Twenty to 30% of patients with rectal cancer will present with unresectable disease. Although chemotherapy is the primary treatment modality for patients with asymptomatic unresectable rectal cancer, half of all these patients may require a palliative procedure at some point due to obstruction, perforation, bleeding and/or pain. The surgeon is critical to the multidisciplinary team and will provide guidance as to the appropriate treatment strategy. Thus, it is imperative that a surgeon who commonly treats these patients to have knowledge of all treatment modalities available. The aim of this chapter is enhance the reader’s knowlege of palliative strategies for patients with stage 4 rectal cancer.