**4. Colonic pseudo-obstruction**

Colonic pseudo-obstruction is a rare, poorly understood surgical complication with multifac‐ torial origins [21]. Characterized by marked colonic distention in the absence of distal obstruc‐ tion (Figure 2), this condition seems to be associated with the disturbance of the autonomic innervation of the colon [22]. Untreated, colonic pseudo-obstruction leads to cecal over-disten‐ tion and subsequent perforation, with reported mortality as high as 15-50% [21, 22]. The critical cecal diameter range at which perforation is more likely to occur is between 9-12 centimeters [23]. The two main management modalities for colonic pseudo-obstruction, used alone or in combination, are neostigmine administration and colonoscopic decompression [22, 24]. De‐ pending on whether indicated by the finding of bowel perforation or repeated episodes of pseudo-obstruction, surgical options vary from cecal decompression (i.e., cecostomy) to colon‐ ic resection with entero-enterostomy or ostomy creation [25]. In the presence of sepsis with he‐ modynamic instability, damage control surgery may be justified [26-28].
