BACKGROUND: The nonoperative approach to recurrent and even multiple recurrent diverticulitis has recently been advocated. This approach, however, may result in more frequent acute attacks requiring emergent colectomy. Our aim was to compare the colectomy outcomes for diverticulitis in the elective and acute settings. METHODS: All patients with diverticulitis undergoing elective (EL) and emergent (EM) colectomy selected from the 2001 to 2002 Nationwide Inpatient Sample Database were analyzed and compared. RESULTS: Five thousand ninety-seven (27.1% emergent) colectomy cases were analyzed. EL patients had a significantly reduced length of stay (7.5 vs 13.3 days) and total hospital charges ($25,420 vs $51,170). Postsurgical morbidity and mortality were significantly higher in the EM group (29.0% vs 14.9% and 7.4% vs .8%, respectively). Colostomy was needed in 5.7% of EL and in 48.9% of EM patients (P = .001). CONCLUSIONS: Emergent colectomy in the setting of diverticulitis is associated with significantly higher morbidity, longer hospitalization, greater hospital charges, and a 9-fold increase in mortality. Prophylactic resection in the setting of recurrent diverticulitis should continue to be an acceptable and possibly more "conservative" approach.