased risk of death (HR=1.07, 95%CI=1.01-1.15, P=0.02; HR=1.30, 95%CI=1.05-1.61, P=0.016; respectively), whereas, females had a decreased risk of death (HR=0.89, 95%CI=0.82-0.94, P<0.001). Patients who underwent cancer-directed surgery have a survival advantage (HR=0.54, 95%CI=0.52-0.56, P<0.001). Of those who had surgery, patients who had local tumor resections (n=142) or total gastrectomies with resection of other organs (n=770) had an increased risk of death over those who had a partial gastrectomy (HR=1.84, 95%CI=1.48 - 2.28, P<0.001; HR=1.16, 95%CI=1.05 - 1.29, P=0.003, respectively). Conclusion: Stage IV gastric cancer is a disease with very poor survival but selected patients may benefit from resection. Further research needs to be done to identify patients who may benefit from resection.