Acute Perforated Large Bowel Obstruction Due to Colorectal Malignancy: A Surgical Emergency With Options

Acute large bowel obstruction caused by colorectal cancer is a critical surgical emergency, often presenting as a life-threatening condition. This case involves a 71-year-old male who presented to the emergency department with complete large bowel obstruction secondary to a sigmoid mass, raising concern for malignancy. Initial plans were made for decompression and colonoscopy. However, the patient left the hospital against medical advice and subsequently returned two days later with massive abdominal distension and peritonitis. Emergent exploratory celiotomy revealed a septic abdomen with gross contamination due to perforation in the ascending colon near the hepatic flexure, which was not amenable to repair. At a minimum, a subtotal colectomy was required. The patient underwent a single-stage oncologic subtotal colectomy with a hand-sewn ileosigmoid anastomosis and fascial closure. Pathologic evaluation confirmed stage IIb invasive sigmoid adenocarcinoma with negative margins and 0/43 lymph nodes. The patient was discharged on postoperative day nine without complications. For patients presenting with abdominal sepsis from fecal contamination caused by large bowel perforation due to sigmoid malignancy and obstruction, surgical management options vary widely. These range from damage control surgery with multiple subsequent procedures to single-stage resection and anastomosis. This case underscores the importance of individualized, careful decision-making both preoperatively and intraoperatively. It highlights the factors to consider when evaluating the feasibility of single-stage oncologic surgery and the risks associated with performing a primary anastomosis during emergent operations.