Synopsis
Choose a site-specific and physiology-led route through malignant colonic obstruction, integrating immediate safety, treatment intent and the consequences of resection or decompression.
- A perforated or ischaemic obstructed cancer needs urgent surgical source control; stenting and elective staging must not delay treatment of a threatened patient.
- For potentially curable left-sided malignant obstruction, discuss expert stenting as a bridge and emergency surgery as reasonable options when the patient is suitable.
- An uncomplicated right-sided obstruction often proceeds to resection; severe physiological derangement may make an immediate anastomosis unsafe.
Key red flags
New continuous pain, generalised guarding, shock, reduced bowel enhancement or extraluminal gas demands urgent source-control planning. Perforation may occur through the tumour or proximally, where a distended caecum fails. These patients are unsuitable for routine bridging stent management.
Investigation priorities
Define the obstructing tumour, proximal bowel condition and urgent complications.
Management branches
A suspected malignant obstruction has been demonstrated clinically and on imaging.
- Begin resuscitation, nil-by-mouth care and surgical assessment. If there is peritonitis, infarction or perforation, provide sepsis treatment where indicated and organise urgent operative source control rather than attempting routine stenting. When an obstructing tumour has caused a remote proximal perforation, the operation must control both the tumour obstruction and the perforated or nonviable proximal bowel. Tailor resection and reconstruction to physiology, contamination and tissue quality, including a stoma or staged approach when an immediate join is unsafe.
- When the bowel appears viable and the patient is stable, define tumour site and provisional treatment intent. For a suitable potentially curable left-colon lesion, discuss expert bridging stenting and emergency surgery, including failure, perforation, stoma and cancer-related trade-offs.