Unfortunately, some patients will present with Stage 4 disease for which cure is not realistic. Determining which symptoms can be surgically palliated is a very diffi cult pro­cess. A patient may have vague symptoms and be found to have metastatic disease, but determining cause and effect for a specifi c symptom, and thereby determining the possibility of surgical palliation, can be challenging. Bowel obstruction may be a more intuitive predicament as CT scanning can often show the site of obstruction, in the case of malignant obstruction, a mass at the transition point (Fig. 6.3 ). The question becomes what to do about the obstruction. Options would include surgical resection, an intraluminal colonic stent, chemotherapy, or hospice, with or without placement of a gastrostomy tube to vent the GI tract. Each of these choices depends heavily on the extent of the disease and the condition and wishes of the patient. Obviously a relatively young patient with extensive disease but otherwise good reserve is often treated very differently from an octogenarian with CHF and chronic renal failure that may have a small amount of bleeding and isolated otherwise potentially resect­able metastases. In general, a malignant bowel obstruction is a very serious and ominous occurrence. Historically, surgical procedures for these patients have been fraught with compli­cations and an in-hospital mortality of 21–28 % [