OBJECTIVE: Compare efficacy, safety and long-term outcomes of bridge-to-surgery and emergency surgery in acute malignant colorectal obstruction. METHODS: Retrospective study of 94 consecutive patients with left-sided acute malignant colorectal obstruction treated with curative intent between 2010-2017. RESULTS: 48 patients underwent stent placement and 46 underwent emergency surgery. Technical and clinical success were 100% and 87%. Laparoscopy and one-staged operation were more frequent in bridge-to-surgery (44% vs 2%, p < 0.001; 73% vs 30%, p < 0.001). Fewer permanent stomas were created in bridge-to-surgery (15% vs 35%, p = 0.013). Overall morbidity was 36%. Immediate and post-procedure stent related-complications occurred in 6% and 13%; surgery-related complications occurred in 28% (bridge-to-surgery: 15% vs emergency surgery: 41%, p = 0.004). No differences were found regarding tumor recurrence, recurrence-free survival and overall survival. R1 resection (HR 47.2, CI:4.1-543.7), number of lymph nodes harvested (HR 0.9 CI:0.8-0.99) and adjuvant therapy (HR 0.1 CI:0.01-0.9) predicted recurrence-free survival; pTMN stage IV (HR 7.3, CI:1.1-47.6), number of lymph nodes harvested (HR 0.90, CI:0.8-0.97), adjuvant therapy (HR 0.1, CI:0.02-0.4) and surgery-related complications (HR 5.3, CI:1.02-27.3) influenced overall survival. CONCLUSION: Stent placement has a high success, similarly to emergency surgery, being associated with higher primary anastomosis and lower stoma rates. Tumor recurrence rate, recurrence-free survival and overall survival were comparable between groups; surgery-related complications influenced overall survival.