A 78-year-old male with a past medical history of bladder cancer in remission following endoscopic treatment, noncontributory psychiatry and social history, and a normal colonoscopy four years prior to presentation. The patient presented to the emergency department (ED) with a four-day history of diffuse abdominal pain, distention, nausea and one episode of bilious emesis. His last bowel movement was three days prior to presentation. The abdomen was distended with diffuse tenderness and no signs of peritonitis. Initial laboratory workup was unremarkable. A computed tomography (CT) of the abdomen and pelvis showed an annular obstructing mass in the sigmoid colon of 4.8 cm in length in addition to a pancreatic body and lesser sac mass involving the gastric antral region and a hepatic lesion suspicious for metastatic disease (, ). The cancer antigen (CA) 19–9 level was elevated to 112,444 U/ml (normal <35 U/ml). Due to the complete colonic obstruction, urgent surgical resection was deemed necessary. Preoperatively, a nasogastric tube was placed, and the patient was resuscitated with isotonic fluids. The procedure was performed by the senior colorectal surgeon in an academic hospital. A laparoscopic approach was chosen. A superficial liver lesion in the segment 4B was identified and a biopsy was performed using laparoscopic biopsy forceps. The abdomen was inspected and no evidence of carcinomatosis was found. On exploration of the pelvis, an obstructing mass in the sigmoid was visualized with decompressed distal rectum. A sigmoidectomy was performed utilizing a laparoscopic gastrointestinal anastomosis (GIA) stapler. A high ligation of the inferior mesenteric artery (IMA) was performed for oncologic purposes. Due to the anticipated need for urgent chemotherapy the decision to defer an anastomosis was made and an end-colostomy was created. The postoperative course was unremarkable. The patient had return of bowel function on postoperative day (POD) 1, the diet was advanced as tolerated and he was discharged on POD 3. The patient was seen in the office 2 weeks after his surgery with no major complaints. Pathology for the sigmoid specimen was consistent with 5 out of 10 lymph nodes positive for metastatic disease. Likewise, the liver biopsy specimen was consistent with the same findings. The patient was referred to medical oncology for further systemic therapy.