Background: Acute colonic obstruction because of advanced colonic malignancy is a surgical emergency. Aim: To compare the clinical outcomes and cost-effectiveness of endoscopic self-expanding metal stent (SEMS) vs. surgery for emergent management of acute malignant colonic obstruction in patients with metastatic colorectal cancer over a 6-month period. Methods: Decision analysis was used to calculate the cost-effectiveness and success of two competing strategies in a hypothetical patient with metastatic colon cancer presenting with acute, malignant colonic obstruction: (i) emergent colonic stent (SEMS cohort); (ii) emergent surgical resection followed by diversion (surgery cohort). Results: Self-expanding metal stent resulted in a success and a lower mortality rate when compared to surgery over a 6-month period. Colonic SEMS was also associated with a lower mean cost per patient ($27 225 vs. $57 398). Mortality in the surgery group was 25 times that of the SEMS cohort. One- and two-way sensitivity analyses identified SEMS as the dominant strategy. Conclusion: Colonic stent insertion is more effective and less costly than surgery for the management of colonic obstruction in patients with metastatic colon cancer.