More effective chemotherapeutic agents have broadened the role of hepatic resection in the management of patients with synchronous hepatic metastases from colon cancer. This study examines the management patterns and the role of hepatobiliary surgical evaluation in patients with synchronous stage IV colon cancer. Patients with synchronous hepatic metastases from colon cancer evaluated and treated from 1/99 to 11/04 were analyzed retrospectively. Demographic, disease-related, and treatment-related variables were reviewed and correlated with disease-specific survival (DSS). One hundred and fifty-one patients were evaluated. The majority of patients (60%) were first evaluated by a medical oncologist while 34% were first evaluated by a hepatobiliary surgeon. Ultimately, 128 patients (85%) underwent surgical evaluation and 77% of those evaluated underwent surgical intervention. Patients who underwent operative exploration +/- debulking had less hepatic disease but also received more chemotherapy than patients not explored and those who never underwent hepatobiliary surgical evaluation. Sixty-eight patients (53%) who underwent hepatobiliary surgical evaluation underwent hepatic resection. Negative independent predictors of hepatic resection were bilobar metastases and extrahepatic disease found during exploration. Variables associated with improved DSS included: carcinoembryonic antigen level < or =200 ng/ml, node-negative primary tumor, < or =4 liver metastases, unilobar metastases, largest metastasis < or =5 cm, and hepatic resection. Five-year DSS following hepatic resection was 54%. We conclude that hepatobiliary surgical evaluation of patients with synchronous hepatic metastases is warranted since many are candidates for hepatic resection. A multidisciplinary treatment approach which combines both medical and surgical modalities may be associated with improved survival.