Background: The ideal surgical strategy for left emergency colectomy remains controversial and is decided on a case-by-case basis. The aim of this study was to analyze our current practice and outcomes to define a standardized approach.Method: This retrospective review included all consecutive patients who underwent left emergency colectomy between July 2006 and June 2013. Demographics, surgical data, and postoperative outcomes were compared between patients with primary anastomosis (PA group) and those having Hartmann’s procedure (HP group).Results: Final analysis included 148 patients (89 men, median age 76 (range 22-95) years). Patients with HP (n=73) were older and had higher ASA score (p< 0.001) and Charlson index (p< 0.001) than patients with PA (n=75). Indications were similar between the comparative groups, but noradrenalin requirements and Hinchey III/IV status were more frequent in the HP group. Patients with HP had higher in-hospital mortality (15 vs. 4%, p=0.020), overall (78 vs. 56%, p=0.005) and severe complications (29 vs. 17%, p=0.033). Anastomotic leak rate was 8% (n=6) after PA. Only 18 patients (25%) of the HP group proceeded to stoma take-down, while all patients with PA were stoma-free 12 months after hospital discharge.Conclusion: Emergent left-sided colectomy remains associated with high postoperative morbimortality. Patient’s condition and intraoperative findings appear to guide surgical decision-making. Hartmann’s procedure does not prevent adverse outcomes and entails a high permanent ostomy rate.