OBJECTIVES. The aim of this study is to analyze surgeons' decision strategies about the optimal treatment for acute sigmoid resection for different patients. In particular, the authors wished to determine the predominant accepted treatment choice among surgeons, to determine the importance of patient characteristics for surgeons' evaluations of the appropriateness of treatments, and to identify the variety in decision strategies. METHODS. A survey was carried out among all surgical members of the Netherlands Society of Gastro Intestinal Surgery, who evaluated 16 patient cases. Approximately 70% of the members completed the survey. RESULTS. Overall, the predominant accepted strategy is resection, delayed anastomosis, and colostomy (Hartmann procedure). Consensus in terms of preferred treatment, however, was low. The most important factors influencing surgeons' evaluations of the appropriateness of treatments were the age of a patient, the degree of peritonitis, and the degree of fecal contamination. Further analysis showed that the variety in surgeons' decision strategies could not be explained by differences in experience, but was shown to be related to the evaluation of the appropriateness of treatment for 60-year-old patients and patients with a local peritonitis. Except for these factors, surgeons did not differ fundamentally in the evaluation of the factors that make a treatment more appropriate. Surgeons agreed about the optimal treatment for older patients in poor condition, although there is no epidemiologic literature to support this consensus position. CONCLUSIONS. This study showed that lack of consensus in surgeons' choice of treatment could be explained partly by disagreement of the appropriateness of treatments for some, rather than all, patients.